COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


m<mmm 


i 


Columbia  ®[nibersJitp     \ 
in  tfje  Citp  of  i^eto  |9orfe 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/systemofpractica01loom 


CONTRIBUTORS  TO  VOLUME  I. 


ATKINSON,  I.  E.,  M.  D. ; 
BYRON,  JOHN   M.,   M.D.  ; 
COLEMAN,  WARREN,  M.D.; 
DOCK,  GEORGE,  A  M.,  M.D.; 
DOTY,  ALVAH    H.,  M.D.; 
DYER,  ISADORE,  M.D.; 
GRIFFITH,  J.  P.  CROZER,  M.  D.; 
JAMES,  WALTER    B,,  M.  D. ; 
LATIMER,  THOMAS   S.,  M.D.; 
OSLER,  WILLIAM,  M.  D.,  F.R.C.P.  ; 
PARK,  WILLIAM    HALLOCK,  M.D  ; 
ROBINSON,  P.  GERVAIS,  M.  D.,  LL.D.; 
ROBINSON,  WILLIAM   FRANCIS,  M.D.; 
STERNBERG,  GEORGE  M..  M.  D.,  LL.D.; 
STEWART,  JAMES,    M.  D.  ; 
THAYER,  WILLIAM    SYDNEY,  M.  D. ; 
WELCH,  WILLIAM    H.,  M.  D. ; 
WELCH,  WILLIAM    M.,  M.D.; 
WEST,  HAMILTON   ATCHISON,  M.  D. ;   ■ 
WILSON,  JAMES  C,  M.D. 


A 


SYSTEM 


PRACTICAL  MEDICINE 

BY 

AMERICAN  AUTHORS. 

EDITED  BY 

ALFRED   LEE   LOOMIS,  M.  D„  LL.D., 

Late  Professor  of  Pathology  and  Practical  Medicine  in  the  New  York  University, 

AND 

WILLIAM  GILMAX  THOMPSON,  M.D., 

Professor  of  Materia  Medica,  Therapeutics,  and  Clinical  Medicine  in  the   New 

York  University  ;  Physician  to  the  Presbyterian  and 

Bellevve  Hospitals,  New  York. 

VOLUME  I. 

INFECTIOUS   DISEASES. 

ILLUSTRATED. 


LEA   BEOTHERS   &   CO., 

NEW  YORK   AXD   PHILADELPHIA. 

1897. 


Entered  according  to  Act  of  Congress  in  the  year  1897,  by 
LEA   BROTHERS   &   CO., 
the  Office  of  the  Librarian  of  Congress,  at  Washington.     All  rights  reserved. 


PRESS    OF 
WESTCOTT    a    THOMSON.  ^     DORNAN,    PHILADA. 

ELEOTROTYPEHS,     PHILADA. 


PREFACE  TO  VOLUME  I. 


RErEXT  vcai's  have  l)C'en  characterized  Uy  triiitt'ul  investigation  of 
till'  i-aiises  nf  disease,  and  i)y  the  increasing  detiniteness  of  modern 
medicine  in  its  practical  applications. 

Such  considerations  render  ol)\i<ni-  the  necessity  for  a  systematic  and 
practical  work  covering  the  entire  field  of  general  and  special  medicine 
in  its  foremost  state  of  development.  To  meet  this  want  the  late  Dr. 
Alfred  Lee  Loomis,  LL.D.,  undertook  the  editorshi]i  of  the  System 
OF  Practical  Medicine  by  American  Authors,  and  associated  me 
with  himself  in  its  charge.  His  eminent  standing  brought  the  willing 
co-operation  of  leading  American  practitioners  and  teachers,  and  it  has 
thus  been  possil)le  to  assign  each  subject  to  an  autlmr  of  the  highest 
repute  in  its  special  branch.  It  is  therefore  not  unreasonable  to  antici- 
pate that  these  volumes  will  be  accepted  as  representative  and  as  satis- 
fving  practical  needs,  and  that  they  will  do  credit  to  the  fair  name  of 
America  in  the  world  of  medicine. 

AVhile  ample  space  is  allotted  for  all  that  the  physician  can  care  to 
know  of  practical  medicine,  matters  historical  and  purely  controversial 
have  been  omitted.  Xo  general  articles  upon  hygiene,  bacteriology,  or 
symptomatology  have  been  introduced,  all  necessary  knowledge  of  such 
character  being  included  in  the  special  articles  upon  the  various  diseases 
— an  arrangement  affording  the  aihantage  of  making  each  subject  com- 
])lete  in  itself.  The  greater  specialties  lying  otit  of  the  domain  of  gen- 
eral medicine  have  likewise  lieen  omitted,  as  readers  can  more  usefully 
consult  the  many  excellent  treatises  on  gynaecology,  ophthalmology, 
dermatology,  etc. 

It  has  thus  been  found  possible  to  present  a  succinct  and  complete 
account  of  medical  practice  in  its  latest  aspects,  each  article  being  a  clini- 
cal monograph  and  proceeding  from  the  cause  and  nature  of  a  disease  to 
its  diagnosis,  prognosis,  and  treatment.  The  therapeutical  sections  have 
been  made  especially  rich  and  precise,  since,  after  all,  the  main  object  of 
medical  science  is  curative.  Prescriptions  and  formulae  will  be  found 
wherever  they  can  be  of  assistance.  Diagrams,  charts,  and  tables  have 
been  frequently  employed,  in  view  of  the  clearness  and  vividness  of  know- 
ledge which  can  be  imparted  by  such  means,  and  illu>tratinns  and  col- 


6  PREFACE  TO    VOLUME  I. 

ored  plates  have  not  been  spared  where  they  could  serve  utility.  IMost 
of  these  illustrations  will  derive  an  added  interest  from  their  originality, 
prepared,  as  they  have  been,  especially  for  this  work.  Careful  study 
has  been  bestowed  upon  the  typographical  arrangement  and  sub-head- 
ings of  the  various  articles,  and  a  system  has  been  followed  which 
will  facilitate  consultation.  ]Much  care  has  been  given  to  the  indexes, 
as  upon  their  completeness  depends  very  greatly  the  convenience  and 
utilitv  of  the  entire  work.  Each  volume  will  be  separately  indexed. 
Due  credit  has  been  awarded  in  the  text  and  foot-notes  for  important 
discoveries  in  medicine. 

A  closing  word  is  due  and  affectionately  rendered  to  Professor 
Loomis.  He  secured  the  authors,  apportioned  their  subjects,  decided 
the  arrangement  and  classification  of  the  entire  work,  and  discussed 
wdth  me  many  important  details,  so  that  in  completing  the  editorial 
duties  alone  I  have  been  able  to  carry  out  the  designs  which  he  had 
alreadv  formulated.  He  was  one  of  the  world's  great  masters  of  medi- 
cine ;  he  leaves  it  richer  for  this  result  of  his  knowledge  of  the  science 
and  of  his  contemporaries  who  could  fitly  join  him  in  expounding  it. 
His  own  article  on  Endocarditis  will  be  read  with  all  the  interest  at- 
taching to  the  latest  production  of  a  man  universally  admired  for  his 
attainments  and  respected  for  his  personality. 

To  the  eminent  clinicians  and  teachers  who  share  in  the  authorship 
of  these  volumes  I  desire  to  extend  thanks  for  their  uniform  courtesy 
and  assistance  in  the  execution  of  an  editorial  task  necessarily  large 
and  difficult. 

W.  GILMAN  THOMPSON,  M.  D. 

ISTew  Yoek,  .January,  1897. 


CONTRIBUTORS  TO  VOLUME  I. 


1.  K.  ATKINSON,  M.D., 

Professor  of  Therapeutics  and  C  linical  Medicine  in  the  T'niversity  of  Maryhmd, 
Baltimore,  Md. 

JOHN    M.   P.YROX,  M.D., 

Late  Director  of  tlie  Bacteriological  Laboratory  in  tlie  Medical  Department  of  the 
New  York  University,  New  York  ;  late  Resident  Physician  at  tlie  New  Y'ork 
Quarantine  Hospitals. 

WAKREN   COLEMAN,  M.  D., 

Instructor  in  Gross  Patliology  in  the  New  Y'ork  L'niversity,  Assistant  Curator  to 
Bellevue  Hospital,  Visiting  Physician  to  the  City  Hospital,  New  Y'ork. 

GEORGE   DOCK,  A.M.,  M.  D., 

Pi'ofeSsor  of  the  Tlieorv  and  Practice  of  Medicine  and  of  Clinical  Medicine,  Uni- 
versity of  Michigan,  Ann  Arbor,  Mich. 

ALVAH  H.  DOTY',  M.  D., 

Health  Officer  of  the  Port  of  New  Y'ork,  New  York  Quarantine. 

ISADORE   DYER,  M.  D., 

Professor  of  Dermatology  in  the  New  Orleans  Polyclinic,  Lecturer  and  Clinical 
Instructor  on  Dermatology,  Medical  Department  of  Tulane  University,  Derma- 
tologist to  the  Charity  Hospital,  Consulting  Dermatologist  to  the  Eye,  Ear, 
Nose,  and  Throat  Hospital,  New  Orleans,  La. 

J.  P.  CROZER  GRIFFITH,  M.  D., 

Clinical  Professor  of  Diseases  of  Cliildren  in  the  University  of  Pennsylvania, 
Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic,  Physician  to  >St. 
Agnes',  tlie  Methodist,  and  the  Children's  Hospital,  Philadelphia. 

WALTER   B.  JAMES,  M.  D., 

Clinical  Lecturer  on  Medicine  in  the  College  of  Physicians  and  Surgeons,  Attend- 
ing Physician  to  the  Presbyterian  Hospital,  New  Y'ork. 

THOMAS  S.  LATIMER,   M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  the  College  of  Physicians 
and  Surgeons,  Baltimore,  Md. 

7 


8  CONTRIBUTORS  TO    VOLUME  I. 

WILLIAM   OSLER,  M.  D.,  F.E.  C.P., 

Professor  of  Medicine  in  the  Johns  Hopkins  University,  Physician-in-Chief  to  tlie 
Johns  Hopkins  Hospital,  Baltimore,  Md. 

WILLIAM  HALLOCK   PARK,  M.  D., 

Assistant  Director  of  the  Infectious  Diseases  Hospital  Laboratory ;  Visiting  Phy- 
sician to  the  Hospitals  of  the  Health  Department  of  New  York  City  ;  Instructor 
in  Contagious  Diseases,  Bellevue  Hospital  Medical  College,  New  York. 

P.  GERVAIS  ROBINSON,  M.D.,  LL.D., 

Professor  of  Principles  of  Medicine  and  Hygiene  in  the  Missouri  Medical  College, 
Consulting  Physician  to  the  City  Hospital,  St.  Louis,  Mo. 

WILLIAM   FRANCIS  ROBINSON,  M.  D., 

Instructor  in  Dermatology  and  Assistant  to  the  Clinic  for  Skin  and  Venereal 
Diseases,  Rush  Medical  College,   Chicago,  Ills. 

GEORGE  M.  STERNBERG,  M.  D.,  LL.D., 

Surgeon-General  U.  S.  A.,  Washington,  D.  C. 

JAMES  STEWART,  M.  D., 

Professor  of  Clinical  Medicine,  McGill  Univei-sity,  Physician  to  the  Royal  Vic- 
toria Hospital,  Montreal,  Canada, 

WILLIAM  SYDNEY   THAYER,  M.  D., 

Associate  Professor  of  Medicine  in  the  Johns  Hopkins  University,  Resident  Phy- 
sician to  the  Johns  Hopkins  Hospital,  Baltimore,  Md. 

WILLIAM   H.  WELCH,  M.  D., 

Professor  of  Pathology  in  the  Johns  Hopkins  University  ;  Pathologist  to  the 
Johns  Hopkins  Hospital,  Baltimore,  Md. 

WILLIAM  M.  WELCH,  M.  D., 

Physician  in  Charge  of  the  Municipal  Hospital  for  Contagious  and  Infectious  Dis- 
eases, Philadelphia. 

HAMILTON  ATCHISON   WEST,  M.D., 

Professor  of  General  and  Clinical  Medicine,  School  of  Medicine,  University  of 
Texas,  Member  of  the  Board  of  Managers  of  John  Sealy  Hospital,  Galveston, 
Texas. 

JAMES  C.  WILSON,  M.  D., 

Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Jefferson 
Medical  College,  Attending  Physician  to  the  Jefferson  Hospital,  the  German 
Hospital,  and  the  Pennsylvania  Hospital,  Philadelphia. 


CONTENTS   OF   VOLUME   I. 


THE    INFECTIOUS    DISEASES. 

PAGE 

MALAEIA 17 

By  William  H.  Welch,  M.  D.,  and  William  S.  Thayer,  M.  D. 

DENGUE 155 

By  Hamilton  A.  West,  M.  D. 

ENTERIC  OR  TYPHOID  FEVER 167 

By  James  C.  Wilson,  M.  D. 

TYPHUS  FEVER 233 

By  Alvah  H.  Doty,  M.  D. 

RELAPSING  FEVER 257 

By  Warren  Coleman,  A.  B.,  M.  D. 

YELLOW   FEVER 267 

By  George  M.  Sternberg,  M.  D.,  LL.D. 

CHOLERA 301 

By  John  M.  Byron,  M.  D. 

DYSENTERY 339 

By  Hamilton  A.  West,  M.  D. 

THE  PLAGUE 391 

By  William  M.  Welch,  M.  D. 

INFLUENZA 399 

By  James  C.  Wilson,  M.  D. 

EPIDEMIC  CEREBRO-SPINAL  MENINGITIS 425 

By  Thomas  S.  Latimer,  M.  D. 

9 


10  CONTENTS  OF  VOLUME  I. 

PAGE 

EEYSIPELAS 451 

By  George  Dock,  A.  31.,  M.  D. 

PYEMIA 477 

By  I.  E.  Atkixsox,  M.  D. 

SEPTICEMIA 495 

By  I.  E.  Atkixsox,  M.  D. 

SMALLPOX  AXD  VAEIOLOID 513 

By  William  M,  Welch,  M.  D. 

VACCINIA 555 

By  William  M.  Welch,  M.D. 

VAKICELLA ' o69 

By  William  M.  Welch,  M.  D. 

SCAELET  FEVEE 577 

By  p.  Gervais  Robixsox,  M.  D.,  LL.D. 

RUBEOLA— MEASLES 625 

By  J.  P.  Crozer  Griffith,  M.  D, 

EUBELLA  .    .    '. 639 

By  J.  P.  Crozer  Griffith,  M.  D. 

DIPHTHEEIA • 647 

By  William  Hallock  Park,  M.  D. 

PERTUSSIS 713 

By  J.  P.  Crozer  Griffith,  M.  D. 

EPIDEMIC    PAEOTIDITIS 725 

By  J.  P.  Crozer  Griffith,  M.  D. 

TUBERCULOSIS 731 

By  William  Osler,  M.  D.,  F.  R.  C.  P. 


SYPHILIS 

By  William  Fraxcis  Robixsox,  M.  D. 


849 


coy  TESTS   OF    VOLUME  I.  11 

PAfJE 

LEPROSY  .    - -.i:.'] 

By  IriAUOKE  DvEii,  M.  D. 

TETANUS 935 

B^'  .Iamks  Stkwaut,  M.  D. 

INFECTIOUS  FEVERS  OF  OBSCURE  NATURE 945 

By  Walter  B.  James,  M.  D. 


MALARIA. 

By  WILLIAM  H.  WELCH,  M.  D.,  and  WILLIAM  S.  THAYER,  M.  D. 

DEFINITION,  SYNONYMS,  HISTORY,  AND 
PARASITOLOGY. 

By  WILLIAM  H.  WELCH,  M.  D. 

Definition. 

Malaria  comprises  the  diseases  caused  by  tlie  specific  protozoan 
parasite  called  Hcematozoon  malarice. 

The  name  "  malaria/'  derived  from  the  Italian  mal'  aria  and  signi- 
fying "  bad  air,"  was  applied  originally  to  the  miasm  or  poison  which 
was  "supposed  to  produce  the  disease.  It  is  now  used  to  designate  the 
disease  itself,  and  is  the  most  convenient  term  for  this  purpose. 

The  most  characteristic  malarial  manifestations  are  intermittent  or 
remittent  fever,  certain  forms  of  the  disease  described  as  "  pernicious," 
and  a  chronic  cachexia  with  enlarged  spleen  and  anaemia.  The  parasite 
discovered  by  Laveran  is  invariably  present  in  malaria  and  produces 
from  the  haemoglobin  of  the  red  blood-corpuscles  the  brown  or  black 
pigment  granules  which  are  characteristic  of  the  disease. 

Synonyms. 

Malarial  fever ;  Intermittent  fever ;  Chills  and  Fever ;  Fever  and 
Ague  ;  Paludism  or  Paludal  fever ;  Swamp  or  Marsh  fever ;  Miasmatic 
fever ;  Periodical  fever  ;  Autumnal  fever. 

Names  derived  from  localities  where  the  disease  has  prevailed  with 
especial  intensity  have  sometimes  been  used ;  as,  Walcheren  fever, 
Batavia  fever,  Hungarian  fever,  African  fever,  Panama  fever,  Chagres 
fever. 

Special  names  have  been  applied  to  certain  types  or  manifestations 
of  malaria ;  as,  remittent  fever,  bilious  remittent  fever,  hemorrhagic 
remittent  fever,  congestive  fever,  dumb  ague,  black-water  fever,  black 
jaundice. 

History. 

There  are  few  diseases  which  can  be  traced  so  surely  and  continuously 
as  malaria  in  medical  writings  from  ancient  times  to  the  present.  Various 
types  of  malarial  fever  are  described  by  Hippocrates,  Celsus,  Galen, 
and  other  ancient  writers,  although  it  is  often  impossible  to  determine 
the  precise  characters  of  many  of  the  fevers  described  by  these  authors. 

Vol.  I.— 2  17 


18  3IALARIA. 

Celsus  and  Galen  divide  intermittent  fevers  into  quotidian,  tertian, 
quartan,  semi-tertian,  and  irregular.  They  recognized  intermittent 
fevers  with  long  intervals.  The  nature  of  their  semi-tertian  fever 
(hemitritseus)  has  given  rise  to  much  discussion.  Certain  forms  of 
intermittent  fever  were  believed  by  Galen  to  have  their  seat  in  the 
spleen,  others  in  the  liver.  The  influence  of  marsh  effluvia  and  of 
seasons  of  the  year  in  the  causation  of  certain  of  these  fevers  was  recog- 
nized. Various  symptoms  were  discriminated  as  to  their  prognostic 
significance,  often  with  much  acuteness  of  observation.  A  passage  in 
Celsus  clearly  alludes  to  the  type  of  malarial  fever  now  called  sestivo- 
autumnal  fever. 

The  Arabian  physician  Rhazes  described  the  so-called  subintrant 
malarial  fevers.  No  important  advance  beyond  the  knowledge  of  Celsus 
and  of  Galen  concerning  malarial  fevers  was  made  until  toward  the  end 
of  the  sixteenth  century,  when  Mercatus  in  his  work  on  malignant  fevers 
described  various  forms  of  pernicious  paroxysms  in  association  with 
intermittent  fever,  particularly  with  the  tertian  type. 

The  introduction  of  cinchona  bark  from  Peru  into  Europe  by  the 
Countess  del  Chinchon  and  her  body-physician,  Juan  del  Vego,  in 
1640,  gave  great  impetus  to  the  study  of  malarial  fevers,  and,  indeed, 
in  its  revolutionizing  influence  upon  medical  doctrines  this  event  marks 
an  epoch  in  the  history  of  medicine. 

In  the  latter  half  of  the  seventeenth  and  the  beginning  of  the  eigh- 
teenth century  there  appeared  a  voluminous  literature  regarding  mala- 
rial fevers.  The  most  notable  of  the  works  upon  this  subject  of  this 
period  are  those  of  Sydenham,  Richard  Morton,  Torti,  Eamazzini,  and 
Lancisi.  These  works  remain  to  this  day  the  great  classics  upon  malaria. 
They  contain  the  fundamental  clinical  and  therapeutical  facts  and  many 
etiological  data  relating  to  this  disease.  Morton  and  Lancisi  demon- 
strated clearly  the  relation  of  malaria  to  marsh  miasm.  Sydenham 
pointed  out  the  differences  between  vernal  and  autumnal  intermittent 
fevers.  Especially  complete  and  keen  in  analysis  is  the  nosography  of 
Torti,^  whose  classification  of  the  malarial  fevers,  particularly  of  the 
pernicious  and  mixed  forms,  has  been  followed  by  most  subsequent 
authors.  The  diagnostic  as  Avell  as  the  therapeutic  value  of  the  prepara- 
tions of  Peruvian  bark  was  recognized,  and  assisted  materially  in  the 
discrimination  of  the  malarial  fevers  from  the  other  so-called  essential 
fevers.  It  is  interesting  to  note  the  relative  accuracy  of  diagnosis  and 
of  description  of  the  group  of  malarial  fevers  from  the  latter  half  of 
the  seventeenth  century  onward,  in  contrast  to  the  confusion  which 
existed  regarding  the  other  essential  fevers  until  the  discrimination  of 
the  latter  by  the  pathological-anatomical  studies  of  the  present  century. 

The  military  and  colonial  enterprises  of  England  in  the  eighteenth 
century  served  to  extend  the  knowledge  of  the  geographical  distribution 
of  malaria,  particularly  in  tropical  climates,  the  works  of  Pringle  and 
of  Lind  containing  especially  notew^orthy  observations  on  this  point. 
But  the  great  mass  of  the  very  extensive  literature  on  the  epidemi- 
ography  of  malarial  diseases  which  has  been  so  industriously  collected 
and  ably  analyzed  by  Hirsch  ^  belongs  to  the  present  century. 

'  Torti :  Therapeutics  s-pedalis  adfebres  quasdam  'perniciosas,  etc.,  Mutinse,  1712. 
^Hirsch:  Handbuch  der  historisch-geograpMschen  Pathologic,  Stuttgart,  1881. 


HISTORY.  19 

The  significance,  as  rejsrards  malaria,  of  the  active  studies  in  morbid 
anatomy  of  the  first  half  of  the  present  eentiirv  relates  to  the  clear  dif- 
ferentiation of  typhoid  fever  from  malarial  and  other  fevers  rather  than 
to  the  actual  contributions  to  the  pathology  of  malaria,  although  these 
were  not  lacking.  The  occurrence  of  enlarged  spleens,  so-called  fever- 
C4ikes  or  ague-cakes,  and  even  the  dark  color  of  the  organs  in  association 
with  malarial  fevers,  had  been  occasionally  observed  by  the  older 
writers,  notably  by  Lancisi,  but  the  intimate  relation  of  these  altera- 
tions to  malaria  was  not  established  until  during:  the  first  half  of  the 
present  century. 

Andouard  (1808,  1812,  1818)  emphasized  congestion  and  enlarge- 
ment of  the  spleen  as  the  essential  anatomical  lesion  of  malarial  fever. 
Bailly  (1825)  noted  in  a  series  of  autopsies  on  cases  of  pernicious  mala- 
rial fever  observed  in  Rome  in  1822  the  dark  color  of  the  cortical  gray 
matter  of  the  brain  and  the  congestion  of  the  cerebral  meninges  and 
substance.  He  laid  especial  emphasis  upon  evidences  of  supposed 
inflammation  of  the  central  nervous  system  and  of  the  stomach  and 
intestine.  These  anatomical  observations,  together  ^*ith  those  of  Xepple 
(1828,  1835),  and,  to  a  less  extent,  of  Maillot  (1835),  were  interpreted 
in  favor  of  Broussaisism,  which  at  this  period  exerted  such  a  pernicious 
influence  upon  medical  practice. 

Valuable  contributions  to  the  pathological  anatomy  of  malarial 
fevers,  especially  of  the  remittent  type,  were  made  in  the  United  States 
during  the  fourth  decade  of  this  century  by  Stewardson  in  Philadelphia, 
Swett  in  Xew  York,  and  Anderson  and  Frick  in  Baltimore.  Steward- 
son  demonstrated  the  bronzed  color  of  the  liver  in  remittent  fevers,  and 
regarded  this  as  the  characteristic  anatomical  criterion  of  the  disease. 
His  observations  were  confirmed  and  extended  by  the  other  ^v^ite^s  named. 
Alonzo  Clark  in  1855  demonstrated  that  the  bronzed  color  of  these 
livers  is  due  to  the  presence  of  granules  of  yellow,  bro^vn,  and  black 
pigment,  which  he  regarded  as  derived  from  the  coloring  matter  of  red 
blood-corpuscles.  The  monumental  work  of  Daniel  Drake  on  The 
Principal  Diseases  of  the  Interior  Valley  of  Xorth  America  (1850,  1854) 
contains  a  large  amount  of  valuable  information,  based  upon  personal 
observation  and  research,  as  to  the  distribution  and  characters  of  the 
malarial  fevers  in  the  then  AVestern  States  of  this  country. 

In  the  light  of  recent  discoveries  it  is  interesting  to  note  the  ingeni- 
ous arguments  advanced  by  John  K.  Mitchell  in  his  work  On  the  Crijp- 
togamous  Origin  of  Malarious  and  Epidemic  Fevers,  published  in  1849, 
in  favor  of  the  doctrine  of  contagium  animatum.  This  book  deserves 
to  rank  with  the  more  frequently  quoted  work  of  Henle  relating  to  the 
same  line  of  argument.  At  about  the  same  period  Bassi  and  Rasori  in 
Italy  also  advocated  the  parasitic  theory  of  malaria. 

The  discoverer  of  the  malarial  pigment  is  Heinrich  Meckel,  who 
found  and  described  the  pigment  in  1848  in  the  blood  and  organs  of  the 
dead  body  of  an  insane  patient.  He  was,  however,  ignorant  of  the 
relation  of  this  pigment  to  malaria.  The  next  report  concerning  the 
pigment  was  in  1849  by  Virchow,  mIio  observed  it  in  the  body  of  a  man 
who  had  suffered  from  chronic  malaria.  There  soon  followed  the  obser- 
vations of  Heschl,  Planer,  A.  Clark,  Tigri,  Frerichs,  and  others,  fully 
establishing  the  relation  of  the  pigment  to  malaria.     The  source  of  the 


20  3IALARIA. 

pigment  was  regarded  by  Meckel  and  Virchow  as  in  the  spleen,  and 
this  doctrine  was  elaborated  by  Frerichs.  Planer  (1854)  was  the  first 
who  saw  the  pigment  in  the  fresh  blood  of  living  patients,  and  he  sug- 
gested that  the  pigment  may  be  formed  in  the  circulating  blood — a 
view  which  was  more  fully  presented  and  advocated  by  Arnstein  (1874) 
and  by  Kelsch  (1875). 

Tliere  is  no  doubt  that  some  of  the  pigmented  bodies  which  are  now 
recognized  as  parasitic  organisms  had  been  seen  by  earlier  observers 
without  knowledge  of  their  true  nature.  Thus  Meckel  noted  the 
presence  of  pigment  granules  in  colorless,  hyaline  bodies  devoid  of 
definite  nuclei.  He,  and  more  particularly  Virchow  and  Frerichs, 
observed  pigment  in  fusiform  and  curved  bodies  in  the  blood,  which, 
although  interpreted  as  endothelial  cells  of  splenic,  origin,  in  all  proba- 
bility were,  at  least  in  part,  the  crescentic  forms  of  the  parasite.  Some 
of  the  larger  pigmented  spherical  organisms  must  have  been  seen  and 
mistaken  for  pigmented  leucocytes. 

In  November,  1880,  Laveran  discovered  the  parasitic  nature  of  these 
and  previously  unrecognized  forms  in  the  blood  of  malarial  patients, 
and  thereby  introduced  a  new  era  into  our  knowledge  of  the  malarial 
diseases. 

The  discovery  of  the  malarial  parasite  has  furnished  an  unfailing 
means  of  diagnosis  of  malarial  diseases,  has  materially  advanced  our 
knowledge  of  their  pathology,  has  led  to  a  better  understanding  of  their 
clinical  phenomena  and  various  types,  has  furnished  important  data  for 
prognosis,  and  has  led  to  improvements  in  methods  of  treatment.^ 

Parasitology. 

Historical. 

In  1879,  A.  Laveran,  a  French  military  surgeon,  stationed  at  the 
time  in  the  province  of  Constantine,  Algeria,  began  to  study  the  path- 
ological anatomy  of  malaria,  and  at  once  directed  his  attention  to  the 
much  discussed  question  of  the  origin  of  the  pigment.  He  observed  in 
the  blood  of  malarial  patients  certain  pigmented  bodies  different  from 
the  melaniferous  leucocytes,  but  he  was  uncertain  as  to  their  nature 
until,  on  November  6, 1880,  he  discovered  that  some  of  these  pigmented 
bodies  threw  out  long  flagella  endowed  with  such  active  lashing  move- 
ments as  to  convince  him,  as  they  have  convinced  every  one  who  has 
since  then  seen  them,  that  they  are  living  parasites.  Laveran  published 
his  observations  in  a  note  to  the  Academic  de  Medecine  in  Paris,  pre- 
sented November  23,  1880.  This  was  followed  by  the  publication  of 
several  notes  in  1880  and  1881,  and  in  the  latter  year  appeared  a  small 
monograph  by  Laveran  on  the  parasitic  nature  of  malaria.^ 

1  The  so-called  bacillus  malarise  described  in  1879  by  Klebs  and  Tomtnasi-Crudeli, 
which  for  a  short  period  had  a  certain  vogue,  chiefly  with  Italian  writers,  never  rested 
upon  satisfactory  observations  which  indicated  that  it  bore  any  relation  to  malaria,  and  it 
deserves  no  more  consideration  than  the  palmella  of  Salisbury  and  the  other  alleged 
malarial  organisms  described  before  Laveran's  discovery. 

■^  Only  occasional  references  to  the  voluminous  literature  on  the  parasitology  of  malaria 
are  given  in  this  article.  A.  full  table  of  references  to  the  works  treating  of  malarial  fever 
since  the  recognition  of  its  parasitic  origin  up  to  and  partly  including  the  year  1895  will 
be  found  in  "The  Malarial  Fevers  of  Baltimore,"  by  William  Sydney  Thayer,  M.  D., 
and  John  Hewetson,  M.  D.  {The  Johns  Hopkins  Hospital  Reports,  vol.  v.,  1895). 


PARASITOLOGY.  21 

In  tlicsc  various  early  publications  Lavoran  describes  (1)  pigmented 
cresoentio  and  ovoid  botlies  ;  (2)  spherical,  transparent  bodies,  sometimes 
free,  sometimes  applied  to  the  surface  of  red  blood-corpuscles,  the 
smallest  about  one-sixth  of  the  diameter  of  a  red  blood-coi-puscle  and 
eontaininti:  only  one  or  two  fine  pio-mcnt  <;'i'anules,  thes(!  representin<^  an 
early  stai>;e  of  development  of  (o)  larger,  pigmented,  spherical  bodies 
averaging  <)  n  in  diameter,  but  sometimes  larger  than  a  red  blood-cor- 
puscle, and  containing  numerous,  often  moving,  pigment  granules ;  (4) 
bodies  similar  to  the  last  mentioned,  but  beset  with  actively  motile 
flagella  ;  (5)  free  motile  flagella  ;  and  (0)  swollen  spherical  or  deformed 
bodies,  8—10  ii  in  diameter,  containing  pigment,  and  regarded  as  cadaveric 
forms  of  the  spherical  parasites.  Laveran  noted  amoeboid  movements 
of  the  spherical  forms,  grouping  of  the  small  spherical  bodies  together, 
and  the  occurrence  of  small,  colorless,  motile  bodies,  without  specific 
characters,  which  he  suggested  may  perhaps  represent  the  first  phase  of 
development  of  the  parasitic  elements.  He  regarded  all  of  the  forms 
as  different  stages  of  development  of  the  same  species  of  organism,  and 
considered  the  free  flagella,  which  he  believed  were  formed  within  the 
spherical  bodies  and  escaped  by  rupture  of  the  enveloping  membrane,  as 
the  most  characteristic  and  perfect  stage  of  development  of  the  parasite. 

Laveran  communicated  his  results  to  his  colleague  Richard,  stationed 
in  Philippe ville,  Algiers,  who  in  February,  1882,  published  a  commu- 
nication confirming  Laveran's  observations  and  adding  certain  points  of 
importance.  He  describes  the  development  of  the  parasite  from  small, 
perfectly  transparent  bodies  contained  in  otherwise  normal  red  blood- 
corpuscles.  This  clear  body  grows  larger,  forms  pigment  out  of  the 
haemoglobin  of  the  enveloping  red  corpuscle,  which  thereby  becomes 
gradually  decolorized  and  reduced  to  a  mere  colorless  shell-like  rim, 
which  finally  ruptures  and  sets  free  the  parasite.  This  now  generally 
accepted  view  as  to  the  intracorpuscular  development  of  the  parasite, 
which  was  first  announced  by  Richard,  was,  however,  in  the  following 
year  abandoned  by  him  in  favor  of  Laveran's  view  that  the  parasites 
develop  either  free  in  the  plasma  or  in  close  attachment  to  the  surface 
of  red  corpuscles  or  in  depressed  spots  on  the  surface.  Richard  observed 
amoeboid  movements  of  the  parasites,  and  noted  spherical  bodies  with  a 
central  block  of  black  pigment  from  which  delicate  lines  radiated  so  as 
to  produce  rosette  forms. 

Laveran  continued  to  publish  brief  communications  in  1882  and  1883, 
and  in  1884  he  published  a  larger  work  '  presenting  his  observations  and 
views  in  detail.  In  this  work  lie  describes  more  fully  the  forms  already 
mentioned,  and  he  notes  the  occurrence  of  segmenting  forms,  which, 
however,  he  interpreted  as  forms  of  degeneration,  not  of  reproduction. 

The  observations  of  Laveran  and  of  Richard  Avere  made  by  micro- 
scopical examination  of  the  fresh  blood.  In  1883  and  1884,  Marchia- 
fava  and  Celli  published  in  a  number  of  articles  the  results  of  their 
studies  of  stained  specimens  of  dried  malarial  blood.  With  the  excep- 
tion of  small,  spherical  stained  bodies  in  the  red  blood-corpuscles,  which 
they  thought  might  be  micrococci,  they  interpreted  the  various  other 
stained  and  usually  pigmented  bodies  found  in  the  red  corpuscles  of 
malarial  patients  as  probably  degenerative  changes.     As  a  matter  of 

^  Laveran  :   Traite  des  Fieireft  palufftres,  Paris,  1884. 


22  '  MALARIA. 

fact,  the  coccus-like  clots  were  probably  in  part  Ehrlich's  degenerations, 
whereas  their  drawings  show  that  the  supposed  degenerative  forms  were 
in  reality  the  actual  parasites,  which  in  many '  of  their  phases  were 
accurately  depicted,  although  not  recognized  as  such. 

In  1885,  Councilman  and  Abbott  in  the  organs  from  two  cases  of 
pernicious  comatose  fever  found  and  described  small  pigmented  hyaline 
bodies  in  and  outside  of  red  corpuscles,  most  abundantly  in  capillaries 
of  the  brain. 

In  1885,  Marchiafava  and  Celli,  as  the  result  of  the  examination  of 
fresh  malarial  blood,  came  to  a  correct  interpretation  of  these  bodies 
and  described  them  fully  and  accurately.  They  emphasized  especially 
the  amoeboid,  unpigmented,  transparent  intracorpuscular  bodies,  to 
which  they  gave  the  inaccurate  name  of  plasmodia,  which  has  been 
widely  adopted.  They  described  clearly  the  intracorpuscular  develop- 
ment of  the  parasite,  the  formation  of  pigment  out  of  the  blood  coloring 
matter,  the  consequent  changes  in  the  blood-corpuscles,  and  they  pointed 
out  the  probable  reproductive  nature  of  the  segmenting  bodies,  which 
they  described  more  fully  and  accurately  than  had  been  done  by  Laveran 
and  Richard.^ 

The  publications  of  Marchiafava  and  Celli  attracted  wider  attention 
than  had  those  of  Laveran,  and  from  the  year  1885  up  to  the  present 
time  there  has  been  a  steadily  flowing  stream  of  literature  upon  the 
various  questions  connected  with  the  parasitology  of  malaria. 

Immediately  following  the  confirmation  of  Laveran's  discoveries  by 
Italian  observers  came  similar  confirmation  from  Sternberg,  Council- 
man, and  Osier  (1886-87),  and  somewhat  later  by  James  (1888)  and 
Dock  (1890),  in  this  country,  and  within  a  few  years  numerous  reports 
from  various  parts  of  Europe,  America,  Asia,  and  Africa  demonstrated 
"the  invariable  association  of  Laveran's  parasites  with  all  cases  of  mala- 
rial fever.  There  are  no  observers  of  any  prominence  who,  with  sujffi- 
cient  opportunity  and  training  for  such  examinations,  have  failed  to 
recognize  the  parasites  in  cases  of  malaria,  nor  is  there  now  any  authori- 
tative voice  of  dissent  from  the  acceptance  of  the  parasite  as  the  specific 
cause  of  this  disease. 

Since  the  fundamental  researches  of  Laveran,  Richard,  and  Marchia- 
fava and  Celli  (1880-85)  other  observers  have  greatly  extended  our 
knowledge  as  to  many  details  concerning  the  structure  and  life-history 
of  the  parasite  and  its  relation  to  various  types,  phenomena,  and  lesions 
of  malaria,  although  not  a  few  important  questions  still  remain  unsettled. 
The  most  important  of  these  later  discoveries  are  due  to  the  demonstra- 
tion by  Golgi  (1885-86)  of  a  definite  relation  between  the  cycle  of 
development  of  the  parasite  and  the  different  stages  of  malarial  fever, 
and  to  the  recognition  by  Golgi  (1885-86)  of  the  two  varieties  of  the 
parasite  belonging  respectively  to  quartan  and  to  tertian  fever,  and  by 
Marchiafava  and  Celli  and  Canalis  (1889)  of  the  variety  or  varieties 
belonging  to  sestivo-autumnal  fever.     These  observations  have  led  to 

^  Marchiafava  and  Celli  claim  for  themselves  the  discovery  of  the  intracorpuscular 
amoeboid  forms  with  and  without  pigment,  and  of  the  segmenting  forms,  but,  as  is  appar- 
ent from  the  review  of  Laveran's  and  Richard's  preceding  publications,  this  claim  cannot 
be  admitted.  Marchiafava  and  Celli,  however,  described  and  interpreted  these  phases  of 
the  parasite  far  better  than  Laveran,  and  to  them  belongs  the  credit  of  demonstrating 
the  intracorpuscular  development  of  the  parasite. 


PA  HA  SITOL  OGY.  23 

two  schools  of  (loctrino — the  ono,  headed  by  Laveran,  holdino;  to  the 
unity  of  a  ])leonu)rj)liic'  mahirial  ])arasite,  the  other,  headed  by  (rolgi  and 
otlier  Italian  writers,  uj)h()ldinu'  the  ])Iurality  (if  malarial  parasites.  The 
latter  ilOetrine  has  the  larger  nimiber  of  sn[)])orters. 

Dock  (l<S90-92)  was  the  iirst  to  differentiate  the  three  principal 
varieties  of  the  malarial  parasite  in  the  United  States,  and  recently 
Thayer  and  Hewetson  '  have  published  a  thorough  study  of  the  malarial 
fevers  of  Baltimore  with  careful  descriptions  of  these  varieties. 

Investigations  concerning  the  intimate  structure  of  the  malarial 
parasites  have  been  made  especially  by  C'elli  and  Guarnieri,  Grassi  and 
Feletti,  Romanowsky,  Sacharoff,  Mannaberg,  Antolisei,  Bastianelli  and 
Bignami,  and  others. 

The  results  of  these  later  studies  concerning  the  malarial  parasites 
will  be  considered  in  various  parts  of  this  article.  They  are  fully  and 
systematically  presented  in  the  recent  monograph  of  Thayer  and  Hewet- 
son, already  cited. 

NOMEXCLATUEE. 

Various  names  have  been  suggested  for  the  malarial  parasite.  Among 
these  may  be  mentioned  Oscillaria  malarise  (Laveran),  Plasmodium 
malarise  (Marchiafava  and  Celli),  Hsematomonas  malarise  (Osier),  H»ma- 
tophyllum  mala  rise  (Metchnikoff"),  Hsemamoeba  malariie  (Grassi  and^ 
Feletti),  H?emococcidium  malaria  (L.  Pfeilfer),  Hffimosporidium  mala- 
rise  (Danilewsky),  Hajmatozoon  or  Hsemocytozoon  malarite  (Osier  and 
various  authors). 

Of  these  names,  Plasmodium  malaria  has  gained  wide  currency,  but 
it  is  on  zoological  grounds  singularly  inapprojDriate,  and  there  is  no 
reason  why  it  should  be  perpetuated. 

The  name  Hsemosporidium  malarise  has  much  to  recommend  it,  but 
it  has  not  been  generally  adopted.  Upon  the  whole,  the  name  Hfema- 
tozoon  malarife,  which  expresses  nothing  as  to  the  zoological  classification 
of  the  parasite,  and  which  has  been  adopted  by  many  writers,  may  be 
provisionally  accepted  until  more  precise  knowledge  is  reached  concern- 
ing the  zoological  position  of  the  parasite.  Hsemocytozoon  is  more 
precise,  bat  the  other  term  has  the  advantage  of  greater  brevity. 

Zoological  Position  of  the  Malarial  Parasite. 

The  malarial  parasite  belongs  to  the  class  of  Protozoa,  under  which 
name  are  grouped  the  unicellular  organisms  with  the  physiological  cha- 
racters of  animals.  Biitschli  divides  the  Protozoa  into  the  orders — 
Sarcodina,  Mastigophora,  Sporozoa,  and  Infusoria.  Grassi  and  Feletti 
classify  the  malarial  parasite  among  the  Sarcodina,  subdivision  Rhiz- 
opoda,  and  adopt  the  name  Hsemamceba  malarise.  Antolisei  considers 
that  the  parasite  belongs  to  the  Gymnomyxa,  or,  more  precisely,  the 
Proteomyxa  of  Ray  Lankester.  The  great  majority  of  authors  classify 
the  malarial  parasite  among  the  Sporozoa,  which  are  divided  by  Balbiani 
into  the  groups  Gregarinida,  Sarcosporidia,  Myxosporidia,  and  Micro- 
sporidia.      Under  the  Gregarinidse  are  included  the  Coccidia,  with  which 

'  Op.  cit. 


■24  MALARIA. 

some  writers  group  the  malarial  parasite.  Kruse  makes  under  the 
Gregariniclae  a  special  family  which  he  designates  as  Hsemogregarinidse, 
and  to  which  he  refers  the  malarial  parasite  and  similar  hsemocytozoa  in 
lower  animals.  Danilewsky  suggests  forming  a  new  group  under  the 
Sporozoa  to  be  called  Hsemosporiclia,  in  which  he  places  the  malarial 
and  similar  hsematozoa,  and  Labbe  calls  the  grouj)  Gymnosporidia. 

As  we  know  nothing  of  the  malarial  parasite  in  the  outer  world,  it  is 
evident  that  our  knowledge  of  its  life-history  is  incomplete,  so  that  any 
attempt  at  a  zoological  classification  must  be  regarded  as  only  provisional. 
Such  information  as  we  possess  favors  classifying  the  parasite  among  the 
Sporozoa,  but  it  possesses  characters  which  do  not  enable  us  to  fit  it 
exactly  into  any  of  the  existing  subdivisions  of  the  Sporozoa,  so  that 
the  suggestions  of  Kruse  and  of  Danilewsky  of  establishing  a  new  sub- 
division of  the  Sporozoa  or  of  the  Gregarinidse  to  include  the  malarial 
parasite  and  similar  organisms  in  birds  seems  to  be  a  good  one,  and  the 
name  Hfemosporidia  for  this  new  subdivision  appears  to  be  appropriate. 
According  to  this  classification,  the  malarial  parasite  may  be  called  the 
Hsemosporidium  malarise. 

Methods  of  Investigation. 

The  methods  for  demonstrating  and  studying  the  malarial  parasite 
will  be  described  under  the  heading  Diagnosis.  It  may  here  be  stated 
that  generally  the  most  useful  procedure  is  the  examination  of  thin 
layers  of  fresh  blood  with  an  oil-immersion  objective.  The  description 
of  the  parasite  which  is  to  follow  is  based  mainly  upon  this  method. 
This  procedure  may  be  advantageously  combined  with  the  examination 
of  stained  specimens.  For  the  study  of  the  finer  details  of  structure 
this  latter  method  is  indispensable. 

General  Morphology  and  Biology. 

The  malarial  parasite  is  a  unicellular,  protozoan  organism  which 
develops  within  the  red  blood-corpuscles,  and  therefore  belongs  to  the 
group  of  Hsemocytozoa.  As  will  be  described  subsequently,  organisms 
closely  resembling  the  malarial  parasite  have  been  found  in  the  blood  of 
birds.  The  numerous  attempts  to  cultivate  artificially  the  malarial 
parasite  have  hitherto  been  unsuccessful,  nor  has  this  organism  been 
recognized  in  the  outer  world.  Our  entire  knowledge  of  it  is  derived 
from  its  study  in  human  beings. 

Three  varieties  of  the  parasite  have  been  diiferentiated.  These 
varieties  are  that  of  quartan  fever,  that  of  tertian  fever,  and  that  of 
sestivo-autumnal  fever.  This  last  variety  it  is  proposed  by  the  writer 
to  call  the  Hsematozoon  malarise  falciparum.  Before  considering  the 
justification  of  this  division  and  the  special  characters  of  each  of  these 
varieties  it  is  desirable  to  describe  the  more  important  characters  com- 
mon to  all  varieties  of  the  malarial  parasite. 

The  cycle  of  development  of  the  malarial  parasite  embraces  a  vege- 
tative and  a  reproductive  phase.  Its  duration  varies  from  twenty-four 
to  seventy-two  hours,  according  to  the  variety  of  parasite. 

The  vegetative  phase  begins  in  the  form  of  small,  colorless,  amoeboid, 


PARASITOLOGY.  25 

hviiliiio  bodies,  1-2  /i  in  (liainc'tcr,  within  the  red  hluod-corpusele.s.' 
These  aniteboid  bodies  increase  in  size,  and,  with  the  occasional  exception 
of  the  a'stivo-autunmal  variety,  they  deveh)])  within  them  a  variabK' 
niMni)er  of  (hirk  piiiiucnt-tiranules,  situated,  as  a  ride,  near  tlie  margin 
of  the  parasite.  The  pit;nuMit  increases  in  aiuoinit  and  in  the  coarseness 
of  the  g-rannles  as  the  organisms  continne  to  dcvch)p.  It  occnrs  in  the 
form  of  irregnhir  grains  and  of  tine  rods,  which  may  be  in  active  motion 
within  the  parasite. 

Having  attained  a  certain  stage  of  development,  whicii  differs  as 
regards  tiie  size  of  tlie  organism  in  the  different  varieties,  the  parasite 
grathially  ceases  its  amoeboid  movements,  assumes  a  spherical  or  oval 
shape,  and  becomes  somewhat  sharper  in  contour.  In  this  condition  it 
may  continue  for  a  while  to  grow.  When  it  has  reached  its  full  size  it 
may  completely  fill  the  red  blood-corpuscle  or  may  occupy  only  a  small 
part  of  it,  these  differences  depending  mainly  upon  the  variety  of  para- 
site.    The  parasite  now  may  be  called  the  full-grown  or  adult  form. 

Coincidently  with  these  stages  of  development  the  enveloping  red 
blood-corpuscle  may  undergo  various  changes,  which  are  of  significance 
in  distinguishing  the  varieties  of  parasite  from  each  other.  The  cor- 
puscle may  become  swollen  and  pale,  or  shrunlven,  or  brassy-green  in 
color,  or  otherwise  deformed,  or  it  may  appear  unaltered,  as  will  be 
described  in  considering  the  varieties  of  the  parasite. 

The  subsequent  stages  in  this  cycle  of  development  belong  to  the 
reproductive  phase,  which  is  shorter  in  duration  than  the  vegetative. 
The  first  evidence  of  this  reproductive  phase  is  the  collection  of  the 
pigment  into  a  mass  of  granules  or  a  solid  block  situated  usually  at  or 
near  the  centre,  but  sometimes  near  the  periphery,  of  the  organism. 
These  bodies  with  clumps  of  pigment  may  be  designated,  in  accordance 
with  Thayer  and  Hewetson's  suggestion,  as  the  presegmenting  forms 
(corpi  con  blocchetto  of  the  Italian  writers). 

Coincidently  with  or  following  this  gathering  of  the  pigment  into  a 
clump,  sometimes  without  a  definite  collection  of  the  pigment,  the  pro- 
cess of  segmentation  begins.  In  its  most  typical  form  segmentation  is 
ushered  in  by  the  appearance  of  delicate  lines  radiating  from  the  per- 
iphery toward  the  centre.  Eventually  the  substance  of  the  spherical 
organism  is  divided  into  a  variable  number  of  round  or  oval  bodies 
called   spores.      The   enveloping    red   corpuscle,  which    now   may   be 

^  As  has  already  been  mentioned,  Laveran  believes  that  the  forms  of  the  parasite 
which  have,  since  the  publications  of  Marcliiafava  and  Celli,  usually  been  regarded  as 
within  the  red  corpuscles,  are  attached  or  applied  (accoles)  to  the  outer  surface  of  the 
corpuscles.  Mannaberg  (1893)  has  again  raised  this  question  by  his  statement  that  many 
of  the  amoeboid  forms,  particularly  in  their  younger  stages  of  development,  are  attached 
to  the  corpuscles,  often  in  little  niches  or  indentations  on  the  surface.  There  is  no  doubt 
that  the  organism  may  be  situated  as  described  by  Mannaberg.  Marchiafava  and  Celli, 
who  had  previously  noted  this  appearance,  interpreted  it  as  indicating  the  extrusion  of 
the  parasite  from  the  red  blood-corpuscle.  It  is,  in  fact,  often  very  difficult  to  determine 
with  precision  whether  the  organism  is  on  tlie  surface  of  or  within  the  corpuscle,  but  the 
evidence  is  that  the  majority  of  the  younger  forms  are  intracorpuscular.  Marchiafava 
and  Bignami  (1894)  describe  in  the  following  words  their  conception  of  the  manner  of 
penetration  of  the  youngest  forms  into  the  corpuscle :  "  The  youngest  amfebfe,  the  otispring 
of  sporulation,  by  virtue  of  the  viscidity  of  their  protoplasm  adhere  to  the  surface  of,  and 
by  their  movements  bury  themselves  in,  the  contour  of  the  red  corpuscle.  In  this  posi- 
tion the  parasite  attacks  the  external  strata  of  the  corpuscle  as  a  means  of  nourishment, 
and  after  altering  these  layers  is  able  to  penetrate  within,  and  thus  becomes  entirely  endo- 
globular.' ' 


26  MALARIA. 

reduced  to  a  narrow  pale  rim,  bursts  and  the  spores  are  set  free,  or  the 
corpuscle  may  have  disappeared  befoi'e  the  process  of  segmentation  is 
completed.  The  pigment  remains  behind,  and  is  quickly  engulfed  by 
phagocytes.  Sometimes  in  the  sestivo-autumnal  variety  segmentation 
occurs  in  organisms  entirely  devoid  of  pigment.  These  segmenting 
bodies  are  called  also  sporulating  forms. 

The  free  spores  speedily  invade  fresh  red  blood-corpuscles,  where, 
as  the  small,  colorless,  amceboid,  hyaline  bodies  already  mentioned,  they 
begin  again  the  cycle  of  development.  The  direct  transformation  of  the 
motionless^  round  spores  into  the  small,  hyaline,  amo?boid  bodies  has 
been  very  rarely  observed,  but  there  is  no  reason  to  suppose  that  there 
exists  any  stage  intervening  between  these  two  forms. 

In  the  complete  sporulating  cycle  of  develojDment  which  has  been 
described  we  can  distinguish,  therefore,  the  following  forms  of  the  para- 
site :  (1)  unpigmented,  amceboid,  hyaline  bodies ;  (2)  pigmented,  amce- 
boid, hyaline  bodies  ;  (3)  full-grown  or  adult  bodies  ;  (4)  presegmenting 
bodies ;  (5)  segmenting  or  sporulating  bodies ;  and  (6)  spores.  All  of 
these  various  bodies  are  depicted  in  Plates  I.  and  II. 

As  already  mentioned,  in  the  sestivo-autumnal  variety  this  cycle 
may  be  completed  without  the  appearance  of  pigment.  These  bodies 
are  to  be  thought  of,  not  as  separate  and  distinct  forms,  but  simply  as 
successive  stages  of  development  with  all  transitions  from  the  youngest 
to  the  most  advanced.  Especially  can  no  sharp  distinction  be  drawn 
between  bodies  (1)  and  (2)  and  between  bodies  (3)  and  (4).  The  recog- 
nition, as  a  distinct  form,  of  the  body  designated  as  f)i"esegmenting  is  of 
less  practical  importance  for  the  quartan  and  tertian  varieties  than  for 
the  sestivo-autumnal. 

The  name  "  plasmodium  "  was  applied  by  Marchiafava  and  Celli 
originallv  to  the  unpigmented,  amoeboid  forms.  It  is  frequently  em- 
ploved  to  designate  both  the  pigmented  and  the  unpigmented  amoeboid 
bodies,  as  well  as  the  parasite  in  all  of  its  forms.  These  amceboid  bodies 
may  be  called,  in  general,  hyaline  forms  or  amoebae. 

As  will  be  explained  subsequently,  it  is  only  the  quartan  variety 
which  is  found  in  all  its  forms  Adth  equal  frequency  in  the  peripheral 
circulation  and  in  the  blood  of  internal  organs;  whereas  segmenting 
tertian  parasites  are  more  abundant  in  the  spleen  and  bone  marrow  than 
in  the  peripheral  vessels,  and  the  sestivo-autumnal  parasite  develops 
mainly  in  the  internal  organs,  its  segmenting  forms  being  extremely 
rare  in  the  peripheral  circulation. 

Each  of  the  forms  of  the  parasite  which  have  been  described  as 
developing  within  the  red  blood  corpuscles  may  also  be  found  free  in 
the  plasma.  They  probably  escape  by  rupture  of  the  enveloping  cor- 
puscle, a  process  which  one  can  often  witness  when  examining  the  fresh 
blood  microscopically.  Extracorpuscular  mature  forms  may  possibly 
segment  in  the  usual  way,  but  there  is  no  evidence  that  forms  in  the 
earlier  stages  may  complete  their  cycle  of  development  free  in  the 
plasma. 

The  important  discovery  was  made  by  Golgi  that  all  of  one  genera- 
tion  of  the  parasite  form  a   group,  the    members    of  Avhich    develop 

1  Plehn  claims  to  have  observed  that  the  spores  are  actively  motile  and  flagellated, 
but  this  statement  is  opposed  to  the  observations  of  all  others. 


PARASITOLOGY.  27 

approximately  at  the  same  time,  and  that  a  definite  relation  exists 
between  the  phases  of  development  of  the  parasite  and  the  stages  of 
malarial  fever.  Tiie  onset  of  a  paroxysm  eorresponds  to  the  ripening 
of  one  generation  of  the  parasite.  A  few  honrs  or  shortly  before  the 
paroxysm  segmenting  forms  appear,  and  enable  the  observer  to  predict 
the  approaehing  jxiroxysm.  The  spores  which  are  set  free  by  the  act  of 
spornlation  invade  the  red  blood-corpnscles  and  start  a  fresh  generation, 
which  pursnes  during  the  paroxysm  and  the  subsequent  apyrexia  so 
regular  a  development  that  in  typical  cases  the  experienced  observer 
can  tell  approximately  by  examination  of  the  blood  the  stage  of  the 
disease — that  is,  the  time  which  has  elapsed  since  the  last  paroxysm  and 
the  time  when  the  next  paroxysm  may  be  expected. 

It  is  not,  however,  always  the  case  that  the  parasite  develops  with 
the  regularity  expressed  by  Golgi's  law,  and  especially  in  the  &estivo- 
autnmnal  fevers  irregularities  are  very  common.  The  simultaneous 
occurrence  of  two  or  more  generations  in  different  stages  of  develop- 
ment may  render  difficult  the  interpretation  of  the  phases  observed, 
although  even  here  careful  observation  will  enable  the  observer  to  draw 
correct  conclusions  in  tertian  and  quartan  fevers. 

It  has  not  been  satisfactorily  demonstrated  that  there  occurs  any 
other  cycle  of  development  of  the  malarial  parasite  in  human  beings 
than  that  which  has  been  described,  although  the  possibility  of  such  an 
occurrence  is  by  no  means  disproven.  Canalis  (1889)  believes  that  he 
has  found  evidence  that  a  second,  slower  cycle  of  development  of  the 
aestivo-autumnal  parasite  occurs,  which  is  represented  in  certain  of  its 
phases  by  bodies  of  the  crescentic  group,  to  be  described  subsequently ; 
and  this  view,  with  certain  modifications,  has  been  accepted  by  Golgi, 
Antolisei  and  Angelini,  Grassi  and  Feletti,  and  Sacharoff.  This  doctrine 
is,  however,  opposed  by  many  observers,  and  it  does  not  at  present  rest 
upon  sufficient  evidence. 

It  seems  necessary  to  suppose,  on  the  basis  of  clinical  evidence,  that 
the  malarial  parasite  may  remain  for  months  in  a  latent  condition  in  the 
human  body,  and  then  begin  to  develop  again,  causing  a  relapse  of  the 
fever.  As  such  relapses  may  occur  in  forms  of  malaria  in  which  cres- 
cents do  not  appear,  there  must  be  in  these  cases  some  resistant  organism 
other  than  bodies  belonging  to  the  group  of  crescents.  We  know  noth- 
ing as  to  the  nature  of  these  resistant  bodies.  The  hypothesis  is  advanced 
by  Bignami  that  they  may  be  spores  which  are  enclosed  within  leucocytes 
and  other  cells,  and  which  have  become  surrounded  by  a  resistant  mem- 
brane and  have  lost  their  usual  staining  properties. 

Besides  the  forms  wdiich  have  already  been  described  as  representing 
phases  of  the  regular  sporulating  cycle  of  development  of  the  malarial 
parasite,  there  occur  other  forms  which  cannot  at  present  be  referred  to 
any  cycle  of  development.  These  other  forms  are — (1)  crescentic  bodies 
and  fusiform,  oval,  and  round  bodies  belonging  to  the  same  group ;  (2) 
flagellate  bodies  and  free  flagella ;  and  (3)  degenerative  forms. 

The  crescentic  and  flagellate  bodies,  from  their  size  and  remarkable 
appearance,  are  the  most  striking  forms  of  the  parasite,  and  from  the 
beginning  have  attracted  much  attention.  Their  significance,  although 
there  are  many  hypotheses  concerning  it,  is  not  understood. 

(1)  The  crescents  develop  only  from  the  aestivo-autumnal  parasites, 


28  MALARIA. 

and  will  therefore  be  described  in  connection  with  these.     They  are 
never  formed  from  quartan  and  tertian  parasites. 

(2)  Flagellate  bodies,  on  the  other  hand,  may  form  from  each  variety 
of  the  parasite,  tertian,  quartan,  or  sestivo-autumnal.  The  weight  of 
evidence  is  that  they  do  not  exist  in  the  circulating  blood,  but  develop 
after  the  blood  has  been  withdrawn  from  the  body,  usually  within 
ten  to  twenty  minutes,  sometimes  earlier.  Some  observers  have  found 
them  frequently,  others  only  rarely.  They  are  frequently  found  if 
the  blood  is  examined  at  the  right  stage  of  the  disease  and  time  is 
allowed  for  their  development.  Councilman  showed  that  they  are  more 
commonly  found  in  blood  aspirated  by  a  hypodermic  needle  from  the 
spleen  than  in  the  peripheral  blood.  They  develop  in  tertian  and  quar- 
tan fevers  from  the  mature,  full-grown  extracorpuscular  forms — in 
tertian  especially  from  swollen  forms  larger  than  the  red  blood-corpus- 
cles. They  are  therefore  found  most  frequently  a  short  while  before 
and  during  the  paroxysm.  In  infections  with  the  sestivo-autumnal 
parasite  the  flagellate  bodies  develop  from  round  bodies  belonging  to 
the  group  of  crescents,  and  do  not  occur  in  definite  relation  to  the 
stage  of  the  fever.   Rarely  intracorpuscular  bodies  may  develop  flagella. 

The  spherical  bodies  which  become  transformed  into  the  flagellate 
bodies  are  always  or  nearly  always  pigmented.  Marchiafava  and  Celli 
state  that  they  once  saw  an  unpigmented  flagellate  body.  These  bodies 
may  be  somewhat  smaller  or  larger  than  the  red  blood-corpuscles,  the  size 
varying  to  some  extent  with  the  different  varieties  of  the  parasite,  as  will 
be  explained  later.  The  process  of  development  of  the  flagella  may  be 
studied  under  the  microscope.  The  pigment  granules,  which  at  first 
(sestivo-autumnal  variety)  may  have  been  in  repose,  usually  begin  to 
dance  about  within  the  organism,  often  in  a  lively  way.  In  the  eestivo- 
autumnal  variety  they  usually  gather  in  the  central  part,  but  in  the 
others  they  may  be  near  the  periphery  or  irregularly  distributed.  The 
spherical  body  may  acquire  an  oscillatory  or  jerking  movement.  Pro- 
jections may  be  formed  and  retracted  at  the  periphery,  and  the  whole 
edge  may  acquire  a  vigorous  undulating  movement.  These  changes 
are  attributed  to  the  movements  of  the  flagella  within  the  body  or  in 
its  ]>eripheral  layers,  and  have  been  graphically  compared  by  Richard 
to  the  struggles  of  an  animal  to  get  free.  Suddenly  the  flagella  shoot 
out  from  the  periphery,  and  with  their  active  lashing  movements 
produce  a  violent  commotion  among  the  red  blood-corpuscles  and  other 
small  particles  which  may  be  in  their  neighborhood  (Plate  I.  Figs.  22 
and  41  ;  Plate  II.  Figs.  43,  44). 

The  flagella  are  pale  and  thin,  and  present  often  at  their  extremities 
and  along  their  course  small  olive-shaped  swellings  which  may  change 
their  position.  Here  and  there  a  pigment  granule  is  occasionally  seen 
in  a  flagellum.  The  flagella  vary  in  size,  number,  and  position.  Their 
length  may  be  three  or  four  times  the  diameter  of  a  red  blood-corpuscle 
or  not  more  than  half  that  size.  One  to  six  may  be  attached  to  the 
spherical  body.  They  may  project  from  one  side  or  from  any  part  of 
the  circumference  of  the  body.  Their  movements  may  be  somewhat 
rhythmical ;  they  may  become  slow  or  even  cease,  and  again  start  up. 

Flagella  may  become  detached  and  move  about  freely  among  the  red 
blood-corpuscles.     On  account  of  their  pallor  such  free  flagella  would 


I'ARASITOLOdY.  29 

usually  be  overlooked  were  it  uot  ior  the  eoiuniotion  whieli  they  produce 
among  the  red  blood-corpuscles.  The  motion  of  the  Hagella  may  be 
observed  on  the  slide  for  half  an  hour,  sometiines  longer. 

These  flagellate  bodies  are  the  most  stai'tling  forms  of  the  malarial 
organism,  and  n<»  one  who  sees  them  donbts  for  a  moment  that  he  is 
looking  at  a  living  j)arasite.  It  is  not  surj)rising  that  they  attracted  in 
an  es])e('ial  manner  the  attention  of  Laveran,  who,  as  already  mentioned, 
regarded  the  Hagella  as  the  most  characteristic  and  perfect  form  oi' 
development  of  the  parasite.  Subsequent  studies  have  not,  however, 
tended  to  (H)nfirm  the  conception  of  Laveran  as  to  their  significaiu-e. 
As  has  already  been  made  clear,  the  flagellated  bodies  do  not  belong  to 
the  regular  sporulating  cycle  of  development  of  the  malarial  parasite  in 
the  human  blood.  The  most  prominent  theories  as  to  their  significance 
are  the  following: 

(a)  They  are  forms  of  degeneration  or  appearances  belonging  to  the 
death-agony  of  the  parasite.  In  support  of  this  view  it  is  urged  that 
the  flagellate  bodies  do  not  belong  to  any  known  cycle  of  development; 
that  they  are  developed  only  outside  of  the  human  body ;  that  they  are 
developed  from  mature  forms  which  are  known  frequently  to  undergo 
undoubted  degeneration,  such  as  hydropic  swelling,  vacuolation,  and 
fragmentation,  and  which  may  already  show  beginning  evidences  of 
degeneration  ;  that  nuclear  substance  is  absent  from  the  flagella ;  and 
that  similar  appearances  of  extrusion  of  motile  filaments  in  other  uni- 
cellular organisms  are  kriown  to  zoologists  and  are  interpreted  as  degen- 
erative. 

(6)  Sacharoif,  from  the  study  of  their  structure  on  stained  specimens, 
believes  that  the  flagella  are  extruded  chromatin  filaments  derived  from 
perverted  karyokinetic  nuclear  division.  He  regards  the  process  as 
degenerative. 

(c)  Dock  suggests  that  the  flagellate  bodies  "  represent  resting  states 
of  the  organism,  capable  of  existing  independently,  perhaps  even  of 
reproducing  themselves,  but  also  able,  under  favorable  circumstances, 
of  reproducing  the  typical  growth  of  the  parasite." 

(d)  Mannaberg's  opinion  is  that  the  flagellate  bodies  may  represent  a 
state  belonging  to  the  saprophytic  existence  upon  which  the  mature 
forms  of  the  parasite  enter  soon  after  the  blood  is  withdrawn  from  the 
body.  On  account  of  unsuitable  conditions  of  environment  they  are 
unable  to  continue  this  existence  in  the  blood  outside  of  the  body  and 
soon  perish.  A  similar  view  is  advanced  by  Manson,  who  suggests  that 
the  flagellate  bodies  represent  the  first  stage,  and  the  detached  flagella, 
in  search  of  their  appropriate  host,  represent  the  second  stage  of  life  of 
the  parasite  outside  of  the  body.  Manson  ^  conjectures  that  the  mosquito 
is  the  extracorporeal  host  of  the  malarial  parasite,  and  he  reports 
observations  of  Ross  showing  the  development  of  flagellate  forms  in  the 
stomach  of  mosquitos  fed  on  malarial  blood. 

There  are  arguments  for  and  against  each  of  these  theories.  Reluc- 
tant as  one  may  be  to  consider  such  striking  forms  as  the  flagellate 

^Manson:  "The  Goulstonian  Lectures  on  the  Life  History  of  the  Malaria  Germ 
Outside  the  Human  Body"  {The  British  Medical  Journal,  189G,  March  14,  21,  28).  Man- 
son  lays  much  emphasis  upon  supposed  analogies  between  the  malarial  germ  and  the 
filaria  sanguinis.  Only  future  investigations  can  determine  the  correctness  of  Manson' s 
hypothesis. 


30  MALARIA. 

bodies  as  phases  of  degeneration,  the  existing  evidence  seems  upon  the 
whole  to  be  more  in  favor  of  this  hypothesis  than  of  any  other  which 
has  been  advanced.  Still,  if  Sacharoif 's  observation  as  to  the  presence 
of  nuclear  material  in  the  flagella  be  correct,  the  objection  of  Grassi 
and  Feletti,  that  the  flagella  are  incapable  of  reproductive  development 
because  the  nucleus  of  the  parasite  does  not  divide  and  enter  them, 
would  be  overthrown  and  the  hypothesis  of  Mannaberg  and  Manson 
would  become  more  probable.  It  is  evident  from  the  description  of 
these  bodies  that  the  use  of  the  word  "  flagella  "  to  designate  the  motile 
filaments  is  of  doubtful  propriety,  but  it  is  the  term  commonly 
employed. 

(3)  There  are  various  bodies,  often  seen  in  the  examination  of  mala- 
rial blood,  which  are  undoubtedly  degenerative  forms  of  the  parasite, 
and  others  which  are  probably  degenerative,  although  opinions  con- 
cerning the  latter  are  divided.  The  more  common  signs  of  degeneration 
of  the  parasite  are  vacuolation,  pseudo-gemmation,  fragmentation, 
deformities  of  shape,  particularly  swelling,  granular  condition  of  the 
protoplasm,  certain  alterations  in  the  arrangement  and  appearance  of 
the  pigment,  disappearance  of  nuclear  material,  defects  and  irregulari- 
ties in  staining,  and  changes  in  the  refraction  of  the  organism.  These 
various  degenerative  changes  produce  forms  too  numerous  to  describe  in 
detail.  They  have  often  been  misinterpreted  and  described  as  special 
forms  of  the  parasite,  some  of  them,  particularly  certain  vacuolated  and 
budding  forms,  as  special  modes  of  reproduction. 

Degenerations  may  occur  in  any  form  of  the  parasite,  but  they  are 
particularly  common  in  the  extracorpuscular  forms.  Mannaberg  de- 
scribes the  disintegration  of  young  intracorpuscular  forms,  with  dis- 
appearance of  their  nuclei.  Fragmentation  of  forms  extruded  from  the 
blood-corpuscles  can  sometimes  be  watched  while  examining  fresh  blood 
under  the  microscope  (Plate  I.  Fig.  21).  As  a  rule,  only  a  certain 
number  of  the  mature  forms  actually  enter  into  reproductive  segmenta- 
tion, and  many  of  the  spores  or  segments  perish.  If  all  segmented  and 
the  offspring  survived,  the  number  of  the  parasites  after  a  few  paroxysms 
would  become  enormous.  As  a  matter  of  fact,  degenerations  of  full- 
grown  parasites  are  often  observed.  An  interesting  form  of  such  degen- 
eration, found  most  frequently  in  the  mature  forms  of  the  tertian  variety, 
is  the  appearance  of  swollen,  pigmented,  so-called  hydropic  bodies,  often 
much  larger  than  red  blood-corpuscles  (Plate  I.  Figs.  18,  40),  and 
sometimes  containing  vacuoles  (Plate  I.  Figs.  18,  19,  23,  24,  40,  and 
42).  Pound  bodies  simulating  spores  are  sometimes  seen  in  these  vacuoles, 
but  on  properly  stained  specimens  they  are  devoid  of  the  nuclear  mate- 
rial of  genuine  spores.  Pseudo-gemmation,  or  the  appearance  of  sarcodic 
buds  on  the  surface  of  the  organisms,  is  doubtless  a  form  of  degenera- 
tion. Such  buds  may  become  separated,  in  the  form  of  hyaline  balls, 
from  the  parent  organism  (Plate  I.  Figs.  19,  20).  These  evidences  of 
degeneration  may  appear  also  in  crescents  and  bodies  belonging  to  this 
group  (Plate  11.  Figs.  40,  41)  and  in  flagellate  bodies.  From  the  latter 
small  hyaline  balls  with  a  flagellum  attached  may  break  off  and  move 
around  actively.  Such  bodies  might  be  mistaken  for  flagellated 
spores. 

There  is  no  good  evidence  that  the  malarial  parasite  ever  multiplies 


PARASITOLOGY.  31 

hv  l)u«](linix'  or  by  simple  cell-division.  The  only  form  of  multiplica- 
tion wliieh  lias  been  demonstrated  is  that  of  sponihition,  also  called  se<r- 
mentation,  already  deseril)ed,  alth()ii<ih  it  cannot  be  denied  that  other 
forms  of  reproilnction  may  exist. 

Various  interestintr  degeni'rative  changes  are  produced  by  the  in- 
fluence of  quinine.  These  will  be  fully  described  under  Treatment, 
Action  of  (Quinine  on  3Ialarial  Parasites,  page  146. 

As  tiie  malarial  parasite  passes  its  vegetative  life  mostly  within  the 
red  blood-corpuscles,  it  is  evident  that  it  finds  its  food  in  this  situation. 
This  food  ma^  be  approi)riatcd  both  by  intussusception  and  by  diffusion. 
Evidence  of  intussusception  is  found  in  the  occasional  presence  of  frag- 
ments of  the  corpuscular  substance  within  the  body  of  the  amoeboid 
forms.  Doubtless  diffusion  is  the  more  important  mode  of  nutrition  of 
the  parasite. 

The  (juestion  has  been  raised  whether  the  })arasite  may  develop  in 
other  cells  of  the  body  than  the  red  blood-corpuscles.  Nearly  all  forms 
of  the  parasite  have  been  found  enclosed  in  cells,  chiefly  leucocytes, 
splenic  or  medullary  cells,  and  endothelial  cells.  As  such  included 
parasites  often  present  evidences  of  degeneration,  these  appearances 
have  been  generally  interpreted  as  referable  to  phagocytic  destruction  of 
the  parasites,  and  such  they  unquestionably  usually  are.  Golgi  and 
IMonti  have,  however,  recently  published  observations  intended  to  show 
that  the  sestivo-autumnal  parasite  may  develop  within  endothelial  and 
other  cells,  as  will  be  explained  in  considering  this  variety  of  parasite. 

The  malarial  parasite  in  the  condition  in  which  it  exists  in  the  human 
bodv  is  very  susceptible  to  injurious  agencies.  It  is  quickly  killed  by 
the  addition  of  distilled  water  and  of  dilute  acids  and  alkalies.  Under 
ordinary  conditions  it  does  not  long  survive  in  blood  withdrawn  from 
the  body.  Under  certain  special  circumstances  it  has  been  kept  appa- 
rently alive  for  two  to  four  days,  possibly  for  a  week.  Sacharoff  observed 
amceboid  movements  in  ^stivo-autumnal  hyaline  bodies  which  had  been 
for  a  week  in  the  intestinal  canal  of  leeches  kept  on  ice,  and  he  obtained 
a  positive  result  by  inoculating  himself  w4th  malarial  blood  preserved 
in  this  way  for  four  days  in  leeches.  The  tertian  and  quartan  parasites 
were  found  to  be  less  resistant  than  the  sestivo-autumnal.  Ripe  bodies 
may  segment  in  blood  outside  of  the  body,  but  no  further  development 
or  multiplication  of  the  parasites  has  been  positively  observed  in  the 
various  attempts  made  to  preserve  or  cultivate  them.  The  parasite 
does  not  continue  to  develop  and  multiply  in  the  limnan  body  after 
death. 

Of  course  no  inferences  can  be  drawn  from  these  observations  as  to 
the  resistance  of  the  parasite  in  its  natural  condition  in  the  outer  world. 
As  to  what  this  natural  condition  is  we  can  only  speculate.  Grassi  and 
Calandruccio  have  thought  that  certain  species  of  amoebae  which  they 
have  observed  in  malarial  districts  might  be  the  extraparasitic  form. 
The  failure  of  artificial  cultivations  and  certain  analogies  drawn  from 
the  zoological  characters  of  the  parasite  have  led  to  the  prevalent  theory 

'  Celli  and  Guamieri  for  a  time  believed  that  spherical  bodies  of  the  crescentic  phiL-<e 
may  multiply  bv  the  formation  of  buds  (gemmation),  but  they  subsequently  abandoned 
this  view  and  adopted  the  now  generally  accepted  opinion  that  these  budding  forms  are 
degenerative.     The  "buds"  are  devoid  of  the  structure  of  genuine  spores. 


32  MALARIA. 

that  the  malarial  parasite  passes  at  least  a  part  of  its  existence  as  a 
parasite  in  animal  or  vegetable  organisms.  Mention  has  already  been 
made  of  Manson's  hypothesis  that  the  mosquito  may  be  a  host  for  the 
malarial  parasite.  That  the  germ  is  capable  of  entering  upon  some 
resistant  phase  of  development  seems  highly  probable  in  view  of  the 
evidence  that  malaria  can  be  contracted  from  the  air.  There  is  no  evi- 
dence that  the  malarial  parasite  is  eliminated  from  the  human  body  in  a 
condition  capable  of  infecting  another  individual  or  the  locality.  The 
disease,  however,  can  be  transmitted  by  inoculating  into  healthy  indi- 
viduals, either  subcutaneously  or  intravenously,  blood  from  a  malarial 
patient. 

Unity  or  Plurality  of  the  Malarial  Parasite. 

As  has  already  been  mentioned,  there  are  two  schools  of  doctrine  as 
to  the  malarial  parasite — the  one  led  by  Laveran  holding  that  the  mala- 
rial parasite  is  a  single  species  with  pleomorphic  characters,  the  other 
believing  that  there  are  three  or  more  species,  or  at  least  varieties,  of 
malarial  parasites.  The  observations  upon  which  the  latter  doctrine  is 
based  originated  with  the  Italians,  and  have  been  supported  by  investi- 
gations in  this  country  and  elsewhere. 

Golgi  in  1885  and  1886  first  differentiated  the  parasite  of  quartan 
fever  from  that  of  tertian  fever,  and  Marchiafava  and  Celli  and  Canalis 
in  1889  and  1890  differentiated  the  variety  of  parasite  characteristic  of 
sestivo-autumnal  fever. ^  There  is  much  difference  of  opinion  as  to  the 
number  of  sestivo-autumnal  parasites.  All  adherents  of  the  doctrine  of 
plurality  agree  that  there  are  at  least  three  varieties  of  malarial  parasite 
— namely,  the  quartan,  the  tertian,  and  the  sestivo-autumnal — distin- 
guished from  each  other  by  morphological  and  biological  characters  to 
be  subsequently  described.  The  discovery  by  Golgi  of  the  definite  cycle 
of  development  of  the  malarial  parasite  and  the  recognition  of  several 
distinct  varieties  have  done  much  to  bring  order  out  of  the  earlier 
chaotic  condition  when  a  multitude  of  parasitic  bodies  were  described 
without  knowledge  of  their  significance  or  relations  to  each  other.  There 
remain,  however,  many  unsolved  problems  which  it  may  be  expected 
that  further  investigations  will  clear  up. 

^  Marchiafava  and  Celli  on  the  one  hand,  and  Canalis  on  the  other  hand,  have  con- 
ducted a  polemic  as  to  which  of  them  belongs  the  credit  of  first  distinguishing  the  sestivo- 
autumnal  parasite.  The  differentiation  of  this  parasite  was  not  made  all  at  once,  and 
with  the  same  precision  in  all  details,  as  in  the  case  of  Golgi' s  sharp  separation  of  the 
quartan  and  tertian  parasites.  Golgi  from  the  beginning  of  his  researches  (1885-86) 
suggested  that  the  crescentic  bodies  belong  to  a  special  cycle  of  existence  different  from 
that  of  the  tertian  and  quartan  organisms,  and  noted  their  occurrence  in  irregular  mala- 
rial fevers.  Councilman  in  1887  emphasized  the  association  of  crescents  with  remittent 
fevers  and  malarial  cachexia.  Golgi  in  February,  1889,  definitely  expressed  the  opinion 
that  in  addition  to  the  malarial  fevers  caused  by  the  quartan  and  the  tertian  parasites  we 
must  recognize  another  type  of  fever  associated  with  unpigmented  amoeboid  forms  and 
crescents.  On  September  13,  1889,  appeared  a  preliminary  communication  of  Marchia- 
fava and  Celli,  which  must  be  regarded  as  furnishing  the  first  clear  and  sharp  description 
of  the  essential  differential  characters  of  the  sestivo-autumnal  parasite,  with  especial  em- 
phasis on  the  occurrence  of  unpigmented  organisms.  On  October  10,  1889,  appeared  the 
preliminary  communication  of  Canalis,  in  which  likewise  the  essential  characters  of  this 
parasite  were  described,  and  a  greater  emphasis  was  laid  upon  its  relation  to  the  crescents 
than  had  been  done  by  Marchiafava  and  Celli.  The  full  publication  of  Canalis  antici- 
pated by  a  short  time  the  complete  article  of  Marchiafava  and  Celli  on  the  sestivo- 
autumnal  parasite. 


PARASITOLOGY.  33 

111  opposition  to  the  doetriiu'  of  plurality  it  is  urt^cd  l»y  Laveran 
that  all  of  the  so-called  varieties  of  the  j)arasite  may  he  explaine(l 
simplv  as  phases  of  a  single  pleomorphic  organism  influenced  hy  various 
conditions  of  environment,  such  as  locality,  season,  individual  j)redispo- 
sition,  and  various  md-cnown  circumstances.  He  contends  that  the 
characters  upon  which  a  division  into  separate  varieties  is  based  are 
iiisutticient  for  such  a  [)urpose  and  inconstant  ;  that  one  so-called  variety 
under  certain  conditions  maybe  transformed  into  another;  and  that 
there  is  no  definite,  necessary  relation  between  the  types  of  fever,  such 
as  qnartan,  tertian,  quotidian,  irregular,  continued,  and  the  form  of 
parasite  present.  The  variations  of  the  malarial  parasite  can  be  ex- 
plained, he  thinks,  in  large  part  liv  the  varying  rajiidity  of  development. 
He  emphasises  the  view  that  malaria  with  all  its  diverse  manifestations 
is  nevertheless  clinically  and  anatomically  one  disease,  and  has  always 
been  so  regarded.  He  argues  that  the  experimental  production  of 
malaria  by  inocidation  does  not  support  the  doctrine  of  plurality. 

In  considering  the  force  of  these  objections  it  must  be  admitted  that 
so  long  as  we  are  unable  to  cultivate  the  malarial  parasite  artificially,  and 
are  ignorant  of  its  life-history  and  the  conditions  of  its  existence  outside 
of  the  human  body,  the  possibility  must  be  admitted  that  under  certain 
conditions,  at  present  unknow^n,  one  variety  may  be  transformed  into 
another.  But,  on  the  other  hand,  the  existing  evidence — and  it  is 
already  considerable — goes  to  show  that  under  the  conditions  which  we 
can  at  present  control  and  study  each  of  the  three  principal  varieties 
of  the  parasite  preserves  its  identity  and  is  not  transformed  into  another 
variety ;  that  is  to  say,  there  is  no  evidence  that  a  quartan  parasite  ever 
becomes  metamorphosed  into  a  tertian,  or  either  of  these  into  an  sestivo- 
autumnal  parasite. 

The  principal  argimients  in  support  of  this  doctrine  of  plurality  may 
be  smnmarized  as  follows  : 

(1)  Each  well-established  variety  of  parasite  presents  morphological 
and  biological  characters  which  suffice  for  its  identification. 

(2)  Each  variety  of  parasite  corresponds  to  definite  types  of  fever. 
Genuine  quartan  fever  can  be  produced  only  by  the  quartan  parasite. 
As  will  be  explained  in  the  clinical  part  of  this  article,  other  types  of 
fever  may  be  caused  by  more  than  one  variety  of  parasite,  and  much 
complexity  may  result  from  multiple  and  mixed  infections  and  various 
irregularities ;  but  all  of  this  does  not  prevent  the  recognition  of  certain 
fundamental  ts'pes  of  fever  especially  characteristic  of  each  variety  of 
the  parasite. 

(3)  Cases  of  pure  infection  with  one  variety  of  parasite  have  been 
carefully  studied  for  weeks  and  months  without  any  indication  of  the 
transformation  of  one  variety  into  another  (Calandruccio,  Grassi  and 
Feletti).  Opportuniries  for  such  study  are  exceptional.  The  appear- 
ance of  a  second  variety  of  parasite  in  localities  where  there  is  oppor- 
tunity for  renewed  infection  cannot  of  course  be  interpreted  in  favor  of 
the  metamorphosis  of  one  variety  into  another. 

(4)  In  certain  localities  only  one  or  two  of  the  varieties  of  the  para- 
site are  met  wdth.  In  a  few  places  only  the  quartan,  or  more  frequently 
only  the  tertian,  parasite  is  observed ;  in  most  places  where  malaria  is 
mild   and  infrequent  only  tertian,  and   occasionally  quartan,  parasites, 

Vol.  I.— 3 


34  MALARIA. 

with  entire  absence  of  sestivo-autumnal  parasites,  are  found.  Instances 
of  this  localized  distribution  of  the  parasites,  which  manifestly  is  a 
strong  argument  in  favor  of  the  doctrine  of  plurality,  Avill  be  subse- 
quently mentioned  (page  99). 

(5)  Strong  arguments  in  favor  of  the  constancy  of  the  varieties  of 
the  malarial  parasite  are  furnished  by  the  experimental  production  of 
malaria.  Gerhardt  in  1882  and  1883  (reported  in  1884)  was  the  first 
to  produce  malaria  experimentally  by  the  subcutaneous  injection  of 
blood  obtained  from  malarial  patients.  At  this  time  the  malarial 
organism  was  not  generally  recognized.  Since  these  first  experiments 
similar  ones  have  been  repeated,  usually  in  the  manner  of  intravenous 
injections  of  malarial  blood,  with  positive  result  in  over  thirty  cases. 
The  experiments  before  1889  were  made  without  determination  of  the 
exact  variety  of  parasite  injected  and  found  in  the  experimental  case. 
In  1889,  Gualdi  and  Antolisei,  without  full  knowledge  of  the  critical 
nature  of  the  experiment,  injected  two  patients  intravenously  with  3  c.cm. 
of  blood  from  a  patient  suiFering  with  quartan  fever  and  possessing  quar- 
tan parasites.  In  each  of  the  inoculated  individuals  irregular  fever  ^dth 
sestivo-autumnal  parasites  developed.  These  two  cases  are  constantly 
adduced  as  a  main  support  of  the  doctrine  of  mutability  of  the  varieties 
of  the  parasite,  but  unjustly  so,  for  it  was  subsequently  determined  that 
the  patient  from  whom  the  blood  was  obtained  had  previously  suffered 
from  irregular  fever,  and  he  subsequently  developed  characteristic 
sestivo-autumnal  organisms,  so  that  the  experimenters  themselves  later 
expressed  the  opinion  that  at  the  time  of  the  inoculation  the  patient 
furnishing  the  blood  had  combined  cjuartan  and  sestivo-autumnal  organ- 
isms, the  latter  being  overlooked.  In  view  of  the  uniform  results  yielded 
by  the  numerous  subsequent  experiments  in  support  of  the  doctrine  of 
immutability  of  the  varieties  of  the  parasite  there  can  be  little  doubt 
that  this  later  opinion  of  Gualdi  and  Antolisei  is  correct.  It  has  been 
found  regularly  since  these  experiments  that  if  blood  containing  only 
the  tertian  or  the  quartan  or  the  sestivo-autumnal  parasite  be  injected 
intravenously  into  a  person  unaifected  with  malaria,  the  variety  of  para- 
site injected,  and  only  that  variety,  appears  in  the  blood  of  the  experi- 
mental case.  When  two  varieties  of  jDarasite  are  injected,  or  when  the 
malarial  blood  is  injected  into  a  patient  already  affected  with  a  malarial 
organism  other  than  that  injected,  then  it  usually  happens  that  one 
variety  supplants  the  other,  most  frequently  the  one  injected  supplanting 
that  already  existing  in  the  inoculated  individual.  For  such  displace- 
ment of  one  organism  by  another  we  have  numerous  examples  in  bacte- 
rial infections. 

The  bearing  of  the  inoculation  experiments  upon  the  determination 
of  the  periods  of  incubation  of  malaria  will  be  considered  in  the  clinical 
part  of  this  article  (pages  97,  98). 

These  already  numerous  inoculation  experiments,  showing  the  iden- 
tity of  the  parasite  in  the  experimental  case  with  that  in  the  blood  used 
for  injection,  furnish  the  strongest  existing  arguments  in  favor  of  the 
plurality  of  the  malarial  parasites.^ 

Whether,  accepting  this  doctrine,  we   shall  designate  the  different 

^  Di  Mattel :  "Contributo  alio  Studio  della  Infezione  Malarica  Sperimentale  nell' 
Uomo  e  negli  Animali,"  Ai-ch.  per  le  Scienze  Mediche,  vol.  xLx.  N.  4,  1895. 


PARASITOLOGY.  35 

types  of  the  malarial  organism  as  separate  species  or  separate  varieties 
is  with  our  j)r('s(Mit  knowledge  a  matter  ot"  secondary  iin])()rtance  and  of 
individual  judgment.  If  it  be  admitted  that  under  no  existing  circum- 
stances one  type  is  transformed  into  another,  then  we  are  jvistified  in 
speaking  of  separate  species  of  malarial  })arasites.  As  at  present  w^e  can 
study  only  a  small  part  of  the  conditions  which  surround  the  entire  life- 
historv  of  the  parasite,  it  seems  to  the  writer  preferable  to  designate  the 
different  types  as  yarieties  rather  than  species. 

Classification. 

We  have  already  had  occasion  repeatedly  to  mention  the  division  of 
the  malarial  parasites  into  three  principal  varieties — the  quartan,  the 
tertian,  and  the  ajstivo-autumnal.  No  further  subdiyision  of  the  quar- 
tan variety  has  ever  been  suggested.  Nor  has  any  attempt  been  made 
to  subdivide  the  tertian  parasite  originally  described  by  Golgi ;  but,  as 
it  has  since  been  found  that  the  sestivo-autumnal  parasite — or,  according 
to  some  observers,  one  form  of  this  parasite — may  likewise  produce  tertian 
fever,  the  latter  form  of  the  sestivo-autumnal  organism  is  designated  by 
Marchiafava  and  Bignami  as  malignant  tertian  or  sestivo-autumnal  (sum- 
mer-autumn) tertian,  and  the  former  is  called  mild  or  vernal  (spring)  or 
genuine  tertian  or  Golgi's  tertian  parasite.  This  so-called  sestivo-autum- 
nal or  malignant  tertian  is,  however,  in  no  sense  a  subdivision  of  the 
tertian  parasite  originally  described  by  Golgi,  wdiich  remains  a  well- 
diiferentiated,  separate  variety.  When  the  name  "  tertian  organism  " 
is  used  without  any  epithet,  it  is  always  this  variety  wdiich  is  meant. 

The  name  "  parasite  of  sestivo-autumnal  fever,"  introduced  by  March- 
iafava and  Celli  and  already  adopted  by  many  writers,  leaves  much  to 
be  desired.  It  is  intended  to  indicate  that  this  form  of  the  parasite  is 
the  cause  of  the  malarial  fevers  prevailing  in  summer  and  autumn.  This 
application,  however,  is  correct  only  for  certain  localities,  chiefly  those 
warmer  regions  where  severe  as  well  as  mild  types  of  malaria  occur.  In 
localities  where  the  prevailing  type  of  the  disease  is  mild  at  all  seasons 
the  summer  and  autumn  malarial  fevers  are  caused  generally  or  exclu- 
sively by  tertian  or  quartan  parasites.  Even  in  the  warmer  situations 
where  the  sestivo-autiminal  parasite  is  common,  not  all  of  the  summer- 
autumn  fevers  are  caused  by  this  parasite,  but  often  a  large  proportion 
are  caused  by  the  ordinary  tertian  parasites.  In  subtropical  and  tropical 
regions  the  sestivo-autumnal  parasites  may  occur  in  winter  and  spring- 
fevers.  It  is  evident  that  the  epithet  "  sestivo-autumnal,"  as  applied  to 
a  special  variety  of  malarial  parasite,  is  sufficiently  designative  for  many 
localities,  as,  for  example,  the  southern  parts  of  the  United  States  and 
Central  and  Southern  Italy,  but  it  is  not  so  for  all. 

The  term  "parasite  of  sestivo-autumnal  fever"  does  not  at  once  sug- 
gest the  relation  of  the  parasite  to  a  definite  type  of  malarial  fever,  and  is 
therefore  out  of  harmony  with  the  designations  "  parasite  of  quartan  fever" 
and  "  parasite  of  tertian  fever."  But  it  is  characteristic  of  a  large  pro- 
portion of  the  fevers  caused  by  sestivo-autumnal  organisms  that  they  do 
not  correspond  to  any  definite  type,  but  are  notably  irregular.  Hence 
these  organisms  were  designated  by  Golgi  and  by  Sacharoff  as  the  "  para- 
site of  irregular  malarial  fevers."    But  the  objection  to  this  latter  name  is 


36  MALARIA. 

that  sestivo-autumnal  organisms  may  cause  typical  quotidian  and  tertian 
fevers.  Indeed,  this  is  the  only  form  of  malarial  parasite  which,  it  is 
believed,  may  complete  its  cycle  of  development  in  twenty-four  hours, 
and  thus  when  present  in  only  a  single  group  or  generation  may  cause 
quotidian  fever. 

As  leading  characters  of  the  sestivo-autumnal  organisms  are  their 
small  size,  their  slight  formation  of  pigment,  and  the  ring-like  shape  of 
the  amoeboid  forms,  they  are  sometimes  spoken  of  as  the  small  malarial 
organisms  (forme  picco/e),  or  the  unpigmented,  colorless,  or  slightly  pig- 
mented organisms,  or  the  ring-like,  annular  organisms.  They  are  also 
called  the  organisms  of  grave  or  pernicious  malaria,  although  they  may 
likewise  cause  mild  types  of  the  disease. 

As  it  is  to  the  group  of  gestivo-autumnal  parasites  that  the  crescents 
exclusively  belong,  these  parasites  have  been  described  as  the  semi- 
lunar variety.  Tliey  may  be  designated  as  crescent  -  producing. 
Hsematozo5n  falciparum  is  suggested  by  the  writer  as  a  suita,ble  techni- 
cal name  for  this  variety  of  parasite.^ 

The  three  varieties  of  the  malarial  parasite  may  therefore  be  tech- 
nically designated — (1)  Hcemafozoon  febris  quartance  ;  (2)  Hcematozobn 
febris  tertiance ;  (3)  Hcematozodn  malarice  falciparum.  The  name 
sestivo-autumnal  parasite,  as  the  more  commonly  used  and  generally 
understood  designation,  will,  however,  continue  to  be  used,  as  well  as 
the  term  "  Hsematozoon  falciparum,"  in  this  article  for  the  last-named 
variety. 

There  is  no  difference  of  opinion,  except  among  the  unicists,  that  the 
gestivo-autumnal  organisms  form  a  variety  or  group  which  is  to  be  differ- 
entiated from  both  the  quartan  and  the  tertian  organisms  even  more 
sharply  than  the  tertian  and  the  quartan  are  differentiated  from  each  other. 
But  the  question  as  to  the  unity  or  the  plurality  of  the  sestivo-autumnal 
organisms  is  still  an  open  one,  and  is  the  most  important  unsolved 
problem  relating  to  the  divisions  of  malarial  parasites.  Its  solution  is 
attended  with  unusual  difficulties,  but  we  may  reasonably  expect  that 
they  will  be  surmounted  by  future  investigations. 

In  distinction  from  the  quartan  and  the  tertian  organisms  the  aestivo- 
autumnal  are  often  irregular  and  atypical  in  their  cycle  of  development. 
Some,  it  is  believed,  may  complete  their  cycle  in  twenty-four  hours, 
others  in  forty-eight  or  a  longer  period  :  their  tendency  to  develop 
simultaneously  in  well-defined  generations  is  far  less  marked  than  is  the 
case  with  tertian  and  quartan  organisms,  so  that  several  or  all  phases 
of  development  of  sestivo-autumnal  forms  may  be  observed  in  the  inter- 
nal organs  at  the  same  time.  The  occurrence  of  multiple  groups  of  the 
parasite  is  common.  Forms  appear  which  pass  through  their  amoeboid, 
mature,  and  segmenting  phases  without  any  formation  of  pigment  within 
the  parasite.  The  development  takes  place  largely  in  the  internal 
organs.     The  development  of  crescents  occurs  at  a  variable  period  after 

1  The  name  Hsematozoon  falciforme  suggested  by  Antolisei  and  Angelini  is  objection- 
able, as  it  implies  that  the  shape  is  always  falciform,  and  is  applicable  only  to  the  cres- 
centic  forms.  The  adjective  "falciparum"  (falx,  ".sickle,"  parire,  "to  bring  forth," 
"to  produce"),  on  the  other  hand,  indicates  that  the  property  of  forming  crescents  is 
a  distinctive  character  of  the  organism,  and  it  is  therefore  applicable  to  the  variety  of  the 
parasite  which  possesses  exclusively  this  property. 


PARASITOLOGY.  37 

the  Diiset  of  the  disease,  but  nirely  in  less  than  a  week.  Correspondintr 
to  these  variations  and  irregularities  the  types  of  fever  with  which 
nestivo-autunmal   oro-anisms  are  associated   are  various   and    irregular. 

The  attempt  has  been  made  to  deduce  certain  laws  controlling  these 
variations  and  ap|)arent  irregularities,  and  to  subdivide  the  sestivo- 
autumnal  organisms  into  certain  varieties  or  snbvarietics,  but  there  is 
little  agreement  of  o])inion  as  to  this  subdivision. 

The  ft)llowing  are  the  principal  divisions  of  the  malarial  parasite 
which  have  been  proposed,  the  essential  diiferences  in  these  various 
divisions  relating,  of  course,  to  the  different  views  held  concerning 
the  a?stivo-autumnal  organisms  : 

I.  Marchiafava  and  Celli  (1889)  recognized  a  short  cycle  of  develop- 
ment of  the  nestivo-autumnal  parasite,  unaccompanied  by  development 
of  pigment,  and  a  longer  cycle  with  formation  of  a  few  pigment  granules. 
Marchiafava  and  Bignami  (1891)  make  two  varieties  of  this  parasite — 
viz.  the  amoeba  of  aestivo-autumnal  quotidian,  with  a  twenty-four-hour 
cycle,  and  the  amoeba  of  sestivo-autumnal  tertian,  with  a  forty-eight- 
hour  cycle — Amoeba  febris  quotidianm  and  Amoeba  febris  tertiance  oestivo- 
autumnalis.  The  latter  variety  is  the  malignant  tertian  organism  of 
these  authors.  The  main  diiferences  between  these  varieties,  according 
to  Marchiafava  and  Bignami,  relate  to  the  length  of  the  cycle  of 
development,  but  there  are  claimed  to  be  also  minor  morphological  and 
biological  differences  to  be  mentioned  subsequently  (page  51). 

These  authors,  therefore,  make  four  different  varieties  of  the  malarial 
parasite.     They  divide  the  malarial  fevers  into  two  main  groups : 

1.  Mild  malarial  fevers  which  prevail  in  winter  and  spring.  These 
are — 

(a)  Quartan  fever  (with  its  varieties  of  double  and  triple  quartan). 
This  is  caused  by  the  Amoeba  febris  quaMance  (Golgi),  which  completes 
its  life  cycle  in  seventy-two  hours. 

(6)  Tertian  fever  (with  double  tertian  and  rarely  certain  subcontinued 
fevers).  This  is  caused  by  the  Amoeba  febris  tertiance  (Golgi),  which 
completes  its  life  cycle  in  forty-eight  hours. 

2.  Severe  or  sestivo-autumnal  fevers,  including  the  pernicious  and 
most  of  the  subcontinued  fevers.     This  group  comprises — 

(a)  ^Estivo-autumnal  quotidian  fever  (to  be  distinguished  from  quo- 
tidians of  tertian  and  of  quartan  origin),  caused  by  the  Amoeba  febris 
quotidiance,  which  completes  its  cycle  in  twenty-four  hours.  This  is 
the  only  variety  of  malarial  parasite  Avhich  can  complete  its  life  cycle 
in  so  short  a  period  as  twenty-four  hours. 

(b)  ^stivo-autumnal  or  malignant  tertian  fever,  caused  by  the 
Amoeba  febris  tertiance  cestivo-autumnalis,  which  completes  its  cycle  in 
forty-eight  hours.  Most  of  the  pernicious  cases  belong  to  this  variety, 
the  remainder  to  the  sestivo-autumnal  quotidian  variety. 

II.  Canalis  (1889)  does  not  subdivide  into  varieties  the  sestivo- 
autumnal  parasite,  which  he  calls  the  ''  semilunar  variety,"  but  he  con- 
siders that  it  has  two  cycles  of  development :  (o)  a  rapid  cycle  with  the 
usual  phases  of  amoeboid,  mature,  segmenting  forms  and  spores,  and 
(6)  a  slower  cycle  associated  with  the  development  of  crescentic  bodies, 
which  he  considers  to  be  reproductive  and  to  represent  one  phase  in  this 
second  cycle.     A  similar  view  is  held  bv  Antolisei  and  Angelini. 


38  MALARIA. 

III.  Grassi  and  Feletti  (1890)  regard  the  crescent-producing  forms 
as  an  entirely  separate  species,  which  they  call  Laverania  malarice,  and 
which  they  distinguish  both  from  the  directly  spore-forming  unpig- 
mented  aestivo-autumnal  forms,  which  they  call  Hcemamceba  immacidata, 
and  from  similar  rapidly  developing,  but  pigmented,  aestivo-autumnal 
parasites,  without  crescents,  which  they  call  Hcemamceba  prceeox.  Their 
classification  of  the  malarial  parasite  is  as  follows :  (a)  Hcemamceba 
malarice,  identical  with  the  cpiartan  parasite ;  (6)  Hcemamceba  vivax, 
which  is  identical  with  the  tertian  parasite  of  Golgi ;  (e)  Hcemamceba 
prceeox,  a  form  of  the  sestivo-autumnal  parasite,  giving  rise  to  quotidian 
fever ;  (d)  Hcemamceba  immaculata,  similar  to  the  preceding,  but  without 
development  of  pigment ;  (e)  Laverania  malarice,  the  crescent-producing 
variety,  giving  rise  to  irregular  fevers. 

Sacharoff  formerly  regarded  the  crescents  as  belonging  to  a  separate 
species  of  malarial  parasite,  and  adopted  the  following  classification : 
(a)  Hcemamceba  febris  quartance  (Golgi),  (b)  Hcemcimceba  febris  tertiance 
(Golgi),  (e)  Hcemamceba  prceeox  (Grassi),  {d)  Laverania  (Grassi).  Re- 
cently (1896)  he  holds  that  all  variations  of  the  sestivo-autumnal  para- 
site are  modifications  of  a  single  variety  due,  mainly,  to  the  development 
of  the  parasite  within  nucleated  red  blood-corpuscles. 

IV.  Mannaberg  (1893)  accepts  Marchiafava  and  Bignami's  division 
of  sestivo-autumnal  parasites  into  quotidian  and  tertian,  and  also  adopts 
Grassi  and  Feletti's  division  into  pigmented  and  unpigmented  quotidian 
parasites.  He  does  not,  however,  consider  the  crescents  as  belonging  to 
a  species  or  variety  distinct  from  these,  but  considers  them  as  developing 
from  each  of  these  three  divisions  of  sestivo-autumnal  parasites.  He  has 
a  peculiar  view  as  to  the  origin  of  the  crescents  from  conjugation  of 
cells,  and  regards  them,  therefore,  as  forms  of  syzygia.  He  divides  the 
malarial  parasites  into  two  groups — the  first  group,  yviih  sporulation  and 
without  syzygia,  comprising  (a)  the  quartan  and  (6)  the  tertian  parasites 
of  Golgi ;  the  second  group,  with  sporulation  and  with  syzygia,  com- 
prising («)  the  pigmented  quotidian  parasite,  (6)  the  unpigmented  quo- 
tidian parasite,  and  (c)  the  malignant  tertian  parasite. 

V.  Golgi  (1893),  an  admirable  and  successful  investigator  of  the 
malarial  parasites,  does  not  consider  the  semilunar  forms  as  belonging 
to  a  species  or  variety  distinct  from  the  ordinary  sporulating  sestivo- 
autumnal  parasite.  He  attempts  no  subdivision  of  the  sestivo-autumnal 
parasite.  His  conception  of  the  mode  of  development  of  this  parasite 
differs  in  essential  points  from  that  of  Marchiafava  and  Bignami  and 
of  most  other  investigators,  as  will  be  explained  in  considering  the 
special  characters  of  the  sestivo-autumnal  parasite. 

The  following  statement  of  Golgi\s  classification  of  the  malarial 
fevers  is  quoted  from  Thayer  and  Hewetson's  work  on  The  3Ialarial 
Fevers  of  Bcdtimore,  already  cited. ^  Golgi  divides  the  malarial  fevers 
into  two  groups : 

(1)  Fevers  the  j)athogenesis  of  which  is  connected  with  parasites 
which  have  their  principal  habitat  in  the  circulating  blood,  where,  by 
preference,  they  accomjjlish  the  phases  of  their  cycle  of  existence. 

(2)  Fevers  the  pathogenesis  of  which  is  connected  with  parasites 

^  The  writer  wistes  to  acknowledge  his  indebtedness  to  this  excellent  monograph  for 
much  valuable  assistance  in  the  preparation  of  this  article. 


PARASITOLOGY.  39 

which  have  their  chief  scats  in  the  internal  organs,  particiihirlv  tlie 
bone  marrow  and  the  spleen,  where,  l)y  preference,  they  accom])Iish  tlieir 
cycle  of  existence  in  conditions  of  relative  stability. 

(1)  The  fevers  of  the  first  g-ronp  are  unqnestionably  associated  with 
different  species  or  varieties  of  the  parasit( — viz.  (d)  the  <|uartan  ])ara- 
site  ;  (/>)  the  tertian  parasite. 

(2)  "  To  the  second  group  belong  the  fevers  which  appear  clinieallv 
under  niultiforni  types,  very  often  irregular,  of  which  for  the  present  it 
is  impossible  to  make  a  grouping  based  upon  an  ascertained  biology  or 

cycle  of  development  of  the  parasite We  are  dealing  in  these 

cases  with  generations  of  parasites  which,  occurring  in  the  parenchyma 
of  organs  in  different  stages  of  development,  give  origin,  at  periods  of  a 
certain  regularity  or  in  a  more  or  less  continuous  succession,  to  colonies 
of  young  forms  which,  in  large  or  small  numbers  or  in  insignificant 
quantity,  may  escape  into  the  blood  current,  permitting  one  to  discover 
by  microscopical  examination  of  the  blood  the  presence  of  the  small 
endoglobular  amoebae."  Golgi  refers  to  the  crescents  as  "  forms  the  biol- 
ogy of  which  has  not  yet  been  well  determined." 

VI.  Thayer  and  Hewetson  (1895)  were  likewise  unable  to  confirm 
Marchiafava  and  Bignami's  subdivision  of  the  sestivo-autumnal  parasite 
into  a  quotidian  and  a  tertian  variety.  They  say:  "  We  have  been 
unable  to  trace  a  constant  length  of  the  cycle  of  development,  and  we 
have  been  unable  further  to  separate  two  or  more  types  of  the  [aestivo- 
autumnal]  parasite  depending  either  upon  the  length  of  the  cycle  of 
development  or  upon  any  other  morphological  or  biological  differences. 
We  believe  that  the  length  of  the  cycle  varies  greatly  in  different  cases, 
lasting  usually  from  twenty-four  hours,  or  even  a  little  less,  to  forty- 
eight  hours  or  more.  After  the  infection  is  five  days  or  a  week  old 
certain  of  the  organisms,  instead  of  segmenting,  pursue  a  further 
growth,  developing  into  the  hyaline,  refractive,  ovoid,  and  crescentic 
bodies."  They  do  not  feel  justified  in  making  any  positive  statement  as 
to  the  significance  or  capacity  of  reproductive  development  of  the 
crescentic  bodies. 

The  question  has  been  raised  whether  in  tropical  regions,  where  per- 
nicious types  of  malaria  are  common,  any  form  of  malarial  parasite 
different  from  those  already  mentioned  occurs.  The  observations  of 
Van  Dyke  Carter,  Dock,  van  der  Scheer,  Plehn,  and  others  show  that 
the  same  parasites  are  found  in  India,  Panama,  Java,  and  other  tropical 
countries  as  elsewhere.  The  negative  reports  which  have  been  published 
are  referable  doubtless  to  insufficient  training  in  such  examinations  on 
the  part  of  the  observers.  The  fact  that  a  large  part  of  the  tropical 
malarial  fevers  are  caused  by  sestivo-autumnal  organisms  which  appear 
in  the  red  blood-corpuscles  as  small,  pale,  feebly-staining,  delicate^ 
diaphanous,  often  unpigmented  amoeboid  rings  of  hyaline  protoplasm, 
difficult  to  detect  in  many  cases,  and  sometimes  scanty  or  at  times  even 
absent,  will  account  for  many  of  these  negative  observations. 

The  singular  distribution  of  the  haemoglobinuric  type  of  pernicious 
malarial  fevers  in  certain  definite  localities  suggests  the  possibility  that 
tliis  may  be  caused  by  a  special  type  of  organism.  The  sporadic  cases 
of  malarial  hemoglobinuria  examined  in  Italy  have  shown,  however, 


40  MALARIA. 

ordinary  sestivo-autiimnal  organisms.  Plelm  ^  found  in  cases  of  black- 
water  fever  occurring  on  the  West  Coast  of  Africa  small,  annular  amoe- 
boid forms,  staining  with  great  difficulty  and  never  pigmented,  in  the 
red  blood-corpuscles.  "  Out  of  the  amoeba  there  develops  by  thickening 
of  the  peripheral  zone  an  oval  or  egg-shaped  body,  with  well-staining 
double  contour.  In  course  of  time  this  divides  into  five  or  six  small 
oval  forms,  staining  at  one  pole,  which,  when  they  are  set  free,  move 
about  with  great  rapidity  in  the  blood.  These  probably  develop  into 
the  amoeboid  forms."  The  organism  never  attained  a  size  larger  than 
one  quarter  of  the  red  blood-corpuscle.  Crescents  were  occasionally 
found.  Plehn  seems  to  regard  this  organism  as  allied  to,  but  not  iden- 
tical with,  the  sestivo-autumnal  parasite  described  by  Italian  writers. 
Although  his  description  presents  certain  peculiarities  of  the  parasite 
which  he  observed  in  the  pernicious  malarial  hsemoglobinuria  and  other 
pernicious  fevers  of  the  West  Coast  of  Africa,  especially  the  constant 
absence  of  pigment,  the  extremely  small  size,  the  sporulation  in  the 
blood,  and  the  apparently  motile  spores,^  nevertheless  it  is  not  suffici- 
ently complete  and  satisfactory  to  justify  the  inference  that  the  organ- 
ism differs  from  forms  of  the  ordinary  sestivo-autumnal  parasite  as 
previously  observed. 

From  the  preceding  review  of  the  various  investigations  and  opinions 
concerning  the  divisions  or  varieties  of  the  malarial  parasite,  especially 
of  the  sestivo-autumnal  form,  we  may  draw  the  conclusion  that  whereas 
the  separation  into  quartan,  tertian,  and  eestivo-autumnal  varieties  rests 
upon  a  sound  basis  of  fact,  the  various  attempts  to  further  subdivide  the 
£estivo-  autumnal  group  have  not  as  yet  been  sufficiently  successful  to  jus- 
tify our  acceptance  at  the  present  time  of  any  of  these  subdivisions.  There 
is,  however,  some  reason  to  believe  that  this  last  group,  as  at  present 
constituted,  may  comprise  varieties  which  will  hereafter  be  satisfactorily 
differentiated  from  each  other. 

We  will  now  consider  the  special  characters  of  each  of  the  three 
varieties  of  the  malarial  parasite. 

I.  The    Parasite   of    Quartan    Fever    (H^matozoon    Ferris 
Quartans)  (Plate  I.  Figs.  25-42). 

In  most  malarial  regions  this  is  the  rarest  form  of  the  malarial 
parasite,  but  there  are  certain  places  (none  of  these  have  been  recog- 
nized in  this  country)  where  it  is  the  prevailing  variety.  Being  par- 
ticularly common  in  the  neighborhood  of  Pavia  in  Italy,  the  quartan 
parasite  was  the  first  to  be  differentiated  and  described  by  Golgi  (1885- 
86),  to  whose  masterly  description  nothing  of  essential  importance  has 
been  added  by  subsequent  investigators,  with  the  exception  of  certain 
details  of  intimate  structure. 

The  quartan  parasite  completes  its  cycle  of  development  in  seventy- 
two  hours  and  entirely  within  the  circulating  blood.  The  youngest  forms 
of  the  parasite  are  small,  amoeboid,  when  at  rest  discoidal,  hyaline  bodies, 

^  Plehn  :  "  Ueber  das  Schwarzwasserfieber  an  der  afrikanischen  Westkiiste,"  Deutsche 
med.   Wochensehrift,  1895,  Nos.  25,  26,  27. 

^  It  may  here  be  mentioned  that  Plehn  considers  that  the  spores  of  all  varieties  of 
the  malarial  parasite  are  flagellated — a  view  which  has  not  been  confirmed  by  other 
observers. 


PARASITOLOGY.  41 

within  the  red  l)l()<»(l-c'orj)usc'lc'.s.  They  are  about  one-fifth  to  one-fourth 
tlie  si/e  of  the  red  hlood-corpusele  (PUite  I.  Fig.  2G).  The  central  part 
of  the  l)()dv  may  appear  paler  than  the  ])eripheral.  These  unpigniented, 
youngest  forms  are  found  during  and  for  several  hoursafter  the  paroxysm  ; 
they  may  begin  to  aj)pear  two  hours  i)efore  the  paroxysm.  The  very  ear- 
liest forms  are  not  to  be  distinguished  from  the  youngest  tertian  parasites, 
but  as  they  begin  to  develop  they  present  a  sharper  outline  and  somewhat 
more  refractive  a])pea ranee,  and  their  amoeboid  movements  are  more  slug- 
gish and  restricted  than  those  of  the  corresponding  stages  of  tlie  tertian 
ori>anism.  These  movements  become  more  active  on  the  warm  staw  of 
the  microscope.  The  presence  of  more  than  one  parasite  in  a  red  blood- 
corpuscle  is  sometimes  observed. 

Shortly,  or  within  twelve  to  eighteen  hours,  after  the  paroxysm  pig- 
ment granules  appear  within  these  hyaline  bodies,  which  continue  to 
increase  slowly  in  size,  and  for  a  while  to  exhibit  lazy  amceboid  move- 
ments (Plate  I.  Figs.  27,  28,  29).  The  pigment  appears  in  the  form  of 
brow'nish  or  black  rods  and  grains,  which  are  coarser  and  darker  than 
those  seen  in  tertian  parasites.  The  rod  form  of  pigment  is  less  common 
than  in  the  tertian  organism.  These  pigment  granules  are  arranged 
generally  in  the  peripheral  part  of  the  parasite,  and  they  present  only  a 
sluggish  uKjvement  in  comparison  with  the  active  motion  of  the  pigment 
in  the  tertian  parasite.  With  the  gradual  increase  in  size  of  the  hyaline 
bodies  and  in  the  amount  of  contained  pigment  the  red  blood-corpuscles 
enclosing  them  may  appear  unchanged,  or  often  they  become  a  little 
smaller,  more  refractive,  and  deeper  in  color,  which  may  be  somewhat 
greenish  or  coppery  in  tint  (Plate  I.  Figs.  28,  29).  There  is  not  that 
tendency  to  decolorization  and  swelling  of  the  infected  red  blood-cor- 
puscles which  is  noticed  in  the  case  of  the  tertian  parasite,  although  in 
the  more  advanced  stages  of  development  there  is  usually  some  loss  of 
color  in  red  corpuscles  containing  quartan  organisms. 

In  the  process  of  development  the  amoeboid  movements  cease,  and 
the  parasite  appears  as  a  quiescent,  pigmented,  spherical,  or  ovoid  body 
occupying  perhaps  one-half  to  two-thirds  of  the  red  corpuscle  (Plate  I. 
Figs.  30,  31).  Such  bodies  are  usually  seen  within  forty-eight  hours 
after  the  paroxysm.  These  bodies  continue  to  grow,  and  when  they  have 
reached  their  full  development  in  sixty  to  seventy  hours  after  the  parox- 
ysm they  are  somewhat  smaller  than  the  normal  red  blood-corpuscles. 
These  full-grown  forms  are  spherical  or  ovoid,  refractive,  hyaline  bodies, 
with  nearly  or  quite  motionless  dark  pigment  granules  of  variable  size, 
but  coarser  than  in  the  tertian  parasite,  and  with  a  tendency  to  periph- 
eral arrangement,  but  at  times  irregularly  distributed.  Around  these 
bodies  a  thin  layer  of  the  colored,  refractive  substance  of  the  red  blood- 
corpuscle  can  usually  still  be  seen  (Plate  I.  Figs.  32,  33,  34),  or  the 
haemoglobin  may  be  entirely  removed,  so  that  only  a  delicate,  thin,  color- 
less rim  or  line  surrounding  the  parasite  is  all  that  is  left  of  the  original 
red  blood-corpuscle.  In  unstained  specimens  these  latter  forms  often 
appear  to  be  free  in  the  plasma  (Plate  I.  Fig.  35),  and  are  sometimes 
spoken  of  as  free  bodies,  which  may  also  occur. 

In  six  or  eight  to  ten  hours  before  the  febrile  paroxysm  the  first 
phases  of  reproduction  begin  to  appear.  These  are  ushered  in  by  the 
gradual  withdrawal  of  the  pigment  from  the  periphery  toward  the  centre 


42  MALABIA. 

of  the  body.  The  pigment  in  this  process  is  often  arranged  in  definite 
radial  strise  (Plate  I.  Fig.  36).  Such  regular  stellate  arrangements  of 
the  pigment  as  are  seen  in  this  stage  of  the  quartan  parasite  are  rarely, 
if  ever,  observed  in  the  tertian  (Thayer  and  Hewetson).  Finally  the 
pigment  is  concentrated  into  a  central  mass  of  granules  or  a  solid  block 
of  coalesced  pigment,  less  frequently  into  two  or  more  collections,  and 
the  organisms  assume  a  somewhat  more  refractive  and  slightly  granular 
appearance. 

At  the  same  time  or  soon  afterward  radial  divisional  striae  begin  to 
appear  in  the  periphery  (Plate  I.  Fig.  37),  and  quickly  extend  to  the 
central  part  of  the  parasite,  whereby  the  substance  of  the  spherical 
organism  becomes  divided  into  six  to  twelve  ovoid  or  pear-shaped  seg- 
ments arranged  with  characteristic  and  exquisite  regularity  around  the 
central  mass  of  pigment  like  the  petals  of  a  daisy  (rosettes  of  Golgi) 
(Plate  I.  Fig.  38).  In  each  of  the  segments  can  be  seen  a  small  round 
glistening  body  which  represents  the  nucleus  or  nuclear  material.  The 
pyriform  segments  assume  rapidly  a  round  or  oval  shape,  and  become 
separated  from  the  central  mass  and  from  each  other.  The  delicate 
enveloping  membrane,  which  may  not  be  recognized  on  unstained  speci- 
mens, derived  from  the  red  blood-corpuscle  ruptures,  or  it  may  previ- 
ously have  disappeared,  and  the  small  round  or  oval  bodies,  each  pro- 
vided with  a  bright  nucleiform  dot,  are  set  free  in  the  plasma  (Plate  I. 
Fig.  39).  These  bodies  are  the  so-called  spores.  Simultaneously  with 
this  process  of  sporulation  young  amoeboid  hyaline  bodies,  formed  di- 
rectly from  the  spores,  make  their  appearance  in  the  red  blood-corpus- 
cles, and  the  cycle  of  development  is  completed  and  another  cycle  is 
begun. 

Segmenting  or  sporulating  forms  of  the  parasite  may  appear  six  or 
eight  hours  before  the  paroxysm,  and  are  most  abundant  shortly  before 
and  during  the  onset  of  the  paroxysm.  It  is  of  course  not  to  be  under- 
stood that  all  of  the  parasites  of  one  group  pass  through  their  develop- 
mental phases  and  mature  at  exactly  the  same  moment.  One  parasite 
of  the  group  may  be  several  hours  in  advance  of  another,  but  this  does 
not  interfere  with  the  recognition  of  distinct  groups  or  generations,  each 
standing  in  definite  relation  to  a  paroxysm,  or  with  the  establishment  of 
Golgi' s  law  that  the  onset  of  each  paroxysm  corresponds  to  the  matura- 
tion of  one  group  of  organisms. 

The  cycle  of  development  of  the  quartan  parasite  is  attended  with 
fewer  irregularities  than  that  of  any  other  variety  of  the  malarial  para- 
site. Nevertheless,  certain  irregularities  may  occur.  As  pointed  out 
by  Antolisei,  segmentation  may  occur  exceptionally  in  pigmented  bodies 
considerably  smaller  than  the  usual  full-grown  forms,  containing  less 
pigment  and  filling  only  a  part  of  the  red  blood-corpuscle.  Here  the 
segments  do  not  usually  exceed  four  to  six  or  eight.  The  accumulation 
of  pigment  in  the  segmenting  forms  may  be  peripheral,  or  distributed 
between  the  spores,  or  otherwise  irregular. 

As  the  quartan  parasite  completes  its  development  entirely  within 
the  circulating  blood,  there  is  no  appreciable  difference  at  any  stage 
between  the  splenic  and  the  peripheral  blood  as  regards  the  number  and 
variety  of  the  parasitic  forms  observed.  Moreover,  segmenting  forms 
of  the  quartan  parasite  are  often  seen  in  small  number  in  the  blood  at  a 


PARASITOLOGY.  43 

periotl  bcfort'  the  total  nunibor  of  organisms  is  siifficiontly  larfje  to  pro- 
duce by  their  ripening-  a  paroxysm,  whereas  se<>;nientin<^  tertian  parasites 
are  very  rarely  seen  in  the  peri])heral  blood  witiiont  the  occurrence  of  a 
paroxysm  in  relation  to  the  se_t;incntin<>;  forms. 

Not  all  of  the  mature  forms  proceed  to  sporulatiou.  Some,  especially 
those  which  may  have  escaped  from  the  red  corpuscles,  swell  uj),  l)ecome 
transj)arent  and  larger  than  a  red  blood-corpuscle,  and  j)resent  irregu- 
larly distributed  and  actively  moving  pigment  granules  (Plate  I.  Fig.  40). 
These  swollen,  hydropic  forms  are  probably  sterile.  It  can  often  be 
seen  in  examining  these  bodies  in  fresh  blood  that  the  pigment  becomes 
quiescent,  the  outlines  of  the  body  become  irregular  and  indistinct,  and 
evidently  cadaveric  forms  result.  Or  these  bodies  may  break  up  into  a 
number  of  fragments  which  become  misshapen  and  indistinct,  or  the 
whole  body  may  become  vacuolated,  as  is  represented  in  Plate  I.  Fig.  42. 
Bodies  more  or  less  resembling  spores,  but  without  the  nuclear  structure 
of  spores,  may  appear  in  these  vacuoles. 

As  may  occur  with  any  variety  of  the  malarial  parasite,  the  mature 
forms  of  the  quartan  parasite,  instead  of  sporulating^  may  develop  into 
flagellate  bodies  in  the  manner  already  described.  These  bodies  are 
smaller  and  contain  coarser  pigment  than  the  flagellate  forms  of  the 
tertian  parasite.  (Compare  Plate  I.  Fig.  41  and  Plate  I.  Fig.  22.)  De- 
generated and  flagellate  forms  are  less  common  in  quartan  than  in 
tertian  infections. 

Not  only  may  mature  forms  degenerate  in  the  ways  described,  but 
forms  in  earlier  stages  of  development  may  be  liberated  from  the  red 
corpuscles  and  likewise  degenerate. 

The  phenomena  of  phagocytosis  are  observed  with  regularity  during 
and  for  some  hours  after  the  paroxysm  in  quartan  as  well  as  in  other 
malarial  infections.  The  pigment  set  free  by  the  process  of  sporulation 
is  taken  up  by  phagocytes.  Extracorpuscular  organisms,  particularly 
the  various  degenerated  forms,  are  engulfed  by  phagocytes.  The  assault 
on  the  flagellate  bodies  by  leucocytes  can  be  watched  with  interest  on 
the  slide  of  fresh  blood.  The  leucocytes  can  also  be  seen  to  take  up 
segmenting  bodies  and  spores  when  the  specimen  of  blood  is  kept  for  a 
while.  The  details  and  the  significance  of  these  phagocytic  phenomena 
will  be  considered  subsequently  (page  65). 

The  intimate  structure  of  the  quartan  and  other  malarial  parasites, 
as  revealed  by  methods  of  staining,  will  also  be  described  subsequently. 

Two  or  more  groups  of  quartan  parasites  are  often  present  in  the 
blood  at  the  same  time,  causing  double  and  triple  quartan  infections. 
On  account  of  the  regularity  in  the  development  of  the  quartan  para- 
site, anticipating,  retarding,  and  irregular  fevers  are  less  common  in 
quartan  than  in  the  other  malarial  infections.  Careful  examination  of 
the  blood  enables  the  observer  to  recognize  the  presence  of  two  or  more 
groups  of  the  parasite  by  noting  the  simultaneous  occurrence  of  bodies 
in  noticeably  different  stages  of  development ;  as,  for  example,  during 
the  paroxysm  the  association  of  segmenting  and  young  hyaline  bodies 
with  half-grown  pigmented  bodies. 


44  3IALABIA. 

II.  The    Parasite    of    Tertian    Fever   (HiEMATOZOON  Febris 
Tertians)  (Plate  I.  Figs.  1-24). 

This  variety  of  the  malarial  parasite  is  common  in  most  malarial 
regions.  Where  only  mild  types  of  malaria  occur  it  is,  as  a  rule,  the 
prevailing,  and  sometimes  the  sole,  variety  observed.  The  tertian  and 
the  quartan  parasites  cause  most,  or  in  some  places  all,  of  the  winter 
and  spring  intermittents,  but  they,  and  especially  the  tertian  parasite, 
may  cause  in  districts  of  even  severe  malaria  not  a  few  of  the  malarial 
fevers  of  summer  and  autumn,  although  the  more  severe  and  irregular 
of  these  latter  fevers  are  caused  chiefly  by  the  sestivo-autumnal  parasite. 
The  tertian  parasite  may,  however,  produce  severe,  as  well  as  mild, 
types  of  malaria. 

The  tertian  parasite  was  differentiated  from  the  quartan  and  described 
in  its  essential  characters  by  Golgi  in  1886  and  1889.  Other  observers, 
particularly  Antolisei  (1889-90)  and  Bastianelli  and  Bignami  (1890), 
have  added  to,  and  in  some  points  corrected,  Golgi's  first  description. 

The  chief  points  to  be  emphasized  in  this  description  of  the  tertian 
parasite  are  those  which  distinguish  it  from  the  quartan  parasite.  Unlike 
the  quartan  parasite,  certain  stages  of  development  of  the  tertian — 
namely,  those  concerned  with  sporulation — take  place  by  preference  in 
the  spleen  and  the  bone  marrow,  although  segmenting  forms  are  seen 
also  in  the  peripheral  blood.  The  cycle  of  development  is  completed  in 
forty -eight  hours. 

During  the  paroxysm  or  shortly  after  it  small,  unpigmented,  hyaline, 
amoeboid  bodies  are  found  within  the  red  blood-corpuscles,  of  which 
they  are  about  one-fifth  to  one-fourth  the  size  (Plate  I.  Figs.  2  and  3). 
Usually  one  hyaline  body  is  found,  but  not  very  infrequently  two  or 
more  are  present,  in  a  single  blood-corpuscle.  The  tertian  aracebse, 
especially  in  their  pigmented  stage,  change  their  shape  and  position 
within  the  corpuscles  much  more  actively  than  the  quartan  amcebse, 
these  movements  being  vigorous  at  ordinary  room  temperature.  Several 
branching  pseudopodia  are  sent  out,  often  reaching  nearly  or  quite  the 
periphery  of  the  corpuscle,  and  are  retracted.  All  sorts  of  shapes 
may  thus  be  assumed  by  the  parasite,  which  with  its  long  branching 
processes  may  seem  to  pervade  nearly  the  whole  corpuscle.  By  the 
union  of  two  pseudopodia  the  shape  may  be  that  of  a  ring  enclosing  a 
bit  of  the  corpuscular  substance  (Plate  I.  Fig.  5).  The  tertian  amoebae 
are  paler,  less  sharply  outlined,  than  the  quartan  (compare  the  two 
varieties  in  Plate  I.).  In  a  short  time  fine  reddish-brown  or  yellowish- 
brown  rods  and  granules  of  pigment,  varying  somewhat  in  size,  appear 
in  the  margins  of  the  amoebae  (Plate  I.  Fig.  5).  Pigment  granules  often 
collect  in  the  bulbous  ends  of  pseudopodia  (Plate  I.  Figs.  6  and  7),  and 
the  intervening  parts  of  the  pseudopodia  may  be  so  thin  and  delicate  as 
to  be  readily  overlooked,  so  that  the  appearance  may  be  that  of  several 
distinct  bodies  within  one  red  blood-corpuscle.  Careful  examination 
will,  however,  detect  the  fine  connecting  processes  or  the  retraction  of 
the  apparently  separate  bodies  into  the  substance  of  one  parasite.  Two 
or  more  parasites  may,  however,  be  present  occasionally  within  one  red 
corpuscle  (Plate  I.  Fig.  4).  The  pigment  is  in  finer  grains  and 
rods,  and  of  a  lighter,  somewhat  different,  tint  in  the  tertian,  than  in  the 


PARASITOLOGY.  45 

([iiartaii  parasite.  (See  Plate  I.)  It  is  tiiso  in  much  more  active  move- 
ment in  the  tertian  anifeha'.  This  movement  is  not  altogether  like  the 
lirunonian  or  molecular  motion,  and  is  probably  due  to  intrinsic  ])roto- 
plasmic  movements  or  currents. 

W^ith  the  continued  g-rowtii  and  increased  ])ioincntati()n  of  the  anuebie 
the  infected  corpuscles  as  a  rule  become  distin(;tly  swollen  and  j)aler 
than  normal — a  change  which  may  be  already  indicated  even  with  (juite 
small  pigmented  forms,  and  which  is  one  of  the  most  distinctive  cha- 
racters of  the  tertian  parasite  (Plate  I,  Figs.  4-9).  Occasionally  the 
enveloping  corpuscle  is  not  noticeably  swollen  or  altered,  and  exception- 
ally it  may  even  shrink  and  acquire  something  of  the  brassy  appearance 
commonly  seen  with  red  corpuscles  infected  with  the  jestivo-autumnal 
parasite. 

On  the  day  of  apyrexia  the  parasite,  now  with  somewhat  sharper 
contour  and  more  richly  pigmented,  may  attain  a  size  equalling  one-half 
to  two-thirds  that  of  the  infected  blood-corpuscle.  The  amoeboid  move- 
ments have  become  more  sluggish,  but  they  persist  in  stages  of  develop- 
ment corresponding  to  which  forms  of  the  quartan  parasite  have  become 
quiescent.     The  pigment  continues  in  active  motion. 

The  fully  developed  parasite  is  about  the  size  of  a  normal  red  cor- 
puscle, sometimes  a  little  smaller,  sometimes  somewhat  larger,  and  it  is 
therefore  smaller  than  the  swollen  corpuscle  in  wdiich  it  is  contained. 
It  is  nearly  or  quite  spherical  in  shape,  and  without  amoebic  movements. 
The  pigment  for  a  while  preserves  its  marginal  arrangement  or  less  fre- 
quently is  irregularly  distributed  (Plate  I.  Fig.  9).  The  expanded  red 
blood-corpuscle  enveloping  the  parasite  becomes  still  paler. 

These  fully  grown  forms  change  into  the  presegmenting  bodies  by 
the  collection  of  the  pigment,  which  has  already  become  quiescent, 
into  a  mass  of  granules  or  into  a  solid  block  situated  usually  in  or  near 
the  centre  or  sometimes  near  or  at  the  margin.  As  with  the  other  varie- 
ties of  the  malarial  parasite,  the  pigment  with  the  development  of  the 
parasite  becomes  coarser,  and  the  delicate  rod-like  forms  of  pigment 
become  relatively  less  numerous.  These  spherical  bodies  with  central 
jiigment  clumps  are  more  refractive  than  is  the  parasite  in  preceding 
stages  of  development.  Stained  specimens  show  that  in  these  preseg- 
menting bodies  there  appear  multiple,  deeply  staining  chromatin  gran- 
ules, which  represent  nuclear  substance,  and  which  are  the  first  indica- 
tion of  the  inception  of  sporulation. 

This  phase  of  segmentation  presents  more  variation  than  is  observed 
in  the  quartan  parasite.  Sometimes  it  begins  with  the  appearance  of 
radial  striation  extending  from  the  periphery  to  the  centre,  and  proceeds 
by  a  division  of  the  substance  of  the  parasite  into  twelve  to  twenty  or 
even  more  segments  arranged  in  a  rosette  form  around  the  central  clump 
of  pigment.  A  little  later  the  pigment  clump  is  surrounded  by  a  group 
of  small  round  bodies,  which  are  the  spores.  More  commonly,  without 
the  formation  of  such  regular  figures,  the  protoplasm  breaks  up  into  a 
mass  of  fourteen  to  twenty  or  more  spores.  Sometimes  one  sees  an  outer 
and  an  inner  ring  of  spores  concentrically  arranged  around  the  central 
mass  of  pigment.  The  larger  number  of  segments  or  spores  formed  by 
the  tertian  as  contrasted  with  the  quartan  parasite  is  an  important  dif- 
ferential characteristic. 


46  3IA  LABIA. 

The  modes  of  segmentation  described  (Plate  I.  Figs.  10-14)  corre- 
spond in  the  main  to  Golgi's  second  type  of  segmentation.  His  first 
mode  of  segmentation  of  the  tertian  parasite  has  not  been  noted  by  other 
observers.  It  is  as  follows  :  After  the  collection  of  the  pigment  in  the 
centre  the  organism  is  differentiated  into  a  peripheral  zone  sharply  sepa- 
rated from  a  central  body  containing  the  pigment.  The  peripheral  ring 
becomes  radially  striated,  and  then  divides  into  fifteen  to  twenty  small 
hyaline  segments.  The  central  pigmented  body  does  not  segment,  but 
remains  behind  after  the  separation  of  the  spores.  Golgi's  third  variety 
of  segmentation  is  now  generally  recognized  as  a  process  of  degenerative 
vacuolation. 

Sometimes  the  segmenting  bodies  show,  instead  of  one  central  accu- 
mulation of  pigment,  two  or  more  clumps  excentrically  placed,  or  the 
pigment  may  be  concentrated  in  the  periphery  or  distributed  between 
the  spores  or  otherwise  irregularly  arranged. 

The  spores  are  set  free  by  rupture  of  the  enveloping  membrane 
derived  from  the  red  corpuscle,  or  this  membrane  may  have  disappeared 
before  the  segmentation  is  completed.  The  individual  spores  are  some- 
what smaller  than  those  of  the  quartan  parasite.  They  usually  show  a 
refractive  nucleiform  dot,  wliich  is,  as  a  rule,  less  distinct  than  in  the 
quartan  spores. 

Coincidently  with  sporulation  the  young,  colorless  amoebae,  formed 
from  the  spores,  make  their  appearance  in  the  red  blood-corpuscles  and 
start  on  a  fresh  cycle  of  development. 

The  segmenting  bodies  may  make  their  appearance  several  hours 
before  the  paroxysm.  They  are  most  numerous  shortly  before  and  dur- 
ing the  onset  of  the  paroxysm.  They  may  be  scanty  in  the  peripheral 
blood,  for  the  process  of  sporulation  takes  place  largely  in  the  internal 
organs.  The  red  corpuscles  containing  mature  and  presegmenting  bodies 
accumulate  especially  in  the  spleen  and  the  bone  marrow,  and  there  the 
organisms  complete  their  reproductive  development.  During  most  of 
the  period  of  apyrexia  no  noticeable  difference  is  observed  in  the  num- 
ber and  kinds  of  parasites  between  the  peripheral  blood  and  that  with- 
drawn by  hypodermic  syringe  from  the  spleen.  But  shortly  before  and 
during  the  paroxysm  far  more  ripe  and  sporulating  forms  are  found  in 
the  splenic  than  in  the  peripheral  blood. 

Precocious  segmentation  into  five  to  ten  spores  may  occur  in  bodies, 
sometimes  containing  only  a  grain  or  two  of  pigment,  which  have  not 
attained  a  size  exceeding  one-half  to  t^vo-thirds  that  of  the  red  blood- 
corpuscles  (Plate  I.  Figs.  16,  17),  the  usual  size  of  a  segmenting  body 
being  about  that  of  a  red  corpuscle,  but  sometimes  considerably  larger. 
Such  immature  forms  of  segmentation  are  associated  by  Bastianelli  and 
Bignami  with  anticipating  fevers,  but  Mannaberg  and  Thayer  and  Hew- 
etson,  although  not  inclined  to  discredit  this  interpretation,  were  unable 
to  convince  themselves  of  this  relation. 

Partly  developed  and  mature  tertian  parasites  are  often  seen  free  in 
the  plasma.  Swollen,  transparent,  extracorpuscular  forms,  which  may 
attain  the  size  of  large  leucocytes,  and  which  contain  scattered  dancing 
pigment  granules,  are  generally  considered  to  be  degenerative  or  inca- 
pable of  reproductive  development  (Plate  I.  Fig.  18).  These  so-called 
hydropic  forms  are  considerably  larger  and. paler  and  more  common  than 


PARASITOLOGY.  47 

the  similar  forms  of  the  quartan  parasite.  These  swollen,  richly  pig- 
mented forms  are  ver^'  common  in  tertian  infections.  In  general,  the 
various  forms  of  degeneration  which  have  already  l)een  described,  such 
as  fragmentation,  vacuolation,  pseudo-gemmation  (Plate  I,  Figs.  19,  20, 
21,  23,  24),  are  more  common  witii  the  tertian  than  tlie  quartan  parasite. 
Flagellate  bodies  are  likewise  more  common.  They  are,  as  a  rule,  larger 
and  contain  finer  pigment  than  the  cpiartan  flagellates  (Plate  I.  Fig.  22), 
They  develop  chiefly  from  the  round,  swollen,  extraccjrpuscular  forms 
with  scattered  ]iigment,  although  flagella  have  been  observed  to  develop 
from  forms  still  surrounded  \\ith  a  distinct  layer  of  hsemogloljin-con- 
taining  substance  of  the  red  blood-corpuscle.  Flagellate  bodies  are  most 
abundant  in  blood  withdrawn  from  the  spleen  shortly  before  and  during 
the  paroxysm.  Phagocytosis  occurs  ^vith  the  same  regularity  and  with 
similar  phenomena  in  tertian  as  in  quartan  infections. 

Infection  with  two  groups  of  tertian  parasites  (double  tertian),  as 
described  for  quartan  infection,  is  more  common  than  with  a  single 
group,  especially  in  the  later  period  of  the  malarial  season  in  the  spring 
and  in  summer  and  autumn.  The  resulting  type  of  fever  is  quotidian. 
In  some  cases  there  seem  to  be  several  irregularly  distributed  genera- 
tions causing  remittent  or  subcontinued  fevers.  It  is  not  necessary  to 
attribute  the  presence  of  two  or  more  groups  of  the  same  variety  of 
parasite  to  corresponding  multiple  infections  from  ^^■ithout.  There  is 
e\'idence  that  certain  members  of  a  group  may,  in  their  development, 
lag  behind  or  advance  beyond  others  of  the  same  group,  and  in  course 
of  time  by  farther  multiplication  may  constitute  a  separate  group  capable 
of  causing  its  own  paroxysms  of  fever.  It  is  remarkable,  however,  that 
the  second  group  should  be  separated  in  its  cycle  of  development  by  such 
definite  intervals  from  the  first  as  we  usually  observe  in  quotidian  fevers 
of  tertian  origin.  Genuine  mixed  infections  with  malarial  parasites,  the 
most  frequent  combination  being  that  of  the  tertian  and  of  the  sestivo- 
autumnal  parasites,  are  not  very  uncommon. 

The  length  of  the  cycle  of  development  of  the  tertian  parasite  may 
occasionally  be  noticeably  shorter  than  forty-eight  hours,  perhaps  only 
forty  hours  or  less,  or,  on  the  other  hand,  it  may  be  longer  than  the 
normal  period.  This  may  explain  the  anticipating  and  the  postponing 
fevers. 

III.  The  Parasite  of  ^STn^o-AUTUMXAE  Feyee  (H^matozoon 
Falciparum)  (Plate  II.), 

This  was  first  clearly  differentiated  from  other  varieties  of  the  mala- 
rial parasite  by  Marchiafava  and  Celli*(1889),  and  was  subsequently  more 
fully  described  by  the  same  authors  and  by  Canalis  (1889-90),  (See  foot- 
note, page  32.)  The  extensive  literature  concerning  the  parasitology  of 
malaria  during  the  last  six  years  has  been  concerned  to  a  large  extent 
^vith  this  variety,  but  we  are  still  far  from  possessing  so  full  and 
accurate  knowledge  regarding  the  characters  and  development  of  the 
IIsematozo5n  falciparum  as  regarding  those  of  the  quartan  and  tertian 
parasites.  Such  knowledge  is  much  to  be  desired  in  view  of  the  fre- 
quency of  the  aestivo-autumnal  parasite  in  regions,  such  as  the  southern 
part  of  the  United  States,  where  the  more  severe  types  of  malaria  occur. 


48  MALARIA. 

and  of  the  almost  exclusive  association  of  this  parasite  with  pernicious 
malarial  fevers. 

Chief  reasons  for  the  difficulty  in  investigating  the  entire  life  history 
of  the  Hsematozoon  falciparum  are  that  it  develops  mainly  within  the 
internal  organs  and  often  in  multiple  groups,  and  that  the  later  repro- 
ductive phases  of  development  are  met  with  in  the  circulating  blood 
only  very  exceptionally.  Under  the  Classification  of  the  malarial  para- 
sites we  have  already  presented  the  more  important  opinions  which  have 
been  advanced  concerning  possible  subdivisions  of  the  sestivo-autumnal 
variety  (page  35  et  seq.). 

The  youngest  forms  of  this  parasite  are  small  hyaline  bodies,  about 
one-sixth  the  diameter  of  a  red  blood-corpuscle,  which  make  their 
appearance  in  the  blood-corpuscles  during  or  shortly  after  the  paroxysm. 
It  is  not  uncommon  to  find  two  or  more  hyaline  bodies  in  a  single  cor- 
puscle. These  sestivo-autumnal  hyaline  bodies  are  in  general  the 
smallest  forms  of  the  malarial  parasite  which  are  observed  in  the  red 
blood-corpuscle  (Plate  II.  Figs.  1  and  2).  The  youngest  forms  may  be 
quiescent,  but  as  they  develop  they  manifest  amoeboid  movements 
resembling  in  their  activity  those  of  the  tertian  amcebte. 

The  young  sestivo-autumnal  amoebse  may  not  be  readily  distinguish- 
able from  the  similar  forms  of  the  quartan  and  tertian  parasites.  Par- 
ticularly characteristic,  however,  of  the  young  hyaline  forms  of  the 
Ha^matozoon  falciparum  when  in  repose  and  in  stained  specimens  is  the 
ring  shape.  The  appearance  in  fresh  specimens  is  that  of  a  somewhat 
refractive,  clear,  hyaline  ring,  usually  thicker  on  one  side,  surrounding 
a  small  round  central,  or  oftener  excentric,  shaded  j)art,  or  sometimes 
two  or  three  such  parts,  through  which  the  color  of  the  red  corpuscle 
shows.  In  stained  specimens  the  ring  appears  thinner  than  in  fresh 
specimens,  and  the  central  or  excentric  part  is  unstained,  while  a  minute 
deeply  stained  granule  is  situated  in  the  outer  ring. 

The  study  of  the  further  development  of  these  forms,  especially  on 
stained  specimens,  has  demonstrated  that  these  apparently  annular 
bodies  are  not  actual  rings,  as  some  have  supposed,  enclosing  a  bit  of 
the  red  corpuscle,  but  that  the  clear  area  which  does  not  stain  is  a  trans- 
parent part  of  the  organism,  which,  as  will  be  subsequently  explained, 
some  regard  as  the  nucleus.  Actual  rings,  however,  as  has  already 
been  mentioned,  may  be  formed  by  the  junction  of  pseudopodia,  which 
thereby  enclose  some  of  the  corpuscular  substance,  but  such  is  not  the 
explanation  of  the  typical  annular  appearance  of  the  sestivo-autumnal 
hyaline  bodies.  It  is  not  uncommon  to  find  free  hyaline  bodies  in  the 
blood  plasma. 

These  hyaline  bodies  may,  while  under  observation,  become  some- 
what expanded  and  paler  and  lose  their  annular  appearance,  and  again 
resume  the  ring  shape.  While  the  very  smallest  intracorpuscular 
hyaline  bodies  may  present  no  amoeboid  movements,  as  they  grow  larger 
these  movements  become  active.  Hyaline  bodies  are  occasionally 
observed  to  change  their  position  within  the  corpuscle  without  change 
in  their  shape.  Manifold  shapes  are  assumed  during  the  amoeboid 
movements  (Plate  II.  Figs.  4-6). 

Usually  in  the  course  of  development  a  few  very  fine  dark  reddish- 
brown    or   black   pigment  granules   appear  in  the  outer  layer  of  the 


PARASITOLOGY.  49 

hyaline  bodies  (Plate  II.  Figs.  8-12).  Tliev  may  be  situated  neai-  the 
periphery  or  on  the  inner  margin  of  the  ring  near  the  elear  part. 
Sometimes  the  pigment  does  not  appear  until  shortly  before  a  paroxysm. 
The  presence  of  many  bodies  containing  a  considerable  number  of  grains 
of  pigment  is  generally  indicative  of  an  ini])ending  paroxysm.  The 
pigment  granules  are  at  first  very  minute  and  few,  and  may  be  readily 
overlooked.  The  granules  of  pigment  increase  in  number  and  size,  but 
it  is  one  of  the  characteristics  of  the  aestivo-autumnal  amoebae  that  the 
formation  of  pigment  is,  as  a  rule,  scanty  and  in  fine  grains.  Often 
only  one  or  two  very  fine  pigment  granules  are  seen  in  the  periphery  or 
on  the  inner  edge  of  the  refractive  border  of  the  hyaline  bodies. 
Usually  about  six  or  seven  granules  of  pigment  are  developed  in  the 
hyaline  bodies.  The  pigment  generally  shows  but  little  motion  in  con- 
trast with  that  in  the  tertian  amoebse. 

The  sestivo-antumnal  amoeboid  forms  do  not  generally  grow  larger 
than  one-quarter  to  one-third  the  diameter  of  the  red  blood-corpuscle, 
and  they  may  remain  smaller.  The  infected  red  corpuscles  may  appear 
otherwise  normal.  They  do  not  become  swollen  and  decolorized  in  this 
stage,  as  is  the  case  in  the  tertian  infections.  On  the  other  hand,  they 
often  become  shrunken,  creased,  or  otherwise  deformed,  and  present 
a  deep  brassy  color  (globuli  rossi  oUonati  of  the  Italian  writers)  (Plate 
II.  Figs.  7,  16).  Sometimes  the  haemoglobin  separates  from  a  part  or 
the  whole  of  the  outer  part  of  the  stroma  of  the  corpuscle  and  collects 
around  the  enclosed  hyaline  body  (Plate  II.  Fig.  13).  These  changes 
in  the  red  corpuscles,  which  are  particularly  characteristic  of  the  sestivo- 
autmnnal  variety,  although  not  absolutely  limited  to  it,  are  to  be 
regarded  as  degenerative  or  necrobiotic.  Marchiafava  and  Celli  and 
some  others  have  thought  that  the  parasite  within  these  profoundly 
altered  corpuscles  is  also  dead  or  incapable  of  further  development. 
Bastianelli  states  that  sporulation  forms  are  not  observed  in  the  brassy 
corpuscles,  but  this  statement  is  opposed  to  observations  of  Marchiafava 
and  Bignami  and  others.  The  view  that  parasites  within  profoundly 
altered  corpuscles  are  incapable  of  further  clevelopment  is  by  no  means 
proven,  and  is  opposed  to  the  natural  interpretation  of  many  observations. 

As  the  time  for  the  onset  of  a  paroxysm  approaches,  the  hyaline 
bodies  gradually  cease  their  amoeboid  movements,  assume  a  spherical  or 
ovoid  shape,  become  somewhat  more  refractive  and  homogeneous,  and 
present  a  small  collection  of  quiescent  or  but  slightly  moving  pigment 
granules  at  about  the  centre  or  often  near  the  periphery  (Plate  II.  Figs. 
13,  16,  17,  18).  This  pigment  usually  fuses  into  a  single  small,  black, 
round  or  irregular  mass  or  block  (Plate  II.  Figs.  14,  15,  19-24),  or 
there  may  be  two  such  blocks. 

These  round,  refractive  bodies  with  pigment  blocks  or  collections  of 
pigment  granules  {cor pi  con  blocchetto)  are  the  presegmenting  bodies,  and 
when  they  are  present  the  onset  of  a  paroxysm,  within  at  most  a  few 
hours,  may  generally  be  safely  predicted.  These  bodies  are  much  smaller 
than  the  corresponding  forms  of  the  quartan  and  tertian  parasites.  They 
do  not  generally  exceed  one-quarter  or  one-third  of  the  size  of  the 
corpuscle,  although  they  may  be  considerably  larger.  They  are  sur- 
rounded with  haemoglobin-containing  substance  of  the  corpuscle,  which 
is  often  of  a  brassy  color. 

Vol.  I.— 4 


50  3IALARIA. 

The  next  phase  of  development  is  that  of  sjjorulation,  but  the  seg- 
menting forms  are  found  in  the  peripheral  blood  only  most  exception- 
ally, save  in  some  pernicious  cases,  in  which  they  may  in  rare  instances 
be  even  abundant.  SacharofF  observed  in  the  Transcaucasus  sporulating 
forms  in  the  blood,  and  on  this  account,  but  apparently  without  suffi- 
cient reason,  he  regards  this  form  as  a  special  variety.  For  a  few  hours 
before  and  during  the  early  stage  of  the  paroxysm  very  few  parasitic 
forms  of  any  kind  are  to  be  found  in  the  circulating  blood,  and  at  this 
period  they  may  be  entirely  absent,  in  marked  contrast  to  quartan  infec- 
tion. During  this  period  the  presence  of  pigmented  leucocytes  in  the 
blood  may  aid  in  the  diagnosis.  In  tertian  infections  an  analogous  con- 
dition is  found,  but  not  in  the  same  degree.  The  disappearance  of  the 
parasites  from  the  blood  is  believed  by  most  authorities  to  be  due  to 
their  deposition  in  internal  organs,  especially  the  spleen  and  the  bone 
marrow,  and  is  attributed  to  the  profound  changes  in  the  red  blood- 
corpuscles  containing  them,  these  changes  rendering  the  corpuscles  vir- 
tually foreign  bodies  which,  like  other  foreign  particles,  are  caught  and 
retained  especially  in  the  spleen  and  the  bone  marrow. 

Blood  Avithdrawn  by  puncture  of  the  spleen  at  this  time  will,  with 
rare  exceptions,  show  abundant  intracorpuscular  and  free  round  bodies 
with  central  or  peripheral  pigment,  and  also  segmenting  forms.  In 
certain  cases  segmenting  forms  are  few  in  the  sj)leen,  but  abundant  in 
certain  other  internal  organs,  as  has  been  shown  by  post-mortem  exam- 
inations. These  sporulating  bodies  are  smaller  than  those  of  the  quartan 
and  tertian  parasites,  and  occupy,  as  a  rule,  only  a  relatively  small  part  of 
the  corpuscle,  which  is  always  altered  in  appearance,  being  shrunken  and 
brassy-colored  or  more  frequently  decolorized.  They  may  apjoear  to  be 
free  or  may  be  actually  free.  In  pernicious  cases  they  are  jDresent  in 
large,  often  enormous,  numbers  in  the  internal  organs,  especially  in  the 
spleen  and  bone  marrow,  and  in  some  types  of  pernicious  fever  in  the 
capillaries  of  the  brain  and  in  those  of  the  intestinal  mucosa.  This 
varied  distribution  of  the  parasites  in  internal  organs  is  in  relation  with 
the  types  of  pernicious  fever.  The  stage  of  sporulation  occupies  a  rather 
long  period  and  takes  place  in  successive  groups.  This  circumstance  is 
believed  to  explain  the  long  duration  of  the  paroxysm  in  sestivo- 
autumnal  fevers.  In  pernicious  cases  sporulation  seems  to  be  going  on 
continually  in  the  vascular  areas  of  certain  internal  organs. 

In  sestivo-autumnal  infections  the  process  of  sporulation  is  in  general 
similar  to  that  of  the  tertian  parasite,  but  it  is  more  irregular  and  A'ari- 
able  and  the  spores  are  much  smaller  (Plate  II.  Figs.  25-28).  The 
number  of  spores  formed  by  a  segmenting  sestivo-autumnal  organism  is 
extremely  variable.  There  may  be  not  more  than  six  to  ten  spores,  or 
even  fewer ;  often  there  are  ten  to  twenty,  and  the  number  may  exceed 
thirty.  Some  segmenting  forms  are  much  larger  than  others.  Golgi 
has  observed  exceptionally  very  large  ones  containing  as  many  as  forty 
to  fifty  spores.  There  are  slight  differences  often  to  be  observed  in  the 
finer  structure  between  the  sestivo-autumnal  spores  and  those  of  the 
quartan  and  tertian  parasites,  as  will  be  described  when  we  consider 
the  intimate  structure  of  the  malarial  parasites. 

The  young  hyaline  bodies  of  the  new  generation  may  be  found  in  the 
blood  in  the  early  part  of  the  paroxysm,  but  often  they  do  not  make 


PARASITOLOGY.  51 

their  appearance  until  several  iiuurs  after  the  l)ei;inning  of  the  paroxysm 
or  durinij;  its  decline. 

Not  all  of  the  festive-autumnal  amoebfe  develop  pi2:ment.  8porula- 
tion  may  occur  in  bodies,  usually  of  small  size,  entirely  devoid  of  pio;- 
ment.  As  a  rule  in  these  cases  l)oth  pigmented  and  unpijj^inented 
forms  occur,  but  cases  of  aestivo-aiitumnal  malaria  have  been  observed, 
especially  in  tropical  climates,  in  which  only  unpigmented  bodies  could 
be  found  at  any  stage  of  the  fever  before  the  appearance  at  a  later 
period  of  crescentic  bodies  which  always  contain  pigment. 

As  has  already  been  mentioned  (page  38)  Grassi  and  Feletti  regard 
the  parasites  which  do  not  develop  pigment  as  belonging  to  a  distinct 
variety  [HiCinainoeba  iiiim((cu/afa),  but  it  is  difficult  to  reconcile  this  view 
with  the  frequent  association  of  pigmented  and  unpigmented  forms,  the 
fre(|uent  transitions  from  one  to  the  other  as  regards  the  quantity  of 
pigment  developed,  and  the  absence  of  any  points  of  distinction  other 
than  the  presence  or  absence  of  a  variable,  but  generally  small,  amount 
of  pigment.  Still  further  researches,  especially  of  the  grave  tropical 
malarias,  may  perhaps  demonstrate  the  existence  of  a  distinct  unpig- 
mented variety  of  the  parasite. 

There  is  considerable  uncertainty  as  to  the  length  of  the  cy<3le  of 
development  of  the  Hpematozoon  falciparum.  This  uncertainty  is  due  to 
the  manner  of  development  of  the  parasite,  usually  in  multiple  groups, 
in  the  internal  organs,  the  most  characteristic  reproductive  phases  being- 
absent  from  the  circulating  blood.  So  far  as  one  can  judge  from  the 
study  of  these  phases  in  connection  with  the  different  types  of  fever 
with  which  they  may  be  associated,  the  length  of  the  cycle  of  develop- 
ment may  vary  from  twenty-four  hours  or  less  to  forty-eight  hours  or 
more. 

The  Haematozoon  falciparum  may  be  associated  with  typical  quotidian 
fever  or  with  tertian  fever,  and  in  some  of  these  cases  the  blood  shows 
apparently  only  one  group  of  organisms.  As  already  mentioned, 
Marchiafava  and  Bignami  believe  that  there  are  two  distinct  varieties 
or  subvarieties  of  the  aestivo-autumnal  parasite,  the  one  a  true  quotidian 
organism,  with  a  cycle  of  twenty-four  hours'  duration,  and  the  other 
their  so-called  malignant  or  summer-autumn  tertian  variety,  with  a  cycle 
of  forty-eight  hours'  duration ;  and  this  division  has  been  accepted  by 
some  other  authors.  This  distinction  is  based  mainly  upon  the  apparent 
duration  of  the  cycle  of  development — in  the  quotidian  about  twenty- 
four  hours,  and  in  the  malignant  tertian  forty-eight  hours,  more  or  less 
— but  there  are  claimed  to  be  other  differences  of  a  minor  character 
relating  to  the  pigmentation,  the  size,  and  the  amoeboid  movements 
of  the  organisms.^     The  differential  diagnosis  is  said  to  be  possible  only 

^  The  following  are  the  biological  aud  morphological  differences  between  the  sestivo- 
autumnal  quotidian  and  malignant  tertian  parasites,  according  to  Marcliiafava  and  Big- 
nami {On  Summer-Autumn  Malarial  Fevers,  translation,  jj.  S3,  The  New  Sydenham  Society, 
London,  1894)  :  Duration  of  cycle  of  development  in  the  quotidian,  about  twenty-four 
hours,  in  the  summer  tertian,  forty-eight  hours,  more  or  less ;  in  the  quotidian  sporula- 
tion  on  rare  occasions  is  completed  before  the  amceba^  have  become  pigmented — this  is  not 
observed  in  the  summer  tertian  :  the  fine  granules  of  pigment  in  the  2)erip]iery  of  the 
summer  tertian  are  sometimes  endowed  with  oscillatory  movements — this  is  not  noticed  in  the 
quotidian  ;  in  the  same  relative  stage  of  development  the  tertian  amceba  is  usually  larger 
than  the  quotidian,  the  adult  pigmented  tertian  forms  may  be  one-third  of  the  size  of  the 
red  blood-corpuscles,  and  the  forms  of  segmentation  may  be  one-half  or  two-thirds  of  it ; 


52  MALARIA. 

with  the  adult  forms.  The  diiFerential  characters  claimed  to  exist  between 
the  quotidian  and  the  tertian  varieties  of  the  sestivo-autumnal  parasite 
are,  for  the  most  part,  only  such  as  one  would  expect  with  a  malarial 
parasite  develojDing  more  rapidly  in  some  cases  than  in  others,  and  they, 
at  least  so  far  as  at  present  formulated,  scarcely  suffice  for  a  distinction 
into  two  well-defined  varieties. 

Thayer  and  Hewetson,  while  confirming  Marchiafava  and  Bignami's 
recognition  of  quotidian  and  tertian  fevers  caused  by  the  sestivo-autumnal 
parasite,  emphasize  the  occurrence  of  intermediate  types  of  fever,  and 
in  general  the  essential  irregularity  of  the  fevers  caused  by  this  organ- 
ism. They  were  unable  to  distinguish  any  morphological  or  biological 
differences  between  the  parasites  associated  with  these  various  types  of 
fever.  Although  unwilling  to  commit  themselves  to  a  positive  conclu- 
sion, they  are  "  inclined  to  believe  that  the  irregularity  of  the  febrile 
manifestations  is  due  chiefly  to  the  tendency  on  the  part  of  the  parasite 
to  irregularities  in  the  length  of  its  cycle  of  development  (this  variability 
being  dependent,  perhaps,  upon  the  malignity  of  the  organism  or  upon 
the  resistance  of  the  individual  affected) ;  to  the  fact  that  the  period  of 
time  required  for  the  sporulation  of  one  group  of  organisms  is  materially 
greater  than  in  the  regular  infections,  owing  to  the  fact  that  the  arrange- 
ment of  the  parasites  in  definite  sharp  groups,  sporulating  nearly  at  the 
same  time,  is  much  less  distinct  than  in  the  tertian  and  quartan  inter- 
mittents  ;  to  the  fact  that,  frequently,  organisms  in  all  stages  of  develop- 
ment are  present  at  one  time,  segmentation  occurring  almost  contin- 
uously." ^ 

Golgi  also  considers  that  Marchiafava  and  Bignami's  division  into 
quotidian  and  tertian  sestivo-autumnal  organisms  is  based  upon  insuf- 
ficient evidence,  and  that  the  duration  of  the  cycle  of  development  of  the 
sestivo-autumnal  parasite  is  indeterminate,  or  at  least  has  not  as  yet  been 
accurately  ascertained.  This  cycle  is  probably,  he  thinks,  longer  than  is 
supposed  by  Marchiafava  and  Bignami.  This  form  of  parasite,  accord- 
ing to  Golgi,  is  characterized  by  the  fact  that  it  develops  entirely  in  the 
internal  organs,  and  that  the  forms,  chiefly  of  the  earlier  stages  of 
development,  which  appear  in  the  circulation,  although  they  are  found 
there  at  certain  periods  of  the  disease  in  practically  all  cases,  are,  in  a 
sense,  accidentally  present  in  this  situation,  being  washed  into  the  circu- 
lation from  their  foci  of  development,  as  nucleated  red  blood-corpuscles 
may  be  conveyed  from  the  bone  marrow  into  the  blood  current  in  certain 
ansemias.  Golgi  at  first  thought  that  the  forms  present  in  the  circula- 
tion degenerate,  but  he  does  not  now  deny  that  they  may  lodge  in 
internal  organs  and  there  develop  into  segmenting  organisms.  Marchia- 
fava and  Bignami  with  much  reason  vigorously  contest  Golgi's  concep- 
tion of  the  "  accidental "  nature  of  the  presence  of  sestivo-autumnal 
organisms  in  the  circulating  blood,  although  they  also  believe  that  a 
large  part  of  the  parasites  develop  wholly  in  the  internal  organs,  and 

in  the  tertian  the  amoeboid  movements  are  maintained  longer,  even  in  the  adult  pigmented 
forms,  and  the  motion  is  more  lively  than  in  the  quotidian  during  the  pigmented  phase  ; 
the  duration  of  the  non-pigmented  amoeboid  phase  in  the  tertian  is  relatively  long  and  may 
exceed  twenty-four  hours  ;  the  young  forms  of  the  new  generation  in  the  tertian  usually 
appear  in  the  blood  several  hours  after  the  beginning  of  the  paroxysm,  which  is  much 
later  than  in  the  quotidian. 
^  Op.  cit.,  pp.  151,  153. 


PARASITOLOGY.  53 

that  sporiilation  occurs  only  most  exceptionally  in  tlic  circiihiting 
blood. 

The  two  most  important  and  oritrinal  points  in  Golgi's  doctrine  con- 
cerning the  sestivo-autumnal  parasite  are  that  groups  of"  the  parasitic 
org*anisnis  are  variously  distributed  in  vascular  areas  in  the  internal 
organs,  and  there  develop  more  or  less  independently  of  each  other, 
"with  relative  stability,"  and  that  a  large  number  of  the  organisms 
develop  within  leucocytes,  endothelial  cells,  and  other  tissue-cells.  All 
phases  of  develojjment,  according  to  Golgi,  are  found  within  these  cells. 
The  spleen  and  the  bone  marrow  are  situations  preferred  by  the  parasite, 
but  the  capillaries  of  the  liver,  of  the  brain,  of  the  lungs,  of  the  intes- 
tinal mucosa,  may  also  contain  them  enclosed  within  cells. 

A.  Monti  ^  has  recently  described  these  intracellular  forms  in  perni- 
cious malaria,  and  he  confirms  the  observation  of  many  others  that  cells 
containing  parasites  frequently  degenerate  and  die.  He  finds  apparently 
intact  parasites  not  infrequently  within  cells,  particularly  endothelial 
cells. 

It  is  contended  by  Marchiafava,  Bignarai,  and  Bastianelli  that  the 
intracellular  inclusions  of  the  parasite,  upon  which  Golgi  bases  his  doc- 
trine, are  simply  the  well-known  phagocytic  phenomena,  and  that  such 
enclosed  parasites  belong  chiefly  to  the  later  stages  of  development 
(presegmenting  and  segmenting  bodies  and  spores),  and  that,  instead  of 
developing,  they  degenerate  within  the  cells.  The  young  amoeboid 
bodies,  which,  according  to  Golgi's  doctrine,  should  be  frequently  found 
Avithin  cells,  they  found  only  with  comparative  infrequency  within  pha- 
gocytes, and  then  almost  always  within  their  corpuscular  hosts,  which 
had  been  swallowed  by  cells.  They  admit  the  possibility  of  some 
development  of  intracorpuscular  parasites  which  have  been  taken  up  by 
phagocytes,  but  not  of  free  parasites  within  cells. 

As  with  the  other  varieties  of  the  malarial  parasite,  the  sestivo- 
autumnal  do  not  all  mature  and  segment.  Extracorpuscular  forms  are 
common,  and  it  is  more  particularly  these  forms,  deprived  of  the  pro- 
tective covering  of  the  red  blood-corpuscles,  which  degenerate.  Adult 
and  presegmenting  bodies  and  bodies  of  the  crescentic  phase  frequently 
become  swollen  and  pale  or  vacuolated  or  fragmented,  or  throw  off  buds, 
or  present  other  degenerative  changes  which  have  been  described. 

Phagocytism  in  the  sestivo-autumnal,  as  in  all  malarial  infections,  is 
a  phenomenon  of  much  importance,  as  will  be  subsequently  explained. 

The  frequency  with  which  two  or  more  groups  of  parasites  in  differ- 
ent stages  of  development  are  found  in  sestivo-autumnal  infections  has 
already  been  repeatedly  emphasized.  Marchiafava  and  Bignami  believe 
that  even  in  the  pernicious  fevers  there  are  not  generally  present  more 
than  two  groups  of  the  sestivo-autumnal  parasite,  and  that  the  short 
cycle  of  development  and  the  prolonged  period  of  sporulation  suffice  to 
explain  the  simultaneous  presence  of  parasites  in  notably  different  stages 
of  development.  Combined  infections  with  the  aestivo-autumnal  para- 
site and  one  of  the  other  varieties  occasionally  occur. 

It  is  important  to  bear  in  mind  the  discrepancy  which  characterizes 
sestivo-autumnal  malaria  between  the  number  of  parasites  in  the  blood 
and  the  number  in  the  internal  organs.     In  the  majority  of  cases  the 

^  A.  Monti  :  Bollettino  della  Society  medico-chirurgica  di  Pavia,  1895. 


54  MALARIA. 

more  severe  the  infection  the  greater  the  number  of  parasites  found  in 
the  circulating  blood,  but  there  are  so  many  exceptions  to  this  that  the 
number  of  parasites  in  the  blood  cannot  be  considered  a  trustworthy 
index  of  the  number  within  the  body.  Pernicious  cases  have  been 
repeatedly  observed  Avhere  the  splenic  blood  examined  during  life  or  the 
internal  organs  examined  after  death  contained  enormous  numbers  of 
sestivo-autumnal  parasites,  although  the  blood  of  the  finger  showed  very 
few.  The  organisms  may  be  few  even  in  the  spleen  when  they  are 
abundant  in  the  cerebral  capillaries  or  in  some  other  situation.  As  will 
be  explained  subsequently,  the  varying  symptoms  and  types  of  perni- 
cious malaria  can  be  explained  in  large  part  by  the  varying  distribution 
of  the  parasites  in  internal  organs. 

It  is  evident  from  the  description  which  has  been  given  of  the  ^stivo- 
autumnal  parasite  that  this  variety  is  characterized  especially  by  its 
great  activity  in  multiplication,  and  it  will  appear  from  the  considera- 
tion of  the  clinical  features  of  the  infections  caused  by  this  parasite  that 
other  most  important  characteristics  are  its  virulence,  greater  than  that 
of  other  varieties,  and  its  greater  resistance  to  quinine. 

There  is  a  group  of  bodies  of  crescentic,  fusiform,  oval,  or  round 
shape,  presenting  certain  common  and  peculiar  characters,  which  develop 
only  from  the  Hsematozoon  falciparum.  The  crescents  are  the  most 
typical  of  these  bodies,  which  may  be  designated,  therefore,  as  bodies  of 
the  crescentic  (or  semilunar)  phase  or  group.  They  merit  special  con- 
sideration. 

Bodies  of  the  Crescentic  G-roup. — When  a  malarial  fever  caused 
by  the  Hsematozoon  falciparum  has  lasted  a  week  or  more  bodies  of  the 
crescentic  or  semilunar  phase  are  likely  to  appear  in  the  blood.  They 
are  very  rarely  found  in  the  blood  in  the  latter  part  of  the  first  week. 
If  the  fever  is  treated  with  sufficient  doses  of  quinine  during  the  early 
part  of  the  first  week,  crescents  do  not  appear,  but  the  administration 
of  quinine  after  the  fever  has  lasted  much  longer  than  a  week  does  not 
prevent  their  appearance.  They  may  persist  in  the  blood  two  weeks  or 
more  after  all  other  forms  of  the  parasite  have  disappeared.  In  such 
cases  they  are  often  unassociated  with  any  febrile  manifestations  or  any 
symptoms  which  can  be  definitely  referred  to  their  presence.  If  a 
relapse  of  the  fever  occurs,  then  the  young  hyaline  bodies  already 
described  are  always  present.  The  crescents  themselves  are  very  resist- 
ant to  the  action  of  quinine.  Councilman  in  1887  called  attention  to 
the  occurrence  of  crescentic  bodies  as  characteristic  of  the  irregular  and 
remittent  forms  of  malarial  fever  and  malarial  cachexia. 

There  was  for  a  time  much  doubt  as  to  the  origin  of  the  crescents, 
but  Marchiafava  and  Celli's  demonstration  in  1886  of  their  intracor- 
puscular  development  has  been  abundantly  confirmed  by  the  later  studies 
of  Canalis,  Bastianelli  and  Bignarai,  and  others.  The  early  intracorpuscu- 
lar  stages  of  development  of  the  bodies  of  the  crescentic  group  are  rarely 
seen  in  the  circulating  blood,  except  in  certain  pernicious  cases,  but  they 
can  often  be  found  in  the  splenic  blood.  Bastianelli  and  Bignami  have 
found  these  early  phases  so  abundantly  in  the  bone  marrow  that  they 
consider  that  they  develop  by  preference  in  this  situation. 

Certain  of  the  intracorpuscular  spherical  forms  of  the  Hsematozoon 
falciparum  with  collected  pigment  granules,  instead  of  continuing  their 


PARASITOLOGY.  55 

regular  cyck'  of"  development  into  segment! n*;-  I'orins,  are  transfornied 
into  the  young  bodies  of  the  seniihinar  phase.  Tliis  transformation 
tiikes  phiee  only  after  a  number  of  febrile  paroxysms  ;  that  is  to  say, 
only  after  the  parasite  has  repeatedly  passed  through  its  regular  sporu- 
lating  cycle  of  development. 

Tiie  young  bodies  of  the  ereseentie  group  occupy  perhaps  one-fjuartcr 
of  the  red  corpuscle.  Their  shape  is  round,  oval,  or  fusiform.  'J'hey 
present  a  characteristic  homogeneous,  refractive  appearance,  being  more 
refractive  than  the  presegmenting  bodies  with  central  blocks  of  pigment. 
They  contain  dark  pigment,  usually  in  the  shape  of  fine  rods,  sometimes 
collected  in  a  mass,  but  oftener  irregularly  distributed.  In  the  fusiform 
bodies  the  pigment  is  often  arranged  along  the  longitudinal  axis  of  the 
spindle.  The  h;emogh)bin  is  frequently  retracted  into  a  denser  stratum 
around  the  l)odies.  These  bodies  increase  in  size  without  a  correspond- 
ingly large  increase  in  the  amount  of  pigment,  and,  as  will  be  explained 
later,  without  a  corresponding  increase  in  their  chromatic  or  staining 
substance — a  point  Avhich  distinguishes  the  direction  of  ereseentie  devel- 
opment from  that  of  the  regular  sporulating  development. 

It  is  some  time  after  these  voung  semilunar  bodies  have  beo:un  to 
form  in  the  bone  marrow  and  spleen  before  the  adult  crescents  appear 
in  the  circulating  blood.  These  completely  developed  typical  crescents 
are  on  the  average  8—10  u  long,  and  in  the  luiddle  2-3  n  broad 
(Plate  II.  Figs.  31,  32,  33).  They  do  not  often  exceed  in  length  one 
and  a  quarter  or  one  and  a  half  times  the  diameter  of  a  red  corpuscle. 
They  present  a  characteristic,  homogeneous,  refractive  appearance.  An 
outer  double-contoured  border  can  sometimes  be  seen,  especially  after 
treatment  with  certain  reagents,  and  this  is  interpreted  by  Laveran, 
Mannaberg,  and  many  authors  as  evidence  of  a  distinct  enveloping 
membrane ;  but  the  weight  of  evidence  is  opposed  to  the  view  that  the 
crescents,  any  more  than  any  other  form  of  the  malarial  parasite,  possess 
a  membrane  other  than  that  which  pertains  to  the  enveloping  red  cor- 
puscle. The  outer  refractive  margin  of  the  crescents,  as  pointed  out  by 
Antolisei  and  Angelini — who  interpret  it  as  a  cuticular  envelope  derived 
from  the  red  blood-corpuscle — may  be  slightly  colored  by  haemoglobin, 
and  it  may  show  evidence  of  this  presence  of  blood  coloring  matter  by 
the  staining  with  eosin.  On  the  typical  crescent-shaped  forms  a  fine 
line  can  often  be  seen  stretching  like  a  bow  across  the  concavity,  its 
attachment  at  each  end  being  within  the  extremities  of  the  horns.  This 
line  is  derived  from  the  red  blood-corpuscle  within  which  the  crescent 
has  developed,  and  represents  the  outer  contour  of  the  partly  or  com- 
pletely decolorized  corpuscle.  This  contour  of  the  corpuscle  can  some- 
times be  detected  also  on  the  convexity  of  the  crescent,  and  parts  of  the 
corpuscle  still  containing  haemoglobin  may  occasionally  be  seen  on  the 
margin  of  the  crescent,  or  the  whole  crescent  may  be  surrounded  with 
haemoglobin-containing  corpuscular  substance  (Plate  II.  Fig.  29).  Sim- 
ilar evidences  of  the  partly  or  completely  decolorized  enveloping  blood- 
corpuscle  can  frequentlv  be  seen  on  the  maro;in  of  the  round  and  oval 
bodies  (Plate  II.  Figs.  34,  35,  36,  38,  39). 

Bodies  of  the  ereseentie  group  are  always  pigmented.  The  pigment 
is  very  dark  in  color,  often  black,  and  mostly  in  fine  rods.  In  the  typ- 
ical crescents  the  pigment,  which  is  without  movement  and  in  fine  rods 


56  MALARIA. 

and  grains,  is  usually  collected  in  the  middle,  sometimes  in  a  single  clump 
or  in  two  clumps,  often  in  a  coronal  shape.  Mannaberg  emphasizes  the 
frequency  with  which  the  pigment  is  arranged  in  two  adjacent  clumps 
near  the  centre,  presenting  a  ligure-of-8  shape.  In  the  immature  cres- 
cents the  pigment  is  often  scattered,  or  is  arranged  longitudinally,  as  it 
often  is  in  the  fusiform  bodies.  The  amount  of  pigment  varies ;  it  is 
often  considerable.  In  certain  pernicious  fevers  young  crescents  with 
scattered  pigment  may  be  abundant  in  the  blood.  In  the  oval  and  round 
bodies  the  pigment  is  usually  concentrated  in  the  centre,  often  in  the  form 
of  a  circle,  but  it  may  be  distributed  throughout  the  body.  Ovoid,  round, 
and  fusiform  bodies  may  be  changed  into  typical  crescents,  and,  on  the 
other  hand,  crescents  may  change  into  fusiform,  oval,  and  round  bodies. 
The  appearance  of  a  fusiform  or  ovoid  body  may  be  presented  when  a 
crescent  is  seen  from  the  convex  side. 

From  the  round  bodies  flagellate  forms  may  develop  in  the  manner 
already  described  (Plate  II.  Figs.  42,  43,  44).  The  sestivo-autumnal 
flagellate  bodies  develop  only  from  round  bodies  of  the  crescentic  group. 
They  are  smaller  than  the  tertian  flagellates,  resembling  rather  the 
quartan.  The  process  of  transformation  of  crescentic  bodies  into  oval 
and  round  forms,  and  the  development  of  flagella  from  the  latter,  can 
sometimes  be  observed  in  studying  the  fresh  blood  microscopically. 
Councilman  once  observed  a  rapid  undulatory  movement  of  a  body 
presenting  the  general  appearance  of  a  crescent. 

Crescents  and  the  other  bodies  belonging  to  the  same  phase  not  infre- 
quently become  vacuolated  or  contain  or  throw  off  from  the  margin  little 
hyaline  balls  (pseudo-gemmation),  or  disintegrate  or  present  other 
degenerative  changes  (Plate  II.  Figs.  34,  41,  40).  Danilewsky  has 
observed  crescents  of  unusually  large  size,  as  much  as  20-22  /x  long  and 
4-6  fj.  broad. 

The  biological  significance  of  the  crescents  is  unknown.  These 
bodies  do  not  belong  to  the  regular  sporulating  cycle  of  development 
of  the  parasite,  and  there  is  no  positive  proof  of  their  capacity  for 
further  development. 

Dr.  Thayer  in  a  personal  communication  to  the  writer  reports  a 
valuable  experiment  made  by  himself  which  demonstrates  the  incapacity 
of  crescents  when  inoculated  into  the  blood  of  healthy  individuals  to 
develop  or  to  cause  any  symptoms.  The  blood  was  taken  from  a  patient 
who  had  had  acute  sestivo-autumnal  fever,  which  was  arrested  by 
administration  of  quinine.  Crescents  persisted  in  the  blood.  For  seven 
days  the  blood  was  examined  without  finding  hyaline  bodies  or  any  form 
of  the  malarial  parasite  other  than  crescents.  Seven  days  after  the 
disappearance  of  the  hyaline  bodies  a  hypodermic  syringeful  of  blood 
containing  crescents  in  considerable  number  was  withdrawn  from  the 
median  basilic  vein  of  the  patient  and  immediately  injected  into  the 
corresponding  vein  of  a  healthy  man.  No  elevation  of  temperature  or 
other  symptoms  followed  the  injection,  nor  did  crescents  or  any  parasitic 
forms  make  their  appearance  in  the  blood,  which  was  examined  daily  for 
two  weeks  and  at  intervals  for  over  a  month.  In  the  inoculation  experi- 
ments of  Gualdi  and  Antolisei  and  others  in  which  it  is  stated  that  the 
blood  contained  only  crescents  and  infection  with  the  Hsematozoon  fal- 
ciparum followed  in  the  inoculated  individual,  it  is  probable  that  hyaline 


p.  I RA  SI  TO  L  0  a  Y.  57 

bodies  were  present  in  the  hlood  used  for  the  inocnhition   in  such  small 
number  that  they  escaped  detection. 

Tiie  tbUowino'  are  the  ])rincij)al  views  whieii  have  been  advanced 
regarding  the  interj)retation  of  the  crescents  : 

1.  Laveran  regards  the  crescentic  bodies  as  encysted  forms  from 
wliicli  the  fiageUa  develop.  There  is  no  proof  that  these  bodies  are 
encysted. 

2.  Canalis  and  Antolisei  and  Angelini  believe  that  they  iiave  found 
evidences  of  s})orulation  in  the  crescents  and  the  ovoid  and  round  bodies 
belonging  to  the  crescentic  phase,  Grassi  and  Feletti  and  8a(;harott' 
likewise  believe  that  these  bodies  may  sporulate.  Golgi  considers  them 
capable  of  reproductive  development  in  long  cycles,  and  brings  them 
into  special  relation  with  relapses  and  with  fevers  of  long  intervals. 
Most  observers  have  been  unable  to  iind  genuine  sporulation  or  other 
evidences  of  reproduction  in  these  bodies. 

3.  Grassi  and  Feletti  consider  that  the  crescents  belong  to  a  separate 
species  which  they  call  Laverania,  and  of  which  they  represent  a  regidar 
phase  of  development.  The  sporulating  hyaline  bodies  with  which  the 
crescents  are  usually  associated  constitute,  according  to  these  writers, 
different  species.  This  view  is  not  generally  accepted,  and  is  opposed 
to  the  observed  facts. 

■4.  Mannaberg  regards  the  crescents  as  encysted  syzygies  formed  by 
conjugation  of  two  sestivo-autumnal  parasites  and  capable  of  reproduc- 
tion by  segmentation.  His  view  is  unconfirmed  by  any  other  observer, 
and  is  improbable.  It  fails  to  explain  the  ovoid  and  round  bodies  which 
belong  to  the  same  phase  of  development,  and  it  cannot  be  reconciled 
with  the  apj)earances  noted  in  the  steps  of  development  of  the  cres- 
cents, as  has  been  shown  by  Bastianelli  and  Bignami. 

5.  Councilman  suggests  that  the  crescents  may  be  of  the  nature  of 
spores.  Several  authors  have  called  attention  to  a  resemblance  between 
these  bodies  and  the  falciform  spores  of  coccidia,  but  there  are  such 
essential  differences  between  the  two  that  the  apparent  resemblance  is 
only  of  the  most  superficial  character. 

6.  Bastianelli  and  Bignami  have  described  the  crescents  as  deviate 
and  sterile  forms.  This  has  been  interpreted  to  mean  that  they  regard 
the  crescents  as  degenerative  forms — a  view  held  by  Kruse  and  some 
others — but  in  their  latest  publication  ^  they  suggest  that  these  bodies 
are  a  rudimentary  phase  of  a  second  developmental  cycle  which  cannot 
be  completed  within  the  human  body,  but  requires  for  its  continuation 
some  new  environment  in  the  outer  world.  They  call  attention  to  the 
occurrence  of  two  cycles  of  development  in  several  unicellular  parasites, 
especially  the  coccidia,  which,  after  passing  through  several  generations 
in  their  ordinary  parasitic  life,  enter  upon  forms  belonging  to  a  second 
cycle.  The  forms  of  this  second  cycle  remain  sterile,  degenerate,  and 
die,  unless  the  parasite  can  escape  from  its  host  and  find  its  appropriate 
new  conditions  of  life.  Manson  independently  also  has  advanced  the 
hypothesis  that  the  crescents  are  intended  for  the  continuance  of  the 
life  of  the  species  in  the  external  world.  It  has  already  been  mentioned 
that  a  similar  view  has  been  suggested  also  regarding  the  significance 

^Bastianelli  and  Bignami:  "vStudi  suUa  Infezione  Malarica,"  Bullettino  delta  R. 
Accademia  Medica  di  Eoma,  Anno  XX.,  1893-94. 


58  MALARIA. 

of  the  flagellate  bodies,  and  that  Manson  believes  that  the  mosquito 
may  serve  as  the  host  for  this  second  cycle  of  development. 

Differential  Diagnosis  of  the  Yaeieties  of  the  Malaeial. 

Paeasite. 

An  inexperienced  observer  may  possibly  mistake  for  the  unpigmented 
intracorpuscular  hyaline  forms  of  the  malarial  parasite  the  vacuoles 
which  occasionally  are  present  within  red  blood-corpuscles  or  the  clear 
spots  which  may  result  from  certain  deformities  in  the  shape  of  the 
corpuscles.  These  vacuoles  and  clear  spots  may  be  distinguished  in  the 
fresh  specimen  by  their  sharp  outlines,  the  absence  of  amoeboid  changes 
of  shape,  and  a  difference  in  refraction  often  suggestive  of  an  empty 
space  or  hole,  and  which  can  be  described  less  readily  than  it  can  be 
appreciated  by  actual  observation.  The  absence  of  definite  staining 
readily  distinguishes  these  vacuoles  from  the  hyaline  bodies  of  the  para- 
site in  stained  specimens. 

There  are  occasionally  seen  in  red  corpuscles  in  stained  specimens  of 
the  blood,  especially  in  anaemic  conditions,  small  stained  dots  which  do 
not  bear  much  resemblance  to  forms  of  the  malarial  parasite,  but  which 
should  be  known  to  the  observer  in  order  to  avoid  the  possibility  of 
mistake.  They  are  believed  by  some  to  be  the  result  of  degenerative 
changes  in  the  corpuscles,  and  by  others  to  be  remnants  of  nuclear 
chromatin  derived  from  the  originally  nucleated  condition  of  the  red 
corpuscle. 

Blood-plates  can  be  mistaken  only  for  free  spores  or  very  small 
extracorpuscular  hyaline  bodies.  In  general  no  attention  should  be 
paid  as  regards  diagnosis  to  bodies  free  in  the  plasma  which  resemble 
blood-plates.  In  fresh  specimens  it  is  practically  impossible  to  diagnose 
free  spores  with  any  certainty.  Clumps  of  blood-plates  have  been  mis- 
taken for  sporulating  bodies,  but  they  can  be  readily  distinguished  from 
the  latter  by  the  absence  of  pigment. 

For  the  sake  of  convenience  the  principal  characters  which  enable 
us  to  distinguish  each  of  the  three  varieties  of  the  malarial  parasite, 
and  which  have  already  been  described  in  detail,  Avill  here  be  summarized. 
For  modifications  and  amplification  of  these  general  statements  the 
reader  must  consult  the  detailed  descriptions  already  given. 

1.  Duration  of  the  Cycle  of  Development. — In  the  quartan 
parasite,  seventy-two  hours ;  in  the  tertian,  forty-eight  hours ;  in  the 
sestivo-autumnal,  irregular,  varying  from  twenty-four  hours  to  forty- 
eight  hours. 

2.  Amceboid  Hyaline  Bodies. — In  their  earliest  stages  often  indis- 
tinguishable from  each  other.  Later,  those  of  the  quartan  parasite, 
sharply  outlined,  somewhat  refractive,  sluggishly  amoeboid,  with  develop- 
ment of  dark  brown  or  black,  relatively  coarse  pigment  granules,  which 
have  but  little  motion.  Amoeboid  movements  cease  in  a  relatively  early 
stage  of  development  of  the  pigmented  hyaline  body. 

Those  of  the  tertian  parasite,  pale  and  indistinct,  actively  amoeboid, 
with  development  of  reddish-brown,  actively  motile,  relatively  fine  pig- 
ment granules,  which  tend  to  accumulate  in  the  bulbous  swellings  at 
the  extremities  of  the  delicate  branching  pseudopodia.     Amoeboid  move- 


rARASITOLOGY.  59 

ments    continue    in    late    stajj^es    of    development    of    the     pijrniented 
anioebje. 

Those  <tf  the  ;estivt)-autuninal  parasite,  small,  somewhat  refraetive, 
in  repose  rini>,-shape(l,  aetively  aiufehoid,  with  development  of  a  few 
very  tine  dark  reildish-brown  or  black,  only  slightly  motile,  pigment 
gr.mnles,  or  sometimes  without  j)igment  throughout  all  phases  of  the 
sporulating  cycle  of  develo])ment. 

3.  F'JLLY  Developed  Hyaline  Bodies. — Tliose  of  the  quartan 
parasite  are  somewhat  smaller  in  size  than  the  normal  red  blood-corpuscle, 
and  are  usually  surrounded  by  a  l)order  of  the  colored  refractive  sub- 
stance of  the  enveloping  red  blood-corpuscle. 

Those  of  the  tertian  parasite  attain  the  full  size  of  a  normal  red 
blood-eorj)uscle  and  lie  in  swollen  decolorized  red  blood-corpuscles. 
Swollen,  extraeorpuscular,  transparent  bodies  with  dancing  pigment 
granules  are  common. 

Those  of  the  lestivo-autumnal  parasite  do  not  generally  exceed  one- 
quarter  to  one-third  the  size  of  the  red  blood-corpuscle.  The  enveloping 
corpuscle  is  often  shrunken  and  brassy.  They  contain  much  less  pig- 
ment than  the  quartan  and  tertian  forms,  and  sometimes  none  at  all. 

4.  Presegmenting  Bodies, — In  the  process  of  collection  of  the  pig- 
ment into  a  mass  or  block  in  the  centre  or  excentrically  the  pigment 
grannies  often  assume  a  more  regular  stellate  arrangement  in  the  quartan 
than  in  the  tertian  forms.  The  differential  points  between  the  three 
varieties  in  this  stage  relate  to  the  same  differences  in  size,  in  the  amount 
of  pigment,  and  in  the  condition  of  the  infected  corpuscle  as  have  been 
mentioned  under  the  preceding  heading.  The  presence  in  the  blood  of 
quartan  and  tertian  presegmenting  bodies  is  associated  with  that  of 
sporulating  forms,  wdiereas  ^vith  the  sestivo-autumnal  presegmenting 
bodies  sporulating  forms  are  almost  always  missed  in  the  circulating 
blood. 

5.  Sporulatixg  Bodies. — Those  of  the  quartan  parasite  in  equal 
proportion  in  the  peripheral  and  the  splenic  blood.  They  are  some- 
what smaller  than  the  red  corpuscles,  and  present  typical  rosette  forms 
with  a  division  into  six  to  twelve  ovoid  or  pyriform  segments,  each 
segment  becoming  an  oval  or  round  spore  containing  a  bright  nucleiform 
dot. 

Those  of  the  tertian  parasite  are  more  numerous  in  the  splenic  than 
in  the  peripheral  blood.  They  are  as  large  as  the  red  blood-corpuscle, 
and  present  less  regularity  in  segmentation  than  the  quartan  parasite. 
They  segment  usually  into  from  fourteen  to  twenty  spores,  which  are  a 
little  smaller  and  with  less  distinct  nucleiform  dot  than  those  of  the 
quartan  organism. 

Those  of  the  lestivo-autumnal  parasite  are  found  only  most  excep- 
tionally in  the  circulating  blood  in  ordinary  cases.  They  are  abundant 
in  certain  internal  organs,  including,  as  a  rule,  the  spleen.  They  do  not 
generally  exceed  one-third  to  one-half  the  size  of  the  red  blood-cor- 
puscle. They  segment  irregularly,  the  number  of  spores  being  some- 
times six  to  ten,  sometimes  ten  to  twenty  or  even  more.  The  spores  are 
smaller  than  those  of  the  quartan  and  the  tertian  parasites.  The  stage 
of  sporulation  is  a  prolonged  one. 

6.  Behavior  of  the  Ixfected  Corpuscles. — These  often  become 


60  ITALAEIA. 

somewhat  shrunken  and  deeper  in  color  in  the  quartan  infections; 
swollen  and  decolorized  in  the  tertian  ;  and  shrunken  and  brassy,  some- 
times with  retraction  of  haemoglobin  from  the  outer  part  of  the  cor- 
puscle, in  the  sestivo-autumnal. 

7.  Crescentic  Bodies. — Crescents  and  bodies  of  the  crescentic 
phase  appear  only  in  infections  with  the  aestivo-autumnal  parasite. 

8.  Pigmexted  Leucocytes. — Most  abundant  during  and  shortly 
after  the  paroxysm,  they  usually  disappear  during  the  period  of  apyrexia 
in  quartan  and  tertian  infections,  whereas  it  is  not  uncommon  to  find 
them  in  all  periods  of  sestivo-autumnal  infections. 

The  Intimate  Structure  of  the  Malarial  Parasite. 

The  first  systematic  study  of  the  finer  structure  of  the  malarial 
parasite  was  made  by  Celli  and  Guarnieri  (1888-89).  This  was 
followed  by  similar  investigations  by  Grassi  and  Feletti,  Romanowsky, 
SacharoflF,  Mannaberg,  Antolisei,  and  Bastianelli  and  Bignami.  The 
small  size  and  the  but  slightly  differentiated  appearance  of  most  forms 
of  the  parasite,  and  the  difficulty  of  obtaining  clear  differential  stain- 
ings,  obscure  the    insight  into  their  intimate  structure. 

Little  detail  of  structure  can  be  made  out  in  unstained  specimens. 
The  substance  of  the  parasite  presents  in  general  a  homogeneous,  color- 
less, hyaline  appearance.  In  the  amoeboid  hyaline  bodies  of  the  quartan 
and  tertian  parasites,  particularly  in  the  larger  forms,  an  area  of 
variable  size  in  the  centre,  or  more  frequently  excentrically  placed,  may 
sometimes  be  differentiated  by  its  clear,  pale  appearance  from  the  more 
refractive  outer  zone.  This  area  corresponds  to  the  unstained  structure 
interpreted  by  many  observers  as  the  nucleus  in  stained  specimens. 
Occasionally  two  or  more  such  clear  spaces  can  be  seen.  Sometimes 
in  the  larger  amoeboid  and  the  mature  forms  a  finely  granular  appear- 
ance of  the  protoplasm  can  be  detected.  It  is  particularly  characteris- 
tic of  the  sestivo-autumnal  parasite  that  the  young  intracorpuscular 
hyaline  bodies  show,  when  at  rest,  a  clear  space  surrounded  by  a  ring 
of  protoplasm,  usually  thin  and  delicate  on  one  side  and  thicker  on  the 
other.  This  clear  space  appears  unstained  on  stained  specimens.  The 
mature  forms  in  which  the  pigment  has  collected  into  one  or  more 
clumps  appear  uniform  in  structure  in  fresh  specimens,  or  may  perhaps 
present  a  slightly  granular  appearance.  Within  the  spores,  especially 
distinctly  in  those  of  the  quartan  parasite,  a  bright  body  can  often  be 
distinguished,  which  represents  the  nucleus  or  a  nucleiform  material. 

The  methods  for  staining  the  parasites  will  be  described  under 
Diagnosis,  ^age  139.  These  methods  are  useful,  not  only  for  the  study 
of  the  finer  structure,  but  also  for  the  ready  detection  of  the  unpig- 
mented  young  hyaline  forms,  particularly  of  the  sestivo-autumnal 
parasites,  which  may,  without  very  careful  observation,  escape  recogni- 
tion on  fresh  specimens,  whereas  the  presence  of  pigment  at  once 
attracts  attention  in  the  fresh  specimens  to  the  other  parasitic  forms. 

On  suitably  stained  specimens  the  intracorpuscular  young  hyaline 
bodies  show  a  stained  outer  part,  an  unstained,  usually  excentrically 
placed,  internal  part,  and  one  or  more  deeply  stained  round  or  elon- 
gated particles  situated,  as  a  rule,  near  the  border  of  the  stained  and 


PARASITOLOGY.  61 

unstained  parts.  Tlie  constant  unstahu'd  [)art  is  not  to  he  confounded 
with  vacuoles  which  may  occasionally  be  present.  There  have  been 
various  interpretations  of  the  structures  thus  ditlerentiated.  Celli  and 
Guarnieri  desi»>nuted  the  stained  part  as  ectoplasm  and  the  unstained 
part  as  end(»plasni.  The  deeply  staining  particles  they  interpreted  as 
the  beginniui;-  ditferentiation  of  a  nucleus,  whi(!h  they  thought  they 
could  reeogni/e  in  larger  forms  as  a  definite,  stained  or  pale  Ixxly  with- 
in the  endoplasni.  Grassi  and  Feletti  do  not  recognize  a  division  of 
the  protoplasm  into  ectoplasm  and  endoplasm,  and  in  this  they  are 
followed  by  most  observers.  The  clear  unstained  part  they  interpret 
as  a  relatively  large,  vesicular  nucleus,  and  the  deeply  staining  particles 
as  nucleoli  i'rom  which  may  proceed  a  delicate  reticulum  of  chromatin 
connecting  them  with  the  nuclear  membrane  which  they  assume  to 
exist.  The  rest  of  the  bladder-like  nucleus  is  filled  with  clear  nuclear 
juice.  Although  not  all  of  these  details  in  the  structure  of  the  nucleus, 
such  as  the  membrane  and  the  reticulum,  have  been  observed  by  sub- 
sequent investigators,  Grassi  and  Feletti's  interpretation  of  the  un- 
stained })art  as  a  nucleus  and  of  the  deeply  staining  particle  as  a  nu- 
cleolus or  a  concentration  of  nuclear  chromatin  has  been  adopted  l)y 
Celli  and  Sanfelice,  Romanowsky,  Sacharoff,  and  Mannaberg,  and  has 
been  widely  accepted. 

Bastianelli  and  Bignami,  while  not  denying  that  this  interpretation 
is  applicable  to  the  quartan  and  tertian  amoebae,  adopt  a  different  view 
as  to  the  structure  of  the  aistivo-autumnal  amoebae,  which  they  have 
studied  with  great  care.  They  differentiate  in  the  latter  an  outer 
colored,  chromatic  cytoplasm  in  the  form  of  a  stained  ring,  usually 
thicker  on  one  side,  and  an  inner  uncolored,  achromatic  cytoplasm, 
which  is  all  of  the  clear  part  enclosed  by  the  ring.  The  deeply  staining 
chromatic  particle  they  find  in  the  chromatic  and  not  in  the  achromatic 
cytoplasm.  Often  there  are  two  particles,  each  at  opposite  points  in  the 
ring.  This  particle  is  the  only  representative  of  nuclear  material  in 
the  parasite,  and  they  interpret  it  as  fulfilling  the  functions  of  a  nucleus. 
They  consider  that  the  rapidity  of  development  and  multiplication  of 
these  sestivo-autumnal  parasites  prevents  the  formation  of  a  definite 
nucleus  in  a  resting  stage,  such  as  is  described  for  the  quartan  and 
tertian  forms. 

According  to  Grassi  and  Feletti  and  Romanowsky,  the  nucleus  and 
nucleolus  can  be  found  in  all  stages  of  the  regular  cycle  of  development 
of  the  parasite.  The  nucleus  di\'ides  directly — or,  according  to  Roman- 
owsky, by  karyokinesis — to  form  multiple  nuclei  just  before  sporula- 
tion,  each  nucleus  then  entering  into  the  structure  of  a  spore. 

The  evidence,  however,  is  in  favor  of  the  view  that  at  a  certain  stage 
of  development  the  nucleus  and  the  nucleolus  disappear  as  differentiated 
structures,  the  latter  to  reappear  in  multiple  form  shortly  before  sporu- 
lation.  Mannaberg  was  the  first  to  demonstrate  this  clearly  in  his  studies 
of  the  structure  of  the  tertian  parasite.  He  observed  that  as  the 
amoeboid  bodies  approach  their  mature  form,  and  then  become  the  pre- 
segmenting  bodies,  the  deeply  staining  particle  (nucleolus)  disappears, 
and  later  the  clear,  previously  unstained  part  (nucleus)  stains  diffusely, 
so  that  there  is  in  this  stage  no  definite  differentiation  of  structure  in  the 
parasite,  although  the  outer  part,  as  a  rule,  stains  more  deeply  than  the 


62  3IALABIA. 

central  part.  He,  however,  speaks  of  the  outer  part,  which  contains 
pigment  granules,  as  the  "  plasma  part,"  and  the  inner  part,  into  which 
the  pigment  does  not  penetrate,  as  the  "  nuclear  part."  He  attributes 
the  deeper  and  more  diffused  staining  of  the  parasite  in  this  stage  to  the 
solution  of  nuclear  chromatin  into  the  protoplasm.  The  first  evidence 
of  sporulation  on  stained  specimens  is  furnished  by  the  appearance  of 
numerous  small,  deeply  staining  granules  of  chromatin  in  the  periphery 
of  the  protoplasm.  These  are  the  forming  nucleoli,  which  increase  in 
size,  and  around  each  the  general  protoplasmic  substance,  during  the 
process  of  segmentation,  divides,  so  that  each  segment  or  spore  is  a  cell 
composed  of  a  nucleiform,  deeply  staining  body  surrounded  by  its  pro- 
toplasmic envelope.  In  the  quartan  and  tertian  spores  a  clear  unstained 
part  later  is  usually  diiferentiated  around  the  chromatin  granule,  and 
the  nucleus  now  resembles  that  seen  in  the  young  amoeboid  hyaline 
bodies  within  the  red  corpuscle. 

Bastianelli  and  Bignami  likewise  demonstrated  the  disappearance  of 
the  deeply  staining  nucleiform  body  in  the  forms  of  the  sestivo-autumnal 
parasite  containing  collected  pigment  (presegmenting  bodies),  and  soon 
afterward  the  appearance  of  diffuse  staining  in  the  previously  achro- 
matic cytoplasm,  so  that  in  this  stage  no  sharp  differentiation  of  struc- 
ture can  be  made  out  within  the  parasite,  which  is  richer  in  chromatic 
material  than  before  the  disappearance  of  the  nucleiform  body.  The 
first  sign  of  sporulation  is  the  formation  of  multiple  nucleiform  chro- 
matin granules  in  the  periphery  and  the  development  of  spores  proceeds 
in  the  manner  already  described,  save  that  the  sestivo-autiminal  spores 
are  composed  only  of  the  deeply  staining  nucleiform  body  immediately 
surrounded  by  cytoplasm.  The  presence  of  the  small,  clear,  unstained 
part,  which  with  the  chromatin  particle  is  interpreted  as  the  nucleus, 
often  seen  in  the  tertian  and  quartan  spores,  is  rarely  observed  in  the 
sestivo-autumnal  spores. 

It  is  evident  from  this  description  that  the  spores  of  the  malarial 
parasite  possess  a  definite  structure,  a  most  important  feature  being  the 
presence  of  a  deeply  staining  body  which  serves  the  function  of  a 
nucleus.  The  recognition  of  this  structure  renders  it  possible  to  dis- 
tinguish from  genuine  spores  the  various  pseudospores  which  have  been 
at  times  erroneously  interpreted  as  phases  of  reproduction  of  the  para- 
site, and  which  belong  to  the  category  of  degenerative  forms.  Although 
Antolisei  has  described  a  double  contour,  which  he  interprets  as  a  mem- 
brane, about  the  spores,  this  observation  has  not  been  confirmed,  and 
the  spores  are  to  be  regarded  as  naked,  thus  belonging  to  the  class  of 
gymnospores.  Some  have  objected  to  the  designation  of  these  segments 
as  spores,  but  this  nomenclature  is  in  accordance  with  that  employed  by 
zoologists  for  similar  bodies  formed  in  a  like  manner  in  certain  other 
unicellular  organisms. 

It  is  evident  from  the  preceding  description  that  investigators  are  not 
wholly  agreed  as  to  what  structure  in  the  malarial  parasite  shall  be 
called  the  nucleus,  some  applying  this  name  to  an  unstained  part  con- 
taining the  deeply  staining  chromatin  particle,  others  regarding  the 
chromatin  granule  itself  as  the  only  representative  of  the  nucleus. 
There  is,  however,  general  agreement  that  this  deeply  staining  particle 
or   body   is   an   essential    constituent   of    the    nucleus,    and    that   the 


PARASITOLOGY.  63 

presence  of  a  nucleus  or  of  a  nucleifonn  body  in  tlic  parasite  has  been 
demonstrated.  This  (h'luonstratiou  fulfils  the  important  hiolo^ieal  con- 
dition that  sometiiing-  performing'  the  functions  of  a  nucleus  belongs  to 
every  cell  capable  of  reproduction,  and  it  has  served  to  remove  any  lin- 
gering doubt  which  may  have  been  entertained  as  to  the  recognition  of 
these  bodies  as  j)arasitic  organisms. 

It  is  interesting  to  note  that  during  the  regular  cycle  of  develop- 
ment there  is  a  continual  increase  in  the  amount  of  staining  or  chro- 
matic substance  from  the  small  hyaline  body  to  the  sporulating  bodies, 
and  that  the  cell  becomes  multinucleated  just  before  segmentation  occurs. 
As  the  chromatic  substance  is  to  be  regarded  as  endowed  with  especial 
functional  activity,  these  changes  are  highly  significant. 

The  mature  crescents,  as  a  rule,  stain  feebly  and  diffusely,  or  often 
only  at  the  poles,  and  perhaps  also  along  the  margin.  Near  the  middle 
one  or  two  deeply  stained  granules,  often  covered  up  by  the  pigment, 
may  be  present,  but  they  are  not  constant.  Mannaberg  finds  often  a 
narrow  stained  band  in  which  are  two  or  more  deeply  stained  granules, 
stretching  across  the  middle  of  the  crescent.  Bastianelli  and  Bignami  find 
that  the  young  developing  bodies  of  the  crescentic  phase  stain  diifusely 
and  less  intensely  than  the  bodies  with  a  central  block  of  pigment  which 
develop  into  segmenting  forms.  Whereas  in  the  forms  of  the  parasite 
which  develop  into  sporulating  bodies  there  is  a  continual  increase  in  the 
chromatic  substance  as  the  bodies  continue  to  develop,  in  the  develop- 
ment of  the  semilunar  bodies  there  is  no  correspondingly  large  increase 
of  staining  substance.  With  rare  exceptions  these  observers  found  no 
chromatin  granules  in  these  developing  crescentic  bodies,  nor  did  they 
ever  find  in  any  body  of  this  group  those  changes  of  structure,  such 
as  the  appearance  of  several  chromatin  granules,  which  indicate  sporu- 
lation. 

Laveran,  Celli  and  Guarnieri,  and,  wdth  especial  emphasis,  Manna- 
berg, consider  that  the  crescents  are  enveloped  in  a  double  contoured 
membrane.  A  number  of  other  observers  have  also  adopted  this  view. 
We  do  not  consider  that  any  definite  membrane,  which  can  be  regarded 
as  a  part  of  the  parasite  itself,  has  been  satisfactorily  demonstrated 
around  the  crescents  or  around  any  form  of  the  malarial  parasite.  A 
double  contour  can  sometimes,  but  not  regularly,  be  seen  in  the  peripli- 
ery  of  the  crescents,  but  this  alone  cannot  be  considered  as  proof  of  the 
existence  of  a  membrane.  The  manner  in  which  little  hyaline  pieces 
(pseudo-gemmation)  can  sometimes  be  seen  to  form  at  the  margin  of  the 
crescentic  bodies  speaks  against  the  presence  of  an  actual  membrane. 

The  Malarial  Pigment. 

The  question  as  to  the  origin  of  the  malarial  pigment,  which  was  so 
long  discussed  without  conclusive  result  before  the  discovery  of  the 
malarial  parasite,  has  been  definitely  settled  by  this  discovery.  The 
pigment  is  formed  by  the  parasite  out  of  the  haemoglobin  of  the  blood- 
corjjuscles  by  w^hat  may  be  regarded  as  a  process  of  digestion.  The 
pigment  occurs  in  the  form  of  little  granules,  which  may  be  fine  or 
coarse,  and  of  distinct  rods  and  spicules,  which  may  be  as  much  as  1  fi 
long.      Such    rods   often   present  a  certain  superficial  resemblance  to 


64  MALARIA. 

deeply  stained  bacilli.  The  pigment  may  occur  in  the  form  of  extremely 
fine  dust-like  particles  not  easy  to  detect.  It  may  be  fused  into  black 
blocks.  The  color  varies  from  a  yellowish-brown  or  rusty,  reddish- 
brown  to  black.  Laveran  speaks  of  fire-red  and  even  light-blue  pig- 
ment, and  Rosenbach  observed  a  greenish  hue  of  the  pigment.  The 
malarial  pigment  is  somewhat  loosely  ranked  by  pathologists  among  the 
melanin  pigments.  The  differences  in  the  characters  of  the  pigment 
belonging  to  the  different  varieties  of  the  malarial  parasite  have  already 
been  sufficiently  described.  The  deposition  of  the  pigment  in  the  various 
organs  will  be  described  under  the  Pathological  Anatomy. 

Since  the  examinations  of  malarial  pigment  by  Meckel  and  by  Frerichs 
it  has  been  known  that  concentrated  sulphuric  acid  and  hydrochloric 
acid  do  not  alter  it,  and  that  it  disappears  upon  the  addition  of  strong 
alkalies  and  of  chloride  of  lime.  Kiener  observed  that  the  pigment  is 
dissolved  by  ammonium  sulphide. 

The  demonstration  of  the  origin  of  the  malarial  pigment  from  the 
blood  coloring  matter  at  once  raised  the  question  whether,  like  many 
pigments  of  hsematogenous  origin,  it  contains  iron  demonstrable  by  our 
micro-chemical  tests.  A  statement  by  Perls  as  long  ago  as  1867,  that 
pigments  in  the  spleen  of  intermittent  fever  respond  to  the  test  for 
iron,  has  given  rise  to  much  confusion.  It  is  not  wholly  clear  that 
Perls  examined  the  malarial  pigment,  but,  if  he  did,  there  can  be  no 
doubt  that  he  mistook  for  the  true  malarial  pigment  other  pigments 
which  are  abundantly  present  in  certain  organs  of  those  dead  of  malaria, 
and  which  respond  to  the  chemical  tests  for  iron  (hsemosiderin).  It  has 
been  shown  by  Neumann,  Bignami,  Stieda,  Dock,  and  others  that  the 
pigment  formed  directly  by  the  malarial  parasite  does  not  contain  iron 
in  a  combination  which  will  respond  to  our  ordinary  micro-chemical 
tests  for  this  element.  This,  of  course,  does  not  prove  that  it  may  not 
contain  iron  in  some  combination,  such  as  that  in  hsemoglobin,  which 
cannot  be  demonstrated  by  our  micro-chemical  reactions.  As  has  been 
pointed  out  by  the  writers  named,  the  organs  of  those  dead  of  malaria, 
particularly  the  spleen,  the  liver,  and  the  bone  marrow,  contain  a  large 
amount  of  hsemosiderin,  the  presence  of  which  is  doubtless  to  be  ex- 
plained by  the  extensive  destruction  of  red  blood-corpuscles  in  malaria. 
There  is  no  evidence  that  hsemosiderin  is  formed  directly  by  the  malarial 
parasite.  Marchiafava  (1889),  however,  has  advanced  the  hypothesis 
that  the  black  pigment  may  be  formed  not  only  within  the  malarial 
parasites,  but  also  within  the  leucocytes  out  of  red  corpuscles  altered 
by  the  action  of  the  parasite.  He  thus  explains  the  intense  melanosis 
of  the  spleen,  liver,  and  bone  marrow  in  certain  sestivo-autumnal  per- 
nicious infections  where  the  parasites  appear  only  slightly  pigmented. 
Bignami  ^  comes  also  to  the  conclusion,  from  his  extensive  examinations 
of  melanotic  organs  in  malaria,  that  the  black  pigment  without  micro- 
chemical  iron  reaction  may  have  this  double  origin,  being  formed  either 
within  the  malarial  parasite  without  an  intermediate  hsemosiderin  stage 
or  within  cells  out  of  hsemosiderin  derived  from  destroyed  red  corpus- 
cles. The  objection  to  this  conclusion  of  Bignami  is  that  hsemosiderin 
is  found  in  the  liver,  spleen,  and  bone  marrow  very  commonly  in 
ansemias,    but   that   the   black    pigment,   without    micro-chemical    iron 

'■  Bullettino  della  Beale  Accademia  Medica  di  Roma,  Anno  xix.  fasc.  ii.  p  230,  1893. 


PARASITOLOGY.  65 

reaction,  Avliich  cluiractcrizcs  inalacial  iiiicctioiis,  docs  not  n])i)car  inidcr 
those  oontlitions.  It  is  possible  tliat  the  niahirial  parasite  may  j)ro(hice 
some  ehemieal  ehaii«!:e  in  the  suhstanee  of  the  red  hlood-eorpuseU'  whieh 
permits  the  transformation  of  the  speeitieally  altered  luemo^lobin  into 
black  malarial  jiiginent  Avithin  certain  cells  of  the  body.  This,  how- 
ever, is  a  pnre  hypothesis. 

PllA(;()('YTISM. 

The  presence  of  malarial  j)igment  in  leucocytes  and  other  t-clls 
has  long  been  known.  Since  the  observation  of  phagocytic  phenom- 
ena in  malaria  by  Laveran,  Marchiafava  and  Celli,  and  Metchnikoif, 
important  studies  of  this  subject  have  been  made,  especially  by 
Guarnieri,  (iolgi,  Bastianelli,  and  Marchiafava  and  Bignami.'  These 
investigations  have  shown  that  phagocytosis  is  a  common  and  import- 
ant phenomenon  in  malaria,  although  there  is  much  difference  of 
opinion  as  to  the  interpretation  of  some  of  the  observed  facts.  Some 
assign  to  the  phagocytes  no  higher  role  than  that  of  scavengers  charged 
with  the  collection  and  removal  of  the  pigment  and  debris  resulting 
from  the  activities  of  the  malarial  parasites  and  from  the  death  and 
disintegration  of  the  parasites  themselves.  The  amount  of  slag  which 
is  produced  in  severe  cases  of  malaria  in  the  form  of  pigment,  dead  and 
disintegrating  red  blood-corpuscles,  and  degenerated  and  broken-up 
parasites  is  so  large  that  even  this  office  of  scavengers  becomes  an 
important  one.  But  ]Metchnikoff,  Golgi,  and  some  others  believe  that 
the  phagocytes  devour  large  numbers  of  intact,  healthy  parasites  in 
certain  phases  of  their  development,  and  that  in  this  contest  between 
cell  and  parasite  is  to  be  found  the  most  important  agency  for  the  de- 
fence of  the  body.  The  arguments  for  and  ag-aiust  this  latter  concep- 
tion are  essentially  similar  to  those  which  are  adduced  as  to  the  phago- 
cytic theory  in  bacterial  infections,  the  main  difficulty  being  to  deter- 
mine to  what  extent  fully  active  and  virulent  parasites  are  taken  up 
and  destroyed  by  phagocytes,  and,  even  admitting  the  occurrence  of  this 
mode  of  disposal  of  the  parasites,  whether  or  not  it  is  the  most  essential 
and  the  predominant  factor  in  their  destruction.  That  malarial  para- 
sites, as  well  as  bacteria,  may  perish  in  the  blood  plasma  without  incor- 
poration within  cells  cannot  be  doubted,  as  we  have  direct  observations 
demonstrating  this. 

The  cells  which  assume  the  functions  of  phagocytes  in  malaiia  are 
the  leucocytes,  the  endothelial  cells  of  the  walls  of  the  bloodvessels, 
and  large  cells,  found  especially  in  the  spleen,  the  bone  marrow,  and 
the  liver,  and  called  by  ]Metchnikolf  "  macrophages."  Of  the  leuco- 
cytes the  large  mononuclear,  the  polymorphonuclear,  and  the  transitional 
forms  act  as  phagocytes.  The  small  lymphocytes  and  the  eosinophils 
have  never  been  observed  to  contain  pigment  or  debris  in  malaria.  Of 
the  leucocytes  it  is  the  large  mononuclear  forms  which  are  the  most 
active  and  important  phagocytes  within  the  body  in  malaria,  but,  as  has 
been  pointed  out  by  Thayer  and  Hewetson,  the  polymorphonuclear  leu- 

^  Especially  valuable  are  tlie  articles  of  Golgi,  "II  fagocitismo  nell'  infezione 
malarica,"  liiforma  Medica,  188S,  and  of  Bastianelli,  "I  leucociti  nell'  infezione 
malarica,"   Bull,   delta  B.   Accademia  Medica  di  Bouia,   1892. 

Vol.  I. — 5 


66  MALAEIA. 

oocytes  are  the  ones  which  can  be  observed  to  be  active  in  the  fresh 
blood  during  examination  under  the  microscope.  It  is  the  latter  which 
pick  up  the  pigment  and  the  extracorpuscular  and  degenerated  parasites, 
and  which  attack  the  flagellated  bodies  in  the  fresh  blood  withdrawn 
from  the  body,  so  that  there  may  be  a  notable  diiference  between  the 
blood  examined  immediataly  after  its  withdrawal  from  the  body  and 
that  examined  at  a  later  period  as  regards  the  number  of  polymorpho- 
nuclear leucocytes  containing  foreign  elements.  Endothelial  cells  con- 
taining pigment,  parasites,  or  fragments  of  parasites  or  of  red  corjjuscles 
are  rarely  seen  in  the  circulating  blood  withdrawn  for  microscopical 
examination ;  but  the  study  of  microscopical  sections  of  organs  of  those 
dead  of  malarial  infections  shows  that  the  endothelial  cells  lining  the 
capillaries  and  small  bloodvessels,  especially  those  of  the  spleen,  bone 
marrow,  and  liver,  in  certain  cases  also  of  the  brain,  intestine,  and  other 
parts,  manifest  extensive  phagocytic  activities.  So  too  the  macrophages, 
although  they  have  repeatedly  been  found  in  the  circulating  blood,  are 
met  with  chiefly  in  the  splenic  blood  and  in  the  microscoj)ical  examina- 
tion of  organs  of  those  dead  of  malaria.  These  macrophages,  which 
may  attain  an  enormous  size  and  are  frequently  destitute  of  jiuclei,  and 
therefore  necrotic,  are  mononuclear  cells  derived  probably  in  part  from 
mononuclear  leucocytes  and  certain  fixed  cells  of  the  pulp  of  the  spleen 
and  bone  marrow.  Their  contents  may  be  varied,  consisting  sometimes 
within  one  cell  of  pigment,  intact  or  degenerated  parasites,  and  red 
blood-corpuscles  and  entire  smaller  phagocytes.  Dock  has  counted  as 
many  as  twenty  parasites  within  one  phagocyte  in  the  spleen.  Under 
Pathological  Anatomy  will  be  described  the  appearances  of  these  various 
phagocytes  as  seen  in  sections  of  the  diflFerent  organs  of  the  body. 

The  foreign  elements  which  are  found  within  these  phagocytes  in 
malaria  are — (1)  malarial  pigment;  (2)  yellowish  or  reddish-yellow  pig- 
ment derived  directly  from  disintegrated  red  corpuscles  (hemosiderin) ; 
(3)  red  corpuscles,  sometimes  intact,  but  usually  more  or  less  altered 
and  fragmented ;  (4)  malarial  parasites,  either  free  or  enclosed  within 
red  corpuscles,  which  are  usually  altered,  such  parasites  appearing  some- 
times intact,  often  degenerated  and  fragmented ;  (5)  particles  which  are 
probably  often  derived  from  the  disintegration  of  parasites,  but  which 
do  not  present  appearances  sufficiently  characteristic  to  enable  one  to 
determine  their  origin.  It  has  already  been  mentioned  that  a  phagocyte 
may  be  enclosed  by  a  macrophage.  Leucocytes  either  with  or  without 
pigment  may  be  thus  enclosed.  As  phagocytes  and  other  cells  often 
degenerate  and  become  necrotic  and  disintegrated  in  malaria,  it  is  evident 
that  from  this  source  may  be  derived  material  for  inclusion  within  living 
cells. 

First  in  order  of  frequency  are  phagocytes  containing  malarial  pig- 
ment. In  the  examination  of  malarial  blood  obtained  from  the  periph- 
eral circulation  the  only  form  of  phagocyte  which  is  to  be  seen  with  any 
frequency  in  the  perfectly  fresh  specimen  is  the  melaniferous  leucocyte. 
Leucocytes  containing  clearly  recognizable  parasites  are  rarely,  if  ever, 
seen  in  the  freshly  drawn  specimen  of  peripheral  blood.  Macrophages 
containing  definite  parasitic  forms  may  occasionally  be  found  in  this 
situation.  Both  mononuclear  and  polymorphonuclear  leucocytes  may 
contain  the  pigment,  but  in  the  perfectly  fresh  specimen  the  former 


PARASITOLOGY.  67 

preponderate.  The  })i<>ineiit  is  t'oiind  must  fV('(|U('ntly  in  tlie  form  of 
bloeks  and  eoarse  <»ranules,  eorresponding  to  that  set  free  by  tlie  process 
of  sporulation,  but  sometimes  the  pigment  within  the  leucocytes  is  in 
fine  rods  and  grains,  sucli  as  belong  to  the  earlier  stages  of  develop- 
ment of  the  j)arasite.  The  inference  is  a  probable  one  that  in  the  latter 
ease  the  leucocyte  may  have  enclosed  the  ])arasite. 

As  has  alri'ady  been  stated,  in  tlie  fresh  blood  remo\ed  from  the 
body  and  examined  for  a  while  under  tlie  microscope  the  ))olyniorpho- 
nuclear  leucocytes  can  be  seen  to  engulf  2)igment  and  certain  parasitic 
forms — viz.  extracorpuscular  forms,  es])ecially  degenerated  and  frag- 
mented forms,  segmenting  forms  and  spores,  and  altered  red  corpuscles 
— and  es])ecially  do  they  attack  the  flagellate  bodies,  as  has  been 
demonstrated  by  Thayer  and  Hewetson  (Plate  II.  Figs.  45-49).  Such 
enclosed  ])arasitic  forms,  with  the  exception  of  the  spores,  can  be  seen 
rapidly  to  become  indistinct  and  unrecognizable  within  the  leucocytes. 

From  the  examination  of  the  fresh  circulating  blood  alone  one  obtains 
a  very  inadequate  conception  of  the  extent  and  nature  of  the  phagocytic 
])rocesses  in  malaria.  A  fuller  idea  of  these  processes  can  be  derived 
from  the  study  of  blood  withdrawn  by  puncture  of  the  spleen,  where 
phagocytic  phenomena  are  far  more  active  than  in  the  circulating  blood  ; 
but  it  is  especially  in  the  microscopical  examination  of  the  organs  of 
those  who  have  succumbed  to  a  malarial  attack  that  the  best  oppor- 
tunity is  afforded  to  learn  the  extent  of  phagocytosis  in  malaria.  Here 
one  flnds  abundantly  leucocytes,  endothelial  cells,  and  macrophages  con- 
taining pigment,  parasitic  forms,  and  altered  red  blood-corpuscles. 

Parasites  in  their  later  stages  of  development,  especially  when  they 
are  free,  are  frequently  taken  up  by  phagocytes — in  their  early  stages 
rarely,  unless  they  have  become  extracorpuscular  or  the  corpuscle  con- 
taining them  is  degenerated.  Sporulating  forms,  and  somewhat  less 
frequently  forms  with  collected  pigment  (presegmenting  bodies),  are  the 
ones  most  commonly  found  in  a  recognizable  condition  within  the  phago- 
cytes. It  is  stated  by  Bastianelli  and  Bignami  that  the  bodies  with  pig- 
ment blocks  (presegmenting)  are  found  most  frequently  within  macro- 
phages, and  sporulating  forms  within  polymorphonuclear  leucocytes. 
Pigmented  amoebse  they  found  rarely,  and  red  blood-corpuscles  contain- 
ing unpigmented  amcebse  very  rarely,  Mithin  phagocytes.  Bastianelli 
gives  the  follomng  as  the  order  of  frequency  in  which  the  various  para- 
sitic elements  are  found  within  phagocytes :  (1)  pigment;  (2)  sporulat- 
ing forms  and  spores ;  (3)  red  corpuscles,  normal  or  decolorized,  con- 
taining sporulating  forms  or  bodies  with  central  pigment  blocks ;  (4) 
brassy  and  decolorized  red  corpuscles  containing  plasmodia  (hyaline 
bodies  in  the  amoeboid  stage) ;  ( 5 )  free  bodies  with  central  pigment 
clumps  ;  (6)  more  rarely  free  amoeba  or  red  corpuscles  of  normal  appear- 
ance containing  parasites  in  the  amoeboid  stage.  According  to  the  obser- 
vations of  the  writer,  free  bodies  with  central  pigment  clumps  occupy  a 
higher  place  in  this  scale  than  that  assigned  to  them  by  Bastianelli. 
Crescents  enclosed  in  phagocytes  may  be  found  even  in  the  circulating 
blood.  The  various  bodies  within  phagocytes  often  lie  in  an  area  sur- 
rounded by  a  clear  zone  like  a  vacuole. 

Golgi  (1887-88)  discovered  that  phagocytosis  occurs  in  quartan  and 
tertian  infections  with  a  definite  periodicity  which  stands  in  relation  to 


68  MALARIA. 

certain  phases  in  the  cyclical  development  of  the  parasite,  and  therefore 
to  certain  periods  of  malarial  fever.  This  is  readily  understood  Avhen 
one  considers  that  it  is  especially  the  free  pigment  and  the  mature  and 
segmenting  parasites  and  the  degenerative  forms  which  are  taken  up  by 
phagocytes.  The  pigment  is  liberated  by  the  process  of  sporulation 
which,  as  has  already  been  explained,  occurs  shortly  before  and  during- 
the  early  stages  of  the  paroxysm.  Corresponding  with  this,  Golgi  found 
that  pigmented  leucocytes  are  present  in  the  circulation  during  the 
paroxysm  and  for  a  short  time  afterward,  and  that  they  disappear  from 
the  circulation  during  the  apyrexia.  This  periodicity  in  the  appearance 
of  melaniferous  leucocytes  and  of  other  phagocytes  can  be  observed 
regularly  in  quartan  and  tertian  infections.  There  are  frequently  indi- 
cations of  it  also  in  sestivo-autumnal  infections,  but  on  account  of  the 
irregularities  in  the  cyclical  development  of  the  Hsematozoon  falciparum,, 
of  the  prolonged  period  of  sporulation,  of  the  frequent  occurrence  of 
multiple  groups  of  parasites,  and  of  the  presence  at  all  periods  of 
degenerated  red  corpuscles,  this  periodicity  in  the  occurrence  of  phago- 
cytosis is  often  obscured  or  is  not  manifest  at  all.  Pigmented  leucocytes 
may  be  found  in  many  cases  of  sestivo-autumnal  infection  during  all 
periods  of  the  disease,  although  they  are  more  numerous  during  the 
paroxysm  and  shortly  afterward.  In  the  severe  prolonged  cases  they 
are  generally  abundant,  and  they  may  persist  in  the  circulation  for  sev- 
eral days  after  cure  is  eifected.  As  long  as  crescents  are  present  pig- 
mented leucocytes  may  be  found. 

Parasites  which,  to  all  appearances,  are  normal  are  found  within 
phagocytic  cells,  AVhat  is  the  fate  of  such  enclosed  parasites?  That 
many  degenerate  and  die  cannot  be  questioned,  for  these  degenerative 
alterations  can  be  directly  observed  in  progress  under  the  microscope  in 
examining  fresh  blood,  and  in  studying  malarial  blood  and  tissues  one 
frequently  encounters  evidences  of  this  fate  of  the  parasites.  It  is 
claimed,  however,  by  Marchiafava,  Bignami  and  Bastianelli  that  enclosed 
spores,  although  prevented  from  further  development,  may  survive  for 
a  long  time  within  leucocytes  and  other  cells,  and  that  such  latent  spores- 
may  after  an  indefinite  period  be  set  free  and  cause  by  their  development 
a  relapse  of  the  fever. 

Attention  has  already  been  called  to  Golgi's  belief  that  the  astivo- 
autumnal  parasite  may,  and  to  a  considerable  extent  does,  develop 
within  the  leucocytes  and  endothelial  cells  of  internal  organs,  in  ordinary 
cases  chiefly  of  the  spleen  and  bone  marrow.  He  adduces  a  number  of 
considerations  in  support  of  this  view,  but  the  objective  evidence  he  and 
his  pupil,  A.  Monti,  find  in  the  detection  of  the  frequent  presence  of 
this  parasite,  apparently  intact  and  in  all  stages  of  development,  within 
these  cells.  In  opposition  to  Golgi,  however,  it  is  claimed  by  Marchia- 
fava, Bignami  and  Bastianelli  that  early  phases  of  development  of  the 
parasite  are  rarely  seen  within  the  cells,  and  that,  therefore,  the  much 
more  commonly  enclosed  late  phases  cannot  have  developed  within  the 
cells  from  young  parasites.  Golgi  also  brings  to  his  support  the  obser- 
vation, made  by  all  who  have  studied  the  subject,  that  many  of  the 
cells  containing  parasites  degenerate  and  die,  as  is  made  evident  especi- 
ally by  the  loss  of  their  nuclei.  He  interprets  this  as  meaning  that  in. 
the  conflict  between   cell  and  parasite  the  latter  often  comes  ofl'  the 


PARASITOLOGY.  69 

victor.  FiirtluT  investigations  arc  needed  to  determine  to  what  extent 
Oolgi's  doctrine  as  to  the  intercellular  residence  and  development  of 
the  Hsematozoon  falciparum  is  correct.  Certainly  the  greatly  prepon- 
derating nunii)er  of  intact  tTestivo-autumnal  parasites  observed  in  exam- 
ining the  organs  of  those  dead  of  pernicious  malaria  are  found  within 
free  red  blood-corpuscles  in  the  vessels  of  internal  organs. 

The  theory  of  Metchnikoff  that  the  essential  factor  in  the  resistance 
of  the  body  to  the  malarial  parasite  resides  in  the  activities  of  phago- 
cvtes  is  opposed  by  many  considerations.  The  most  important  factors 
in  determining  the  gravity  and  the  course  of  a  mahirial  infection  are 
the  degree  and  (piality  of  virulence  possessed  by  the  parasite,  on  the  one 
hand,  and  the  resistance  of  the  individual  receiving  the  parasite,  on  the 
other  hand.  There  is  no  evidence  that  phagocytic  functions  are  in 
abeyance  in  severe  and  pernicious  cases  of  malaria.  On  the  contrary, 
we  find  here  often  enormous  numbers  of  parasitic  enclosures  within 
])hagocytes.  There  is  no  proof  that  spontaneous  recoveries  from  malaria 
are  associated  with  an  increase  of  phagocytic  activity.  Inasmuch  as 
phagocytes  regularly  attack  degenerated  and  fragmented  parasites,  and 
as  we  know  that  such  degenerations  occur  frequently  \\nthin  parasites 
free  in  the  plasma,  it  is  permissible  to  suppose  that  many  of  the  para- 
sitic forms  found  within  phagocytes  were  already  impaired  in  their 
vitality  before  they  were  engulfed  by  cells.  After  the  administration  of 
(piinine,  which  directly  injures  the  malarial  parasite,  a  distinct  increase 
in  the  number  of  phagocytes  has  been  often  observed.  Certainly  qui- 
nine does  not  stimulate  the  leucocytes  to  swallow  the  parasites.  Here 
the  increase  in  the  phagocytes  must  be  attributed  to  the  increase  in  the 
numl^er  of  damaged  parasites. 

There  is  evidence  that  the  blood-plasma  may  exert  a  parasiticidal 
effect  upon  the  malarial  organism,  as  well  as  ujjon  other  protozoa  (Fag- 
gioli),  when  the  parasite  has  escaped  from  the  protective  covering  of  the 
red  blood-corpuscle.  The  period  when  the  largest  number  of  malarial 
parasites  are  destroyed  is  that  of  sporulation  and  of  free  spores,  and  it 
is  during  this  phase  of  the  life-history  of  the  parasite  that  quinine  acts 
most  effectively.  We  may,  at  least  provisionally,  adopt  a  theory  to 
explain  natural  resistance  to  the  malarial  parasite  similar  to  that  which 
many  accept  regarding  resistance  to  bacteria — \\z.  that  the  parasites  are 
destroyed  by  parasiticidal  substances  contained  both  in  the  plasma  and 
within  leucocytes  and  other  phagocytic  cells.  The  substances  injurious 
to  the  parasite  are  in  the  last  analysis  furnished  to  the  plasma  by  the 
cells,  and  are  in  a  more  concentrated  or  potent  form  within  the  cells 
than  in  the  fluids.  This  theory  assigns  to  the  phagocytes  a  higher  role 
than  that  of  mere  scavengers.  They  are  endowed  in  especial  degree 
with  the  power  of  destroying  the  parasite,  but  this  power  is  shared  by 
the  plasma. 

Pathogexesis. 

The  discovery  of  the  malarial  parasite  has  placed  within  our  reach 
the  means  of  solving  many  problems  concerning  malaria  which  we  could 
not  formerly  even  attack  with  any  hope  of  success.  Already  we  have 
attained  a  satisfactory  understanding  of  not  a  few  previously  unexplained 
manifestations  of  malaria,  and  other  formerly  obscure  malarial  phenom- 


70  MALARIA. 

ena  have  been  brought  at  least  within  the  range  of  our  comprehension. 
Much  still  remains  to  be  elucidated,  but  we  cannot  doubt  that  further 
studies  will  continue  to  throw  fresh  light  upon  what  remains  obscure. 

In  the  description  of  the  symptoms  and  lesions  of  malaria  attention 
will  frequently  be  called  to  their  relations  to  the  parasite,  and  in  this 
connection  only  certain  salient  points,  relating  more  particularly  to 
pathogenic  properties  of  the  parasite,  require  consideration. 

The  mere  presence  of  the  malarial  parasite  in  the  body  is  not  suf- 
ficient to  cause  symptoms.  The  organisms  must  have  multiplied  to  a 
certain  point  before  their  presence  is  manifested  by  recognizable  symp- 
toms. The  bearing  of  this  fact  upon  certain  malarial  phenomena,  more 
particularly  upon  the  varying  periods  of  incubation  as  determined  by 
experimental  inoculations  of  malarial  blood  and  upon  fevers  with  long 
intervals,  will  be  considered  in  the  clinical  part  of  this  article. 

It  may  be  stated  as  a  general  rule,  which  was  first  formulated  by 
Golgi,  that  the  larger  the  number  of  organisms  present  in  the  body  the 
more  severe  are  the  manifestations  of  the  disease ;  but  the  number  of 
the  organisms  is  by  no  means  the  only  factor  which  determines  the 
gravity  of  the  disease.  The  variety  of  parasite  which  is  concerned  in 
the  infection  is  a  factor  of  fundamental  importance.  The  quartan  variety 
produces  the  mildest  attacks,  the  tertian  is  more  virulent  than  the 
quartan,  and  the  sestivo-autumnal  variety  is  the  most  virulent  of  all, 
and  is  the  one  which  is  almost  exclusively  associated  with  the  pernicious 
attacks.  These  variations  in  virulence  are  best  explained  upon  the 
assumption  that  the  malarial  organism  produces  toxic  substances  of 
varying  virulence  according  to  the  variety  of  parasite.  There  is  also 
clinical  evidence  that  one  and  the  same  variety  may  vary  in  virulence, 
so  that,  for  example,  some  sestivo-autumnal  parasites  are  more  virulent 
than  others. 

In  seeking  an  explanation  of  the  varying  clinical  characters  of  mala- 
rial infections  we  have  to  reckon  not  only  with  the  number,  the  varie- 
ties, and  the  virulence  of  the  parasites,  but  also  with  several  other 
factors,  such  as  predisposing  conditions  on  the  part  of  the  individual 
infected,  the  occurrence  of  multiple  groups  of  the  parasite,  the  distri- 
bution of  the  organisms  in  internal  parts,  the  circulatory  and  other  ana- 
tomical disturbances  induced  by  the  parasites. 

Periodicity  is  the  most  striking  clinical  characteristic  of  malarial 
fevers,  and  the  explanation  of  this  phenomenon  has  exercised  the  minds 
of  pyretologists  from  ancient  times.  It  is  true  that  intermittence  is  not 
limited  to  fevers  of  malarial  origin,  but  regularity  of  rhythm  in  the 
occurrence  of  the  paroxysms  is  especially  characteristic  of  malaria. 
One  of  the  most  interesting  additions  to  our  knowledge  resulting  from 
the  discovery  of  the  malarial  parasite  is  the  demonstration  by  Golgi, 
which  has  been  abundantly  confirmed,  that  this  rhythm  in  the  malarial 
paroxysms  corresponds  to  a  rhythm  in  the  development  of  successive 
generations  of  the  parasite. 

The  onset  of  each  paroxysm  corresponds  to  the  ripening  and  sporu- 
lation  of  a  generation  of  parasites  and  the  setting  free  of  a  new  brood.^ 

^  The  old  idea  that  the  periodicity  of  malarial  fevers  depends  upon  the  periodical 
production  in  the  blood  of  a  materia  peccans  is  thus  confirmed.  It  is  interesting  in  this 
connection  to  note  the  line  of  argument  presented  by  Griesinger  in  his  admirable  and  sug- 


PARASITOLOGY.  71 

Kxactlv  what  the  connection  is  hctwccn  this  act  oi"  sporulation,  with  the 
lil)crati()n  of  a  fresh  brood  of  yoiin<;-  parasites,  and  tlie  cansc  of  the 
febrile  jjaroxysni,  is  not  dctiniteiy  known.  It  was  at  first  snggested  by 
Golj^i  (1887)  that  the  paroxysm  is  due  to  the  invasion  of  the  red  blood- 
corpusch^s  by  tiie  new  grouj)  of  parasites,  but  it  was  shown  by  Antohsei 
(181X))  that  the  paroxysm  (lei)ends  rather  upon  the  act  of  segmentation 
than  u|)on  the  invasion  of  the  bh)od-corpusch'S  by  a  new  generation  of 
organisms,  for  quinine,  administered  before  a  paroxysm  in  suificient 
(piantity,  may,  by  ck\stroying  the  fresh  brood,  completely  prevent  the 
invasion  of  the  red  corpuscles,  but  it  cannot  prcv(;nt  the  segmentation 
and  the  impending  paroxysm.  The  view  is  now  widely  held,  and  seems 
j)huisible,  that  in  the  act  of  sporulation  and  of  liberation  of  the  spores 
chemieal  poisons  are  set  free,  and  that  these  poisons,  by  their  action  on 
the  nervous  centres  concerned  in  the  production  of  fever,  cause  the 
febrile  paroxysms.  This  toxic  theory  of  malaria  has  been  elaborated 
especially  by  Baccelli. 

The  fact  that  the  malarial  parasite  resides  in,  feeds  upon,  and  de- 
stroys the  red  blood-corpuscles  furnishes  an  entirely  satisfactory  explan- 
ation of  two  of  the  most  characteristic  and  important  manifestations  of 
malaria — the  melantemia  and  the  anaemia.  The  malarial  pigment,  for 
which  we  formerly  had  no  adequate  explanation,  is  formed  as  an  un- 
digested residue  within  the  body  of  the  parasite  by  metabolic  processes 
directly  out  of  the  haemoglobin  of  the  infected  red  blood-corpuscle. 
Various  stages  of  the  formation  of  the  pigment  within  the  parasite  can 
be  seen.  The  liberation  of  this  pigment,  its  inclusion  by  phagocytes, 
its  deposition  in  various  internal  organs,  have  all  been  described,  and 
will  be  further  considered  under  the  Pathological  Anatomy.  The 
relations  of  the  biological  characters  of  the  parasite  to  malarial  anaemias 
and  to  haemoglobinnria  will  be  fully  considered  in  the  anatomical  and 
clinical  parts  of  this  article  (pages  93,  116,  125,  and  130). 

The  ways  in  which  the  red  blood-corpuscles  may  be  altered  by  the 
action  of  the  malarial  parasite  are  various.  The  extent  of  these  changes 
varies  with  the  variety  and  the  virulence  of  the  parasite.  They  are 
least  in  quartan  infections,  greatest  in  the  aestivo-autumnal.  The  in- 
fected blood-corpuscle  may  appear  otherwise  normal.  It  may  be 
swollen  or  shrunken  or  variously  deformed.  It  may  divide  into  two  or 
more  pieces.  It  may  be  partly  or  completely  decolorized,  or  the  haemo- 
globin may  separate  from  the  stroma  and  be  dissolved  in  the  plasma, 
or  may  be  concentrated  around  the  parasite.  Especial  significance  in 
the  aestivo-autumnal  infections  attaches  to  that  alteration  in  the  cor- 

gestive  article  on  the  malarial  diseases  ( Virchow's  Handb.  d.  spec.  Path.  u.  Themp.,  Bd.  ii. 
Abth.  2,  2te  Auflage,  p.  41,  Erlangen,  1864) :  "Tlie  cause  of  the  periodicity  of  the  fever 
cannot,  therefore,  be  referred  to  the  disposition  of  the  nervous  system  to  rhytlimical  vital 
actions,  as  many  have  formerly  done,  but  it  must,  at  least  according  to  our  present 
although  very  incomplete  knowledge  concerning  the  causes  of  heat,  be  attributed  to  some- 
thing periodically  occurring  in  the  blood,  wliich  is  connected  with  the  increased  produc- 
tion of  heat.  It  has  been  formerly  conceived  that  a  certain  substance,  a  materia  peccans, 
appears  periodically  in  the  blood  and  incites  the  febrile  heat  and  reaction  :  this  material 
requires  for  its  production  and  complete  development  sometimes  longer,  sometimes  shorter, 

periods,  and  herein  lies  the  cause  of  the  rhythm  of  the  fever As  an  explanatory 

hypothesis  this  conception  accomplishes  more  than  the  later  attempts  at  explanation 

The  continuous  morbid  process  which  causes  the  poisoning  incites  periodically  changes  in 
nutrition  or  in  the  blood  which  arouse  the  nervous  apparatus  to  abnormal  manifestations." 


72  MALARIA. 

puscle  which  has  been  repeatedly  referred  to  as  the  brassy  change,  on 
account  of  the  resemblance  in  the  color  of  the  shrunken  corpuscles  to 
brass,  sometimes  compared  also  to  copper  or  old  gold.  Nor  are  the 
corpuscles  which  are  actually  infected  by  the  parasite  the  only  ones 
which  may  be  altered.  Uninfected  corpuscles  may  also  be  changed 
in  appearance,  and  may  be  destroyed,  especially  in  cases  of  hsemo- 
globinuria. 

These  changes  in  the  red  blood-corpuscles,  which  must  be  regarded 
as  degenerative  and  destructive,  cannot  be  brought  wholly  into  parallel- 
ism with  the  development  of  the  malarial  pigment.  In  fact,  the  most 
profound  lesions  and  the  greatest  destruction  of  the  red  corpuscles  occur 
in  infections  with  the  sestivo-autumnal  parasite,  which  is  characterized 
by  the  small  amount  or  even  the  entire  absence  of  pigment.  To  explain 
many  of  these  changes  we  must  have  recourse  again  to  the  theory  that 
toxic  substances  are  produced  by  the  parasite  and  directly  damage  the 
blood-corpuscles. 

These  alterations  in  the  red  blood-corpuscles  not  only  explain  the 
malarial  ansemias  and  the  h&emoglobinuria  with  their  concomitant  symp- 
toms and  lesions,  and  the  accumulation  of  malarial  and  other  pigments 
in  certain  organs,  but  they  are  utilized,  although  less  conclusively,  to 
explain  certain  other  malarial  phenomena.  We  know  from  physiological 
observations  that  the  physical  integrity  of  the  red  blood-corpuscles  is  an 
important  condition  in  the  maintenance  of  their  circulation  within  the 
blood  current.  It  is  reasonable  to  suppose  that  corpuscles  as  profoundly 
altered  as  are  many  of  those  infected  with  the  malarial  parasite  will 
circidate  with  difficulty,  and  will  tend  to  accumulate  in  certain  situa- 
tions wdiere  local  conditions  of  the  circulation  favor  the  lodgement  of 
foreign  particles  which  get  into  the  circulation.  Many  writers,  there- 
fore, attribute  to  these  alterations  in  the  physical  properties  of  the  in- 
fected red  corpuscles  the  accumulation  of  the  parasites  within  the  vessels 
of  certain  internal  organs,  more  particularly  the  spleen,  the  bone  mar- 
row, the  liver,  and  the  brain,  and  they  explain  the  absence  of  such 
accumulation  in  quartan  infections  by  the  comparatively  slight  lesions 
of  the  infected  corpuscles,  and  the  large  accumulation  in  tertian,  and 
still  more  in  sestivo-autumnal,  infections  by  the  more  serious  damage 
inflicted  upon  the  infected  red  corpuscles  by  the  varieties  of  the  parasite 
causing  these  latter  infections.  Doubtless  these  factors — changes  in  the 
infected  red  (lorpuscles  and  local  conditions  of  the  circulation — are 
important  in  determining  the  localization  of  the  parasites  in  certain 
internal  parts,  but  with  our  present  knowledge  we  cannot  explain  the 
varying  distribution  of  the  parasites  observed  in  diflFerent  cases  exclu- 
sively by  their  aid,  any  more  than  we  can  adopt  a  similar  explanation 
for  the  localization  of  the  micro-organisms  in  other  infections. 

The  localization  of  the  parasites  in  some  cases,  more  particularly  in 
sestivo-autumnal  infections,  within  definite  vascular  areas  of  internal 
organs  stands  in  relation  to  corresponding  symptoms  and  lesions.  The 
comatose  and  the  choleriform  types  of  pernicious  malaria  are  associated 
with  an  accumulation,  which  may  be  enormous,  of  the  parasites  in  the 
capillaries  and  small  vessels  of  the  brain  and  of  the  stomach  and  intes- 
tine respectively.  Other  special  localizations  of  the  parasites  will  be 
mentioned  in  the  subsequent  part  of  this  article.     In  these  cases  cap- 


PARASITOLOGY.  73 

illarics  ami  (itlicr  .small  l)l(»(i(lvi'ssels  may  be  partly  or  completely 
])liiir^ed  with  })arasitc.s,  chiefly  within  red  blood-corpuscles.  Swollen, 
dciiciuTatcd,  and  (IcscjMamatcfl  endothelial  cells,  ])it::ment,  macrophages, 
and  other  j)ha<i()cytes  eonti'ibiite  to  this  occlusion  of"  the  vessels.  Genu- 
ine thrombi  also  occur. 

Serious  disturbances  of  the  circulation  must  result  from  such  exten- 
sive plut>iiing  of  the  vessels.  It  is  not  easy  to  determine  how  far  these 
mechanical  disturbances  of  the  circulation  are  responsible  for  symptoms 
and  lesions  with  which  they  are  associated.  Marchiafava  and  Bignami 
and  others  regard  them  as  the  essential  cause  of  the  grave  nervous 
svmptoms  in  comatose  j)ernicious  fever,  and  of  other  sym])toms  and  of 
lesions.  Many  years  ago  Frerichs  likewise  attached  much  importance 
in  the  causation  of  cerebral  symptoms  to  accumulations  of  pigment  and 
the  formation  of  coagula  within  the  cerebral  vessels.  It  appears,  how- 
ever, to  the  writer  that,  aside  from  certain  general  pathological  consid- 
erations and  analogies  with  similar  conditions  in  other  diseases,  this 
mechanical  explanation  is  inadequate,  and  that  here  too  the  toxic  prod- 
ucts of  the  parasite  are  (operative.  The  pnjmptness  with  which  the 
grave  cerebral  symptoms  may  subside  after  administration  of  quinine  is 
not  easily  reconcilable  with  the  theory  that  they  are  due  to  plugging  of 
the  vessels. 

Even  the  focal  necroses  which  are  common  in  the  liver  in  pernicious 
cases,  and  may  occur  in  the  spleen,  the  kidneys,  and  elsewhere,  are  best 
interpreted  as  due  to  the  toxic  products  of  the  parasite,  rather  than  as 
the  result,  as  is  claimed  for  the  liver  by  Guarnieri,  of  plugging  of  the 
bloodvessels.  These  necroses  do  not  differ  from  those  observed  in 
diphtheria,  typhoid  fever,  and  streptococcus  and  other  infections,  and 
that  they  may  be  purely  toxic  in  origin  has  been  demonstrated  by  AVelch 
and  Flexner.' 

The  capillary  hemorrhages  which  have  been  observed  in  the  brain  in 
the  comatose  form  of  pernicious  fever,  and  which  may  occur  elsewhere, 
may  be  referred  to  the  hyperaemia  and  stasis  resulting  from  plugging  of 
the  vessels.  The  interesting  fact  has  been  observed  that  in  these  capillary 
hemorrhages  the  extravasated  red  corpuscles  are  without  parasites,  while 
the  neighboring  bloodvessels  are  filled  with  red  corpuscles  containing 
parasites.  The  explanation  of  this  which  is  given  by  Marchiafava  and 
Bignami  and  adopted  by  others  is  that  the  corpuscles  containing  para- 
sites on  account  of  their  greater  adhesiveness  stick  to  the  walls  of  the 
vessels  and  thus  are  prevented  from  escaping.  The  writer  offers  another 
explanation  as  the  more  probable.  The  examination  of  these  small 
hemorrhages  shows  that  they  are  the  result  of  diapedesis,  and  not  of 
actual  rupture  of  the  vessels  (rhexis).  It  is  not  difficult  to  comprehend 
that  red  corpuscles  altered  by  the  invasion  of  parasites  would  not  par- 
ticipate in  the  process  of  diapedesis,  whereas  it  is  not  easy  to  understand 
why  they  should  not  escape  from  ruptured  vessels. 

It  is  evident  from  what  has  been  said  that,  while  occlusion  of  vessels 
and  consequent  disturbances  of  the  circulation  are  common  in  severe 
malarial  affections,  and  are  dovibtless  of  importance  in  causing  some  of 
the  lesions  and  symptoms,  the  more  important  and  characteristic  symp- 
toms  and  lesions   are,  in   the   opinion   of  the  writer,  w'ith  our  present 

^  The  Johns  Hopkins  Hospital  Bulletin,  March,  1892. 


74  MALARIA. 

knowledge,  better  explained  by  the  toxic  theory  of  the  pathogenic  action 
of  tlie  malarial  parasite  than  by  any  mechanical  theories  which  have 
yet  been  offered. 

We  have,  however,  no  positive  demonstration  of  the  existence  of  spe- 
cific malarial  toxins.  The  investigations  as  to  the  toxicity  of  the  urine 
of  malarial  patients  will  be  described  on  page  123.  They  have  not  led 
to  any  positive  results  as  to  the  detection  of  specific  malarial  poisons. 

It  is  a  very  old  conception  that  the  febrile  reaction  of  the  malarial 
paroxysm  is  conservative  in  the  sense  that  this  response  of  the  body  to 
the  presence  of  pyogenic  agents  in  some  way  aids  in  the  elimination  or 
destruction  of  injurious  substances.  This  conception  is  not  altogether 
without  support  from  the  parasitological  study  of  malaria.  The  fever 
begins  at  the  time  of  the  birth  of  a  new  generation  of  parasites.  These 
young  organisms  before  they  have  entered  the  red  blood-corpuscles  are, 
of  all  phases  of  development  of  the  parasite,  in  the  most  vulnerable 
condition,  as  has  been  shown  by  investigations  of  the  action  of  quinine. 
That  a  large  number  of  them  perish  during  the  febrile  paroxysm  seems 
to  be  demonstrated,  at  least  in  quartan  and  tertian  infections,  by  the 
contrast  between  the  number  of  sporulating  forms  and  the  number  of 
succeeding  infected  corpuscles.  EsjDecially  suggestive  of  increased 
potency  of  parasiticidal  agencies  during  the  febrile  paroxysm  are  cases, 
especially  of  quartan  or  tertian  infection,  in  which,  after  a  sharp 
paroxysm,  the  symptoms  and  the  parasites  disappear,  perhaps  perma- 
nently, but  often  to  return  after  a  long  interval  as  a  recrudescence  of  the 
fever  (page  121). 

Similar  H^matozoa  in  the  Lowee  Animals. 

Great  interest  attaches  to  the  presence  in  the  blood  of  certain  lower 
animals  of  protozoan  parasites  closely  resembling  the  malarial  parasite. 
Attention  was  first  called  to  this  resemblance  by  Danilewsky  (1885-86), 
who  described  more  fully  certain  forms  which  were  previously  known, 
and  added  the  discovery  of  new  forms,  especially  that  of  hsematozoa  in 
birds  which  bear  close  resemblance  to  the  human  malarial  parasite. 
Since  Danilewsky's  first  publications  there  have  been  a  number  of 
investigations  on  this  subject  by  Kruse,  Celli  and  Sanfelice,  Grassi  and 
Feletti,  Laveran,  Labb6,  and  others. 

In  the  blood  of  frogs,  turtles,  lizards,  and  some  other  cold-blooded 
animals  hsematozoa  presenting  some  points  of  resemblance  to  the  mala- 
rial parasite  are  not  uncommon.  Of  these  the  -best  studied  and  most 
interesting  is  the  Drepanidium  ranarum  (Lankester),  identical  with 
Gaule's  "Wlirmchen,"  in  the  blood  of  frogs.  It  is,  however,  certain 
hsematozoa  in  birds  which  bear  such  close  resemblance  to  the  malarial 
parasite  that  their  identity  with  the  latter  has  been  assumed  by  Dani- 
lewsky and  Grassi  and  Feletti,  who  speak  of  the  existence  of  malaria 
and  of  malarial  parasites  in  these  animals.  Most  of  the  observations 
thus  far  reported  have  come  from  Russia  and  Italy,  but  the  parasites 
have  been  found  in  birds  also  in  Germany  and  France,  and  recently  in 
the  United  States. 

In  birds  thus  infected  have  been  found  forms  similar  to  those  of  the 
malarial    parasite    in    man — viz.  unpigmented  and  pigmented  hyaline 


PARASITOLOGY.  75 

bodies  (which,  however,  in  Jistinetion  tVoui  similar  l)()dies  in  man,  iiuuii- 
fest  little  or  no  amoeboid  movement),  sporulating  forms,  crescents,  and 
flagellated  bodies.  The  bird's  hsematozoa  are  also  parasites  of  the  red 
blood-corpnscles,  from  which  they  produce  black  pigment :  they  pass 
throngh  the  same  stages  of  development  as  the  latter,  and  the  same 
diversity  of  views  exists  as  to  the  origin  and  significance  of  the  crescents 
and  flagellated  bodies.  The  name  H.i^iMDProteus  was  introduced  by 
Kruse  to  designate  these  so-called  mahirial  parasites  of  birds,  and  various 
other  names  have  also  been  suggested.  Grassi  and  Feletti  adopt  the 
same  names  and  the  same  classification  for  these  parasite  of  birds  as  for 
the  human  parasites  (page  38).  There  are  differences  between  the 
hiematozoa  found  in  different  species  of  birds,  and  in  the  same  species 
apparently  different  varieties  of  the  parasite  have  been  observed,  but 
there  are  at  present  no  definite  classification  and  no  certainty  as  to  the 
number  of  varieties  which  may  exist. 

Although  these  hsematozoa  of  birds  evidently  belong  to  the  same  class 
of  organisms  as  the  malarial  parasite,  there  are  several  reasons  which  in- 
dicate that  they  are  not  identical  with  the  latter.  They  present  certain 
morphological  and  physiological  differences  which  it  would  lead  too  far 
here  to  describe.  Although  found  thus  far  chiefly  in  birds  from  mala- 
rial regions,  it  is  not  proven  that  they  may  not  exist  in  birds  elsewhere. 
The  inoculation  of  uninfected  birds  with  the  blood  of  birds  containing 
the  parasites  has  been,  in  a  large  preponderance  of  the  experiments, 
unsuccessful  in  the  result.  The  inoculation  of  birds  with  blood  from 
human  beings  affected  with  malaria,  and  the  inoculation  of  human 
beings  with  the  blood  of  birds  containing  the  hsematozoa,  have  been 
uniformly  without  positive  result  (Di  Mattel).  Large  doses  of  quinine 
have  no  influence  upon  the  parasites  in  birds.  The  presence  of  the 
haematozoa  in  birds  is  usually  without  recognizable  disturbance  of  the 
health  of  the  birds,  although  it  may  cause  a  chronic  or  an  acute  affec- 
tion. While,  then,  we  must  admit  a  close  relationship  between  certain 
hsematozoa  of  birds  and  the  human  malarial  parasite,  the  existing  evi- 
dence is  opposed  to  their  identification. 


DESCRIPTION   OF   PLATES   I.   AND   11.^ 

The  drawings  were  made  with  great  care  and  skill  by  Mr.  Max  Broedel,  with  the 
assistance  of  the  camera  lucida,  from  specimens  of  fresh  blood.  A  Winkel  microscope, 
objective,  1-14  (oil-immersion),  ocular,  4,  was  used. 

Figs.  4,  13,  23,  24,  and  42  of  Plate  I.  were  drawn  from  fresh  blood,  without  the 
camera  lucida. 

PLATE  I. 

The  Parasite  of  Tertian  Fever. 

1. — Normal  red  corpuscle. 

2,  3,  4.  — Young  hyaline  forms.     In  4  a  corpuscle  contains  three  distinct  parasites. 

5,  21. — Beginning  of  pigmentation.  The  parasite  was  observed  to  form  a  true  ring 
by  the  confluence  of  two  pseudopodia.  During  observation  the  body  burst  from  the  cor- 
puscle, which  became  decolorized  and  disappeared  from  view.  The  parasite  became, 
almost  immediately,  deformed  and  motionless,  as  shown  in  Fig.  21. 

6,  7,  8. — Partly  developed  pigmented  forms. 
9. — Full-grown  body. 

10-14. — Segmenting  bodies. 

15.— Degenerative  form  simulating  a  segmenting  body. 

16,  17. — Precocious  segmentation. 

18,  19,  20. — Large  swollen  and  fragmenting  extracellular  bodies. 

22.— Flagellate  body. 

23,  24. — Degenerative  forms  showing  vacuolation. 

The  Parasite  of  Quartan  Fever.  ^ 

25. — Normal  red  corpuscle. 
26. — Young  hyaline  form. 

27-34 — Gradual  development  of  the  intracorpuscular  bodies. 

35. — Full-grown  body.  The  substance  of  the  red  corpuscle  is  not  visible  in  the  fresh 
specimen. 

36-39. — Segmenting  bodies. 

40. — Large  swollen  extracellular  form. 

41. — Flagellate  body. 

42. — Degenerative  form  showing  vacuolation. 

PLATE  II. 

The  Parasite  of  vEstivo-atjtumnal  Fever  {Hcemaiozoon  falciparum). 

1,  2. — Small  refractive  ring-like  bodies. 

3-6. — Larger  disk-like  and  amoeboid  forms. 

7. — King-like  body  with  a  few  pigment  granules  in  a  brassy,  shrunken  corpuscle. 

8,  9,  10,  12. — Similar  pigmented  bodies. 

11. — Amoeboid  body  with  pigment. 

13. — Body  with  a  central  clump  of  pigment  in  a  corpuscle  showing  a  retraction  of 
the  haemoglobin-containing  substance  about  the  parasite. 

14-20. — Bodies  with  central  pigment  clumps  or  blocks.     Presegmenting  forms. 

21-24. — Larger  bodies  with  central  pigment  blocks.  Presegmenting  bodies.  Seen  in 
the  peripheral  circulation  during  a  severe  paroxysm. 

25-28. — Segmenting  bodies  from  the  spleen.  Figs.  25-27  represent  one  body  where 
the  entire  process  of  segmentation  was  observed.  The  segments,  eighteen  in  number,  were 
accurately  counted  before  separation,  as  in  Fig.  27.  The  sudden  separation  of  the  seg- 
ments, occurring  as  though  some  retaining  membrane  were  ruptured,  was  observed.       ' 

29-37.— Crescents  and  ovoid  bodies.  Figs.  34  and  35  represent  one  body  which  was 
seen  to  extrude  slowly,  and  later  to  withdraw,  two  rounded  protrusions. 

38,  39. — Round  bodies. 

40. — Pseudo-gemmation,  fragmentation. 

41. — Vacuolation  of  a  crescent. 

42-44. — Flagellation.  The  figures  represent  one  organism.  The  blood  was  taken 
from  the  ear  at  4.15  p.  M.  ;  at  4.17  the  body  was  as  represented  in  Fig.  42.  At  4.27  the 
flagella  appeared  ;  at  4.33  two  of  the  flagella  had  already  broken  away  from  the  mother 
body. 

45-49. — Phagocytosis.     Traced  with  the  camera  lucida. 

1  These  plates  are  taken  by  permission  from  The  Johns  Hopkins  Hospital  Reports,  vol.  v.,  1895. 
Four  figures— viz.  Figs.  21,  22,  23,  and  24— have  been  added  to  Plate  II.,  and  are  also  from  the  draw- 
ings of  Mr.  Max  Broedel. 

2  The  color  of  the  pigment  in  these  figures  of  the  quartan  parasite  has  too  much  of  a  reddish 
tint. 

76 


PLATE    I. 


d 


y^^'^ 


'-        f  . 


'^? 


v^ 


v*v  •■'-;'■■■ 


%      ■ 

<<.i>^' 

^■•^t; 

.^!^' 

'•'^'\' 

J^ 


9    9 


Q 


& 


■^^ 


PLATE    II. 

:,ite  of  Aestivo 


•  e  #  e 


f 


1 


k 


O  '        0 


t?^ 


^ 


etioloGtY,    pathological  anatomy,   symptoms, 
diagnosis,  prognosis,  and  treatment. 

By  WILLIAM  S.  THAYER,  M.  D. 


Etiology. 


Distribution. — The  malarial  fevers  are  widely  distributed,  occur- 
ring in  almost  all  regions  of  the  earth.  There  are,  however,  certain 
principal  foci  where  the  disease  is  permanently  endemic.  These  regions 
are  chiefly  in  the  warmer  temperate  and  tropical  countries.  Generally 
speaking,  the  farther  one  departs  from  the  equator  the  less  common  are 
the  malarial  fevers.  A  sharp  line  of  delimitation  cannot,  however,  be 
drawn.  Occasionl  cases  have,  according  to  Celli,^  been  observed  as  far 
north  as  Irkutsk  in  Siberia,  Haparanda  in  the  Gulf  of  Bothnia  (65°  N. 
latitude),  Juliushaab,  Southern  Greenland,  and  jSTew  Archangel  in  Alas- 
ka, while  to  the  south  malaria  has  been  reported  to  exist  as  far  as  the 
isotherm  of  60°.  It  must,  however,  be  remembered  in  considering  any 
statistics  concerning  the  distribution  of  malaria  that  the  diagnosis  of 
malarial  fever  has  been,  until  very  recently — and  is,  alas  !  far  too  fre- 
quently today — made  upon  a  very  insufficient  basis.  In  many  regions 
tqday  an  intermittent  fever  with  chills  is  without  further  investigation 
assumed  to  be  of  malarial  origin,  and  even  at  the  present  time,  in  some 
of  the  large  cities  of  this  country,  there  are  official  statistics  of  mortality 
due  to  malaria — statistics  showing  thousands  of  deaths  every  year — 
which  are  almost  absolutely  incorrect. 

About  the  main  foyers  of.  malaria  there  is,  however,  little  doubt. 
In  Europe  the  disease  is  common  in  the  low  lands  about  the  coasts  of 
Italy,  Sicily,  Corsica,  Greece,  the  Black  and  Caspian  Seas,  and  in  the 
lands  bordering  upon  the  Po,  the  Tiber,  the  Danube,  and  the  Vol- 
ga. About  the  coast  of  certain  parts  of  France,  Spain,  and  in  Denmark 
and  Sweden,  an  occasional  case  is  seen.  In  Holland  and  Belgium  the 
milder  forms  of  the  disease  are  not  uncommon,  while  a  few  cases  of  the 
same  nature  are  seen  in  Germany  about  the  mouth  of  the  Elbe  and 
along  the  Baltic  coast  of  Prussia,  in  Silesia,  the  plain  of  the  river  ]\Iark, 
and  in  Pomerania.  In  tropical  Africa  the  disease  appears  in  its  most 
severe  forms,  especially  along  the  West  Coast.  The  chief  foyers  of 
the  disease  in  Europe  are  in  Italy  and  Southern  Russia.  In  India, 
Ceylon,  and  in  the  East  Indies  it  is  particularly  common,  while  in 
Southern  and  Southwestern  China  it  is  also  endemic.  In  Japan  the 
disease  is  rare.  In  the  Western  Hemisphere  malaria  is  seen  in  the  low- 
lands about  the  coast  from  New  England  to  Florida,  though  above  Vir- 
ginia the  severe  forms  are  rare.  In  the  Gulf  States  and  along  the 
banks  of  the  Mississippi  and  its  tributaries,  in  most  of  the  Southern 
States,  the  disease  is  almost  always  present.  About  some  of  the  Great 
Lakes,  both  in  the  United  States  and  Canada,  malarial  fevers  are  occa- 

'  Verhandl.  d.  X.  Internal.  Med.  Cong.,  Bd.  v.  Abth.  xv.  p.  68. 

77 


78  MALARIA. 

sionally  seen,  while  a  certain  number  of  cases  are  reported  from  the 
Pacific  coast. 

In  Cuba,  Mexico,  and  Central  America  some  of  the  most  fatal  forms 
of  the  disease  are  met  with.  The  much  feared  Chagres  fever  of  the 
Isthmus  of  Panama  is  a  pernicious  malarial  infection.  About  the  low- 
lands of  the  eastern  coast  of  South  America,  particularly  in  the  Guianas 
and  in  Brazil,  the  disease  is  endemic  in  its  most  malignant  forms.  On 
the  west  coast  it  is  less  frequent,  though  its  occurrence  in  Peru  and 
Bolivia  has  been  known  for  years.  Indeed,  it  is  from  the  Peruvian 
Indians  that  we  learned  the  value  of  the  specific  remedy  for  the  disease. 
In  Australia,  New  Caledonia,  and  the  islands  of  the  Pacific  the  disease 
is  very  rare,  and  in  some  regions,  such  as  Hawaii,  Samoa,  New  Zealand, 
and  Van  Diemen's  Land,  notwithstanding  the  existence  of  extensive 
low  marshy  tracts,  it  is  quite  unknown. 

In  cases  of  malarial  fever  which  occur  sporadically  in  regions 
where  the  disease  is  uncommon  the  infection  may  often  be  traced  to  a 
previous  sojourn  in  a  malarious  district.  Extensive  epidemics  and  pan- 
demics of  malarial  fever,  spreading  over  the  greater  part  of  the  earth, 
have  been  described.  In  most  of  these  instances,  however,  consider- 
able uncertainty  exists  as  to  the  true  nature  of  the  process. 

Physical  Geography. — The  physical  geography  of  the  country 
has  much  to  do  with  the  prevalence  of  malarial  fever.  In  the  words 
of  Laveran,  "  The  principal  foyers  of  paludism  are  situated  on  the  coast 
or  along  the  banks  of  large  rivers."  High  altitudes  are  usually  free 
from  malarial  fever,  and  the  mountains  and  plateaus  in  the  neighbor- 
hood of  malarial  districts  are  often  used  as  sanitaria  by  the  inhabitants. 
The  high  altitudes  may  not,  however,  be  a  protection,  as,  according  to 
Hertz,^  fevers  occur  in  the  Tuscan  Apennines  at  a  height  of  1100  feet, 
in  the  Pyrenees  at  5000  feet,  on  the  island  of  Ceylon  at  6500  feet,  in 
Peru  at  from  10,000  to  11,000  feet.  It  is,  however,  by  no  means 
improbable  that  many  of  these  fevers  which  have  been  called  "  mala- 
rial "  are,  in  reality,  of  some  other  nature.  This  has  been  shown  to  be 
true  in  the  case  of  the  "  mountain  fever  "  of  the  Western  States,  which 
is  for  the  most  part,  probably,  typhoid  fever. 

The  Soil.^Low,  marshy  regions  are  particularly  likely  to  be 
malarious ;  hence  the  term  "  paludism"  which  is  so  generally  used. 
Mixed  salt  and  fresh  water  marshes  seem  to  be  particularly  favorable 
for  the  development  of  the  disease.  Low,  moist,  ill  drained  lands,  rich 
in  vegetable  matters — lands  which  have  been  allowed  to  fall  out  of  cul- 
tivation— are  particularly  dangerous.  All  marshy  regions,  however, 
even  in  tropical  countries,  are  not  of  necessity  malarious,  an  example 
of  this  being  shown  in  some  of  the  South  Pacific  islands,  as  already 
mentioned.  And,  while  the  disease  is  particularly  common  in  marshy 
districts,  it  may  occur  in  other  regions  in  sandy  or  clayey  soil,  or, 
indeed,  in  rocky  regions.  An  impervious  subsoil  is  believed  to  be 
particularly  dangerous. 

JEfects  of  Turning  up  the  Soil. — In  many  instances  the  denudation  of 
a  soil  covered  by  forests  or  rank  vegetation,  or  the  turning  up  of  the 
soil  in  a  district  which  was  previously  free  from  the  disease,  may  be  fol- 
lowed by  an  outbreak  of  malarial  fever,  while  in  other  regions  where 

^  V.  Ziemssen's  Cyclopcedia  of  the  Practice  of  Medicine,  vol.  ii. 


ETIOLOGY.  79 

tlu'  disease  already  exists  similar  interference  with  the  vegetation  or  the 
soil  may  oreatly  intensity  the  severity  of  the  process.  An  example  of 
this  latter  condition  is  shown  in  the  severe  outbreak  of  malarial  fever 
which  was  associated  with  the  excavation  of  the  Panama  Canal.  In 
Paris,  which  for  many  years  had  been  free  from  paludism,  the  digging 
of  the  Canal  Saint  Martin,  and  again,  in  1840,  the  excavations  for 
the  fortifications,  were,  in  each  instance,  followed  by  an  outbreak  of 
characteristic  intermittent  fever.  Irrigation  of  low  lying  districts 
without  proper  drainage  has  been  followed  by  an  outbreak  of  mala- 
ria or  an  increase  in  the  severity  of  the  cases.  Such  a  condition  of 
things  has  been  noted  in  some  of  the  irrigated  districts  in  Southern 
California. 

Effects  of  Drainage. — Efficient  drainage  of  marshy  districts  which 
have  been  rich  in  malarial  fevers  has  a  marked  effect  upon  the  frequency 
and  severity  of  the  manifestations  of  the  disease.  Years  ago  malaria 
was  common  in  the  surroundings  of  London,  which  were  marshy  and 
ill-drained ;  today,  thanks  to  good  drainage,  the  disease  is  unknown. 
The  low  lands  of  Holland  used  to  be  the  seat  of  very  severe  malaria  ; 
today,  only  occasional  cases  of  the  mildest  forms  of  the  disease  occur. 
The  effect  of  good  drainage  upon  the  Roman  Campagna  has  been  very 
striking,  the  severity  of  malarial  fever  diminishing  materially. 

Cultivation. — The  cultivation  of  many  marshy,  malarious  districts 
has  been  followed  by  a  marked  improvement  in  the  sanitary  condition. 
The  planting  of  trees  has  been  supposed  to  have  a  particularly  good 
effect,  possibly  because  of  the  drainage  of  the  soil  which  is  thus  accom- 
plished. For  some  time  it  was  supposed  that  certain  trees,  particularly 
the  eucalyptus  globulus,  had  an  almost  specific  effect  in  protecting  the 
neighborhood  against  malarial  fever.  The  advantages  of  this  particular 
tree  have,  however,  been  much  exaggerated.  Malarial  fever  never  orig- 
inates at  sea.  Those  cases  which  have  been  reported  date  their  infection, 
unquestionably,  to  some  period  before  the  voyage.  There  is  much  to 
suggest  that  the  soil  has  some  intimate  connection  with  the  development 
of  the  coutagium  of  paludism. 

Variations  ix  Distribution. — One  of  the  most  striking  character- 
istics of  malarial  fever  is  the  manner  in  which  it  leaves  one  region  in  which 
it  has  existed  for  some  time,  to  appear  in  another  which  may,  for  a  con- 
siderable period,  have  been  quite  free  from  any  manifestations  of  the 
disease.  This  change  in  the  distribution  of  the  disease  is  in  great  part 
due  to  the  activity  of  man.  On  the  one  hand,  an  outbreak  may  follow 
the  abandonment  or  neglect  of  richly  cultivated  areas  which  have  been 
well  drained  and  taken  care  of,  as,  for  instance,  the  Roman  Campagna 
in  the  time  of  Augustus,  while,  again,  in  other  regions  the  turning  up 
of  the  soil  may  bring  about  an  outbreak  where  it  is  least  expected.  But 
this  explanation  does  not  answer  all  cases.  The  appearance  of  malarial 
fevers  in  the  New  England  States  during  the  past  fifteen  years,  after  a 
long  period  of  almost  entire  quiescence,  is  a  striking  example  of  these 
inexplicable  changes  in  location.  Again,  in  districts  where  malaria  is 
permanently  endemic  there  are  often  cycles  in  the  severity  of  the  disease 
which  are  impossible  to  explain. 

Climate. — Heat  and  moisture  are  important  for  the  development 
of  the  fever.     In  malarious  districts  a  very  dry  season  is  usually  more 


80  ■  MALARIA. 

healthy.  Laverau  ^  states  that  in  Algeria  the  rainy  years  show  a  more 
severe  endemic  than  the  dry,  while  the  first  "  rains  of  the  autumn  give 
rise,  almost  always,  in  Algeria  to  a  recrudescence  of  the  fever." 

Season. — In  tropical  countries  malaria  exists  usually  throughout  the 
year,  but  it  is  almost  always  most  severe  in  the  summer  and  fall.  As 
one  approaches  the  temperate  climate  the  cases  in  winter  and  spring 
become  very  rare.  Along  the  eastern  coast  of  the  United  States,  just  as 
in  Rome,  the  cases  in  the  winter  are  very  few,  while  with  the  spring  a 
certain  number  of  infections  begin  to  appear.  It  is,  however,  not  until 
July  that  the  real  malarial  season  begins.  The  height  of  the  malarial 
season  is  reached  in  the  months  of  August,  September,  and  October. 
The  following  table,  showing  the  number  of  cases  of  malarial  fever 
treated  at  the  Johns  Hopkins  Hospital  between  January  1,  1890,  and 
January  1,  1894,  gives  a  good  idea  of  the  variations  in  the  occurrence 
of  the  disease  to  the  seasons  of  the  year : 

Jan.      Feb.      Mar.      Apr.      May.      June.      July.      Aug.      Sept.      Oct.      Nov.'    Dec.      Total. 
9         8  8  17         21         18  38         66       122       120       38        25        490 

The  earliest  cases  show  also  the  mildest  types  of  infection.  Thus, 
in  the  spring  the  first  cases  are  usually  tertian  or  quartan  infections.  As 
the  season  advances  double  tertian  infections  become  more  frequent, 
while  at  the  height  of  the  malarial  season  the  majority  of  cases  are  of 
the  sestivo-autumual  type,  the  most  severe  form  of  malaria.  Thus,  out 
of  542  cases  analyzed  by  Hewetsou  and  the  author,^  there  were — 

First  half  year.  Second  half  year. 

Regularly  intermittent  fevers 113  230 

-iEstivo-autumnal  fevers 5  183 

Combined  infections 3  8 

"m  42r=542 

At  the  height  of  the  malarial  season,  during  the  months  of  September 
and  October,  there  were — 

Regularly  intermittent  fevers 109 

jEstivo-autumnal  fevers 120 

Combined  infections 5 

This  observation  concerning  the  variation  of  the  types  of  the  fever 
with  the  times  of  the  year  is  as  old  as  Hippocrates.  It  has  long  been 
popularly  supposed  that  the  early  cases  of  fever  in  the  winter  and  in 
the  spring  represent,  in  toto,  relapses  from  infections  of  the  preceding 
fall,  the  fevers  of  first  invasion  beginning  only  with  the  summer  months. 
The  analyses  of  our  cases  at  the  Johns  Hopkins  Hospital  tend,  hoAvever, 
to  show  that,  while  the  proportion  of  fevers  of  first  invasion  is  less  in 
the  spring  than  in  the  summer  months,  yet  they  do  occur. 

Winds. — There  is  much  which  tends  to  suggest  that  the  infective 
agent  may  be  carried  by  the  wind.  It  has  been  asserted,  for  instance, 
that  along  the  banks  of  a  stream  in  a  malarious  district  the  fevers  are 
often  more  frequent  and  severe  on  the  side  toward  which  the  prevailing 
winds  blow.     Again,  in  other  instances  it  has  appeared  that  strips  of 

1  Traite  des  Fievra  palustres,  Paris,  1884,  p.  8. 

^  "The  Malarial  Fevers  of  Baltimore,"  Johns  Hopkins  Hospital  Reports,  vol.  v. 


ETIOLOGY.  81 

forest  land  liavc  an-cstcd  the  spread  of"  tlic  disease,  suf^gesting  that  some 
inteetioiis  suhstanee  may  l)e  filtered  out  by  the  trees.  Thus,  Laueisi 
believed  that  it  was  through  the  influence  of  the  winds  that  the  Roman 
Campagna  became  more  unhealthy  after  the  removal  of  the  sacred 
groves.  These,  he  believed,  acted  as  a  protection  l)y  filtering  from  the 
air  infectious  substances  carried  by  the  winils  which  i)lew  over  the 
Pontine  marshes. 

Altitude. — It  has  been  repeatedly  observed  that  in  malarious 
districts  the  dangers  of  infection  are  much  greater  close  to  the  ground. 
Sleeping,  upon  the  ground  is  particularly  dangerous.  The  upper  stories 
of  a  house  are  safer  than  the  lower.  Infection  appears  to  take  place 
more  readily  by  night  than  by  day. 

DiNXKixc;  Water. — Many  have  laid,  and  still  do  lay,  much  stress 
upon  drinking  water  as  the  source  of  the  disease.  The  experiments, 
however,  of  Celli,'  ^Nlarino,'  and  Zeri,^  who  caused  individuals  to  drink 
in  large  quantities  water  wdiich  was  obtained  from  the  most  malarious 
districts,  without  any  bad  effects,  and  of  Grassi  and  Feletti,'  who  fed 
individuals  upon  dew  collected  from  malarious  regions,  with  similar 
negative  results,  are  strong  arguments  against  this  idea.  It  should  be 
remembered,  however,  that  while  these  experiments  are  strong  evidence 
that  the  malarial  poison  is  not  introduced  through  the  drinking  water, 
yet  it  is  no  proof  that  water  may  not  contain  the  parasite,  or,  indeed, 
form  an  actual  culture  medium  for  some  forms  of  the  organism.  We 
are  wholly  ignorant  of  the  manner  of  entry  of  the  parasite  into  the 
system,  of  the  form  in  which  it  exists  outside  of  the  body,  or  of  the 
changes  which  it  may  pursue  in  other  media  than  the  circulating  blood. 
It  is  not  impossible  to  imagine  a  body  which  might  pursue  a  part  of  its 
development  in  water,  reaching  its  truly  infectious  form  only  in  a  later 
stage  and  in  some  other  medium. 

Grassi  and  Feletti  have  shown  that  the  living  parasite  from  the 
circulating  blood  does  not,  when  ingested,  cause  fever.  Thus,  they 
caused  an  individual  to  drink  the  fresh  blood  of  a  malarial  patient 
without  result,  while  inoculation  experiments  with  similar  blood  are 
almost  always  positive.     (See  page  34.) 

Race. — In  many  malarial  districts  the  natives — negroes,  Arabs, 
Indians,  Tamils — appear  to  have  a  relative  insusceptibility  to  the  dis- 
ease, the  degree  of  which  varies  in  different  localities  and  according  to 
different  authors.  Our  observations  in  Baltimore  would  tend  to  show 
that  here  the  susceptibility  of  the  negro  is  only  about  one  third  that 
of  the  white. 

OccuPATiox. — The  occupation  has  much  to  do  with  susceptibility  to 
the  disease.  Soldiers  and  tramps  who  sleep  upon  the  ground  in  malarious 
districts  are  particularly  susceptible.  Fishermen  in  the  bays  and  inlets 
along  the  southern  coast  of  the  United  States,  as  well  as  farmers  and 
berry  pickers  in  the  same  regions,  are  particularly  open  to  infection. 

Age  has  apparently  no  effect  upon  the  susceptibility,  excepting  in  so 
far  as  the  very  young  and  the  very  old  are  less  likely  to  be  exposed. 

1  BhU.  d.  Soe.  Lane.  d.  Roma,  1886,  vi.  1,  39  (5  Dec,  1885). 

2  Eifonnn  Medica,  31  Oct.,  1890,  >'o.  251,  1502. 

»  Bull.  d.  R.  Ace.  Med.  di  Roma,  1889-90,  xvi.  2-44. 
*  Centralblatt  fur  Backt.,  1891,  ix.  403,  429,  461. 

Vol.  I.— 6 


82  MALARIA. 

Predisposing  Causes. — It  is  generally  believed  that  in  malarious 
districts  almost  anything  which  tends  to  diminish  the  vitality  of  the 
patient  acts  as  a  predisposing  cause  to  malarial  infection.  It  is  often 
asserted  that  where  a  previous  attack  has  existed  injuries  of  various 
sorts  are  particularly  likely  to  be  followed  by  a  relapse  of  the  malaria. 
It  has  been  asserted,  for  instance,  that  an  injury  to  the  spleen  in  a 
patient  who  has  formerly  had  malarial  fever  may  call  forth  a  relapse. 
With  regard  to  the  effects  of  traumatism,  the  observation  of  nearly  a 
thousand  cases  during  the  last  five  or  six  years  has  not  given  any  posi- 
tive answer,  while  the  complications  of  malaria  with  other  acute  diseases 
have  been,  perhaps,  rather  surprisingly  infrequent.  It  seems  reasonable 
that  trauma  or  operation,  by  reducing  the  condition  of  the  patient, 
should  render  him  more  susceptible  to  a  fresh  malarial  infection  or 
more  liable  to  a  recrudescence  of  an  already  existing  process.  The  fact, 
however,  that  in  nearly  seven  years  not  a  single  case  of  post-operative 
malaria  has  occurred  in  the  Johns  Hopkins  Hospital  has  led  us  to 
believe  that  many  of  the  chills  occurring  under  these  circumstances, 
generally  supposed  to  be  malarial,  are  probably,  in  reality,  septic 
in  origin. 

Manner  of  Infection. — The  discoveries  of  Laveran  have  revealed 
to  us  the  infectious  agent  in  malaria,  while  its  specific  action  has  been 
abundantly  demonstrated  by  clinical  observation  and  inoculation  experi- 
ments. And  yet  it  must  be  confessed  that  we  are  wholly  ignorant  as  to 
the  manner  in  which  the  parasite  exists  outside  of  the  body  or  how  in- 
fection takes  place.  The  most  important  points  of  entry  into  the  system 
which  have  been  suggested  are — 

(1)  The  respiratory  tract; 

(2)  The  digestive  tract ; 

(3)  The  skin  (insect  bites,  etc.). 

(1)  There  is  a  very  general  belief  that  infection  may  take  place 
through  the  respiratory  tract,  though  positive  proof  of  its  occurrence  is 
as  yet  wanting.  In  favor  of  this  view  are  the  observations  of  Lancisi 
and  others  concerning  the  winds. 

(2)  Many  observers,  as  has  been  said,  still  believe  that  the  parasite  is 
introduced  chiefly  through  the  digestive  tract.  The  observations,  how- 
ever, of  Celli,  Marino,  Zeri,  Grassi  and  Feletti,  already  referred  to,  are 
very  suggestive  evidence  against  this  idea. 

(3)  The  inoculation  experiments  referred  to  in  the  description  of  the 
parasites  have  given  positive  proof  that  infection  may  take  place  when 
the  parasite  is  introduced  beneath  the  skin.  This  renders  more  plausi- 
ble the  old  idea  that  insect  bites  may  sometimes  serve  to  convey  the 
contagium.  In  this  connection  one  may  remember  the  remarkable 
observations  of  Theobald  Smith,^  who  has  shown  that  the  hsemocytozoon 
of  Texas  fever  in  cattle  {Pyrosoma  higeminum)  is  conveyed  from  animal 
to  animal  by  means  of  the  cattle  tick  (Boophilus  bovis). 

Experimentally  it  has  been  shown  that  although  infection  through 
the  alimentary  tract  is  improbable,  subcutaneous  infection  is  possible, 
while  clinical  observation  is  strongly  in  favor  of  the  view  that  infection 
through  the  respiratory  tract  may  occur. 

^  U.  S.  Dept.  of  Agriculture,  Bureau  of  Animal  Industry,  Bull.  No.  1,  Washington, 
1892. 


'    PATHOLOGICAL  AXATOMY.  83 

In  Saiimuiri/. — The  malarial  fuver.s  lluuri.-li  in  low,  moist,  hot  regions, 
the  borders  of  rivers  and  marshes,  places  where  the  water  is  brackish 
being  particularly  dangerous.  High,  dry,  sandy,  or  rocky  regions  are 
rarely  malarious.  In  a  malarious  district  there  is  greater  danger  of  in- 
fection near  the  ground,  by  night  than  by  day.  There  is  suggestive 
evidence  that  the  contagium  may  be  carried  In'  the  winds.  Age  has  no 
marked  influence  on  the  susceptibility.  The  negro  is  relatively  much 
more  insusceptible  than  the  white.  The  manner  of  existence  of  the 
parasite  outside  the  body  and  the  manner  in  which  the  infection  takes 
place  are  still  wholly  unknown. 

Pathological  Anatomy. 

(1)  Anatomical  Changes  in  Acute  Malarial  Infections  ;  (2) 
Changes  folloaving  Eepeated  or  Chronic  Infections. 

Cases  of  the  regularly  intermittent  fevers  are  so  rarely  met  with 
upon  the  autopsy  table  that  our  knowledge  of  the  pathological  changes 
present  in  the  internal  organs  are  largely  based  upon  a  study  of  the 
cases  of  pernicious  sestivo-autumnal  fever.  Our  knowledge  of  the 
pathology  of  the  malarial  fevers  has  been  greatly  increased  in  late  years 
by  the  investigations  made  since  the  discovery  of  the  parasite  by 
Laveran,  Councilman  and  Abbott,  Guarnieri,  Dock,  Bignami,  Barker, 
and  Monti.  One  of  the  most  interesting  points  which  at  once  strikes 
the  careful  observer  is  the  extreme  variation  in  the  distribution  of  the 
malarial  parasites  in  the  body,  and  the  anatomical  changes  produced  by 
them  in  diiferent  cases.  This  difference  in  the  localization  of  the  para- 
sites and  in  the  seat  of  the  important  anatomical  changes  may  bear,  as 
has  been  pointed  out  in  the  description  of  the  parasite,  a  direct  relation 
to  the  symptoms  which  have  existed  during  life. 

The  most  striking  point  in  the  appearance  of  the  organs  in  malarial 
fevers  is  the  melanosis  which  gives  a  characteristic  slaty  gray  color  to 
many  of  the  organs.  This  results  from  the  accumulation  of  the  pigment 
produced  by  the  parasites  from  the  haemoglobin  of  the  blood-corpuscles, 
and,  while  almost  invariably  present,  its  distribution,  as  in  the  case  of 
the  parasites,  and  the  degree  in  which  diiferent  organs  are  aifected,  varies 
considerably  in  different  cases. 

The  Brain. — The  most  striking  changes  in  the  brain  are  to  be  met 
with  in  the  cases  of  comatose  pernicious  fever.  The  brain  may  be  the 
seat  of  but  few  macroscopical  changes.  Melanosis  may  be  entirely 
absent.  At  times,  however,  there  may  be  a  slight  subpial  oedema  with 
hypereemia  of  the  cerebral  substance,  and  perhaps  punctate  hemor- 
rhages ;  more  commonly,  however,  the  gray  cortex  shows  a  slats^  or 
chocolate  color,  which  may  be  quite  deep.  The  vessels  are  markedly 
injected,  and  in  places,  as  has  been  said,  punctate  hemorrhages  may  be 
found.  In  these  instances  the  microscopical  appearances  are  most 
striking.  The  cerebral  capillaries  are  crowded  with  parasites,  which 
are,  for  the  most  part,  within  red  corpuscles,  and  may  form  an  actual 
comjjlete  injection  of  many  of  the  cerebral  vessels.  This  is  generally 
most  striking  in  the  gray  substance.  These  parasites  (usually  of  the 
sestivo-autumnal  type)  may  be  in  all  stages  of  development,  though 
generally  one  of  the  stages  is  most  marked.     Sometimes  in  cases  where 


84  3IALAEIA. 

death  has  occurred  during  the  paroxysm  actual  thrombi  of  segmenting 
organisms  may  exist.  Sometimes  the  organisms  may  not  be  so  numer- 
ous, but  evidence  of  their  previous  existence  is  found  in  free  clumps  of 
pigment  and  swollen  pigmented  endothelial  cells,  as  well  as  leucocytes 
containing  pigment  and  red  blood-corpuscles.  There  is  usually  decided 
granular  and  fatty  degeneration,  and  often  pigmentation  of  the  endothe- 
lium of  the  vessels — a  change  upon  which  the  punctate  hemorrhages 
probably  depend.  Some  endothelial  cells  may  be  greatly  swollen,  almost 
occluding  the  lumen  of  the  vessels  :  these,  as  has  been  demonstrated, 
especially  by  Monti,  may  contain  a  considerable  number  of  apparently 
well  preserved  parasites  in  various  stages  of  development ;  they  may  be 
within  shrunken  or  brassy  corpuscles  or  full  grown  and  free.  Occasion- 
ally large  macrophages  are  seen  almost  occluding  the  capillary,  which 
appear,  according  to  Monti,  to  be  endothelial  cells  which  have  broken 
loose  and  are  free  in  the  current. 

These  lesions  are  particularly  marked  in  the  comatose  form  of  per- 
nicious malaria.  In  some  instances  different  parts  of  the  central  ner- 
vous system  may  be  differently  affected.  In  one  case,  for  instance, 
studied  by  Marchiafava,^  where  the  patient  died  with  symptoms  of 
bulbar  paralysis,  a  special  localization  of  the  changes  was  noted  in  the 
medulla.  In  other  instances  the  cerebral  lesions  may  be  slight ;  the 
collections  of  parasites  in  the  capillaries,  as  well  as  the  degenerative 
changes  in  the  endothelium,  are  not  to  be  made  out. 

Monti  ^  has  recently  studied  the  changes  in  the  nerve  cells  in  the 
gray  cortex  in  pernicious  malaria,  according  to  Golgi's  method,  with 
interesting  results.  In  some  cases  these  elements  Avere,  so  far  as  could 
be  made  out,  quite  normal,  while  in  others  interesting  changes  were 
noted  :  these  cases  were  chiefly  those  showing  grave  nervous  symptoms, 
such  as  coma,  during  life.  The  alterations  were  not  uniformly  diffused 
throughout  the  cortex,  and  never  affected  all  the  elements  in  a  given 
zone.  Usually  cells  more  or  less  profoundly  altered  were  found  among 
other  cells  and  fibres  which  were  quite  normal,  although  a  tendency  to 
a  focal  arrangement  of  these  changes  could  be  made  out.  The  altera- 
tions affected  chiefly  the  protoplasmic  prolongations  of  the  nervous  cells 
of  the  cerebral  cortex.  Sometimes  the  prolongations  appeared  thinned 
and  studded  with  fine  nodes.  Not  infrequently  these  alterations  were 
limited  to  the  more  delicate  and  distant  branches,  though  it  was  not 
difficult  to  find  cells  of  which  all  the  dendrites  presented  the  beaded 
appearance  which  is  so  well  observed  in  the  nerve  cells  of  animals  dead 
of  inanition.  In  other  points  the  alterations  consisted  of  simple  irregu- 
larities of  contour  in  dendrites  which  were  much  thinned,  extending 
from  cells  the  bodies  of  which  were  sometimes  normal,  more  often 
swollen,  rarely  thinned,  shrunken,  or  atrophic.  Coarser  alterations 
were,  however,  not  wanting.  Cells  were  found  whose  dendrites  showed 
coarse  varicosities  and  very  marked  constrictions,  so  that  they  appeared 
as  if  formed  of  masses  of  protoplasmic  matter  connected  only  by  the 
finest  filaments  of  protoplasm.  Similar  changes  were  observed  in  the 
brains  of  animals  in  which  embolisms  were  produced  by  the  injection 
of  lycopodium. 

1  Lav.  del.  III.  Cong.  del.  Soc.  Ital.  di  Med.  Int.,  Eoma,  1890,  142. 

2  Bull.  d.  Soc.  Med.-Chir.  di  Pavia,  1895. 


PATHOLOGICAL  ANATOMY.  80 

In  most  of  Monti's  cases  the  axis  eyliiulers  were  well  preserved  ;  the 
principal  lesion  u})peared  to  consist  in  alterations  of  the  protoplasmic 
prolon<rati()ns.  In  some  cases,  however,  especially  in  one  severe  case  of 
comatose  })ernicions  fever,  certain  alterations  were  to  be  made  out  in  the 
axones.  In  this  case  the  alterations  of  the  nervous  elements  appeared 
more  marked  throuo^hout  the  brain  than  in  the  other  cases  ;  the  altera- 
tions in  the  dendrites  were  more  frequent  and  marked,  while  the  nervous 
])roloni)atioMs  also,  had,  in  many  points,  lost  their  normal  character. 
Instead  of  being  smooth  and  regular  as  usual,  they  presented  sometimes 
small  nodes,  more  rarely  larger  swellings.  Also,  among  the  axones,  as 
well  in  the  cerebral  cortex  as  in  the  cerebellum,  there  were  occasionally 
varicosities.  The  alterations  of  the  nervous  fibres  were,  however, 
always  less  marked  than  those  of  the  dendrites. 

Monti  believes  that  these  changes  are  due  to  the  grave  circulatory 
disturbances,  the  occlusion  of  capillaries,  lesions  of  their  walls,  the  stasis, 
and  the  hemorrhages  produced  by  the  malarial  parasites.  It  may  be 
noted  that  many  of  these  changes  are  not  dissimilar  to  those  described 
by  Dr.  Berkley  in  animals  after  the  injection  of  ricin. 

The  Spleex. — The  spleen  is  always  enlarged  ;  there  is  a  pronounced 
"  acute  splenic  tumor."  The  capsule  is  tense.  The  parenchyma  is 
cyanotic  and  sometimes  is  of  a  markedly  slaty  gray  color ;  it  is  soft  and 
is  often  almost  diffluent.  In  acute  malaria  death  may  occasionally  occur 
from  rupture  of  an  enlarged  spleen.  Microscopically,  the  pulp  contains 
enormous  numbers  of  red  corpuscles,  many  of  which  contain  parasites. 
These  parasites  may  be  in  various  stages  of  development.  Sometimes, 
in  the  same  organ,  diiferent  areas  show  separate  groups  of  parasites  in 
different  stages  of  development.  Generally  the  pigmented  and  segment- 
ing forms  may  be  found  in  large  numbers.  Free  forms  of  the  parasite 
are  relatively  rare.  One  of  the  most  striking  appearances  in  the  splenic 
pulp  is,  however,  the  presence  of  great  numbers  of  phagocytes,  some 
smaller  and  apparently  leucocytic  in  nature,  others  very  large  cells,  rich 
in  protoplasm,  containing  a  single  large  nucleus  and  occasionally  a 
coarse  granulation.  These  cells  may  reach  an  enormous  size.  They  are 
laden  with  pigment,  either  in  large  clumps  or  spheres,  in  rodlets,  or  in 
very  fine  granules  ;  the  granules  sometimes  present  the  same  arrange- 
ment which  they  had  in  the  body  of  the  parasite.  The  fine  pigment 
may  be  distributed  in  delicate  lines  throughout  the  whole  mass  of  proto- 
plasm of  the  phagocyte  ;  it  often  seems  to  vary  in  its  color  in  different 
parts  of  the  cell,  but  on  focussing  this  appearance  is  found  to  be  due  to 
differences  in  plane.  These  large  cells  also  contain  red  corpuscles, 
which  are  often  partially  or  completely  decolorized  and  contain  para- 
sites ;  and,  finally,  entire  smaller  phagocytes  with  their  included  pig- 
ment or  corpuscles,  as  well  as  clumps  of  haemoglobin  of  the  color  of 
old  brass  and  fragments  of  degenerated  red  corpuscles.  Golgi  and 
Monti  have  called  particular  attention  to  the  frequency  with  which  these 
macrophages  contain  apparently  well  preserved  parasites  in  different 
stages  of  development.  They  believe  that  the  shrunken  and  brassy  para- 
sitiferous  red  corpuscles  are  engulfed  in  the  phagocytes  as  would  be  any 
foreign  body,  while  the  included  parasites  continue  their  development 
within.  Some  of  these  macrophages  may  show  evidences  of  necrosis. 
In  some  cases  one  may  find  in  the  pulp  actual  focal  necroses,  very  much 


86  MALARIA. 

like  those  which  may  be  seen  in  typhoid  fever.  These  changes  have 
been  well   described  by  Barker.' 

There  may  be  malarial  jjigment  free  in  the  intercellnlar  spaces  in  the 
pulp.  Pigmented  polymorphonuclear  cells  are  relatively  rare ;  the 
small  mononuclear  elements  and  the  lymphocytes  of  the  follicles  never 
contain  pigment.  The  capillaries  are  usually  filled  with  corpuscles  con- 
taining parasites,  while  the  splenic  veins  show  relatively  few,  though 
they  always  contain  phagocytes  containing  pigment  and  fragments  of 
blood-corpuscles. 

The  Liver. — The  liver  is  often  of  an  intense  slaty  gray  color, 
which  depends  upon  the  enormous  numbers  of  parasites  and  of  pigment 
contained  in  the  capillaries.  The  distribution  of  the  pigment  is  diiferent, 
as  will  be  pointed  out  later,  in  this  acute  malarial  infection  from  that 
characteristic  of  repeated  attacks.  There  is  always  a  marked  cloudy 
swelling.  Microscopically,  the  capillaries  are  often  crowded  with  leuco- 
cytes and  contain  numerous  phagocytes ;  some  of  the  largest  macro- 
phages are  here  observed.  Not  infrequently  the  endothelial  cells  may 
be  also  observed  to  show  evidences  of  phagocytic  action.  The  perivas- 
cular tissue  in  the  portal  spaces  may  show  numerous  pigment  bearing 
cells,  while  frequently  liver  cells  may  be  found  to  contain  clumps  of 
pigment  derived  from  the  blood  and  altered  red  corpuscles.  This  con- 
dition, similar  to  that  observed  in  pernicious  ansemia,  accounts,  doubt- 
less, for  the  polycholia  and  the  subicteric  hue  so  commonly  observed  in 
the  malarial  fevers.  Ordinarily  relatively  few  parasites  within  red  cor- 
puscles are  to  be  found  within  the  vessels  :  these  are  more  numerous  in 
the  interlobular  branches  of  the  portal  vein.  In  the  intralobular  veins 
one  more  often  sees  the  macrophages. 

Among  the  most  interesting  changes  to  be  noted  in  the  liver  are 
occasionally  occurring  disseminated  areas  of  local  necrosis  of  the  liver 
elements  with  fragmentation  of  the  nuclei,  wandering  in  of  leucocytes, 
and  sometimes  with  evidences  of  proliferation  of  cells  in  the  surround- 
ing tissue.  These  changes  are  very  similar  to  those  already  noted  in 
typhoid  fever  and  other  acute  infectious  diseases,  and  proven  by  Welch 
and  Flexner  ^  to  be  produced  in  diphtheria,  and  by  Eeed  ^  in  typhoid 
fever,  by  a  circulating  toxic  substance.  The  occurrence  of  these  foci  in 
the  liver  was  first  described  by  Guarnieri,*  who  ascribed  them  to  the  cut- 
ting off  of  the  nutrition  by  the  extensive  blocking  of  the  intralobular 
capillaries  with  pigment  bearing  phagocytes.  Barker^  describes  and 
pictures  capillary  thromboses  in  association  with  many  of  these  areas. 

The  Lungs. — The  alveolar  capillaries  show,  generally,  large  num- 
bers of  phagocytes,  which  are,  however,  smaller  than  the  largest  macro- 
phages of  the  liver  and  spleen.  Their  substance  may  show  evidence 
of  necrosis.  Occasionally  pigment  may  be  found  in  the  endothelial 
cells  of  the  capillaries  and  small  veins,  but  much  more  rarely  than  in 
the  capillaries  of  the  brain  or  of  the  liver.  Leucocytes  containing 
malarial  pigment  are  seldom  found  in  the  interior  of  the  alveoli.  Mono- 
nuclear phagocytes  are  much  more  frequent  than  ordinary  polymorpho- 

'  Johns  Hopkins  Hospital  Reports,  vol.  v.,  1895. 

2  The  Johns  Hopkins  Hospital  Bulletin,  No.  20,  March,  1892. 

*  Johns  Hopkins  Hospital  Reports,  vol.  v.,  1895. 

*  Atti  della  R.  Ace.  Med.  di  Roma,  1887,  s.  ii.  v.  iii.  247-266.  '  L^e.  cit. 


PATHOLOGICAL  AXATO.VY.  87 

mu'lcar  leucocytes,  wliicii,  when  present,  contain,  usually,  finer,  smaller 
particles  of  ])iginent.  The  nuicropha«j:es  are  generally  collectecl  about  the 
periphery  of  the  smaller  veins.  The  en(loo:l<»'>ular  ])arasites  show,  usu- 
ally, all  stages  of  development.  The  endothelium  of  the  capillaries  and 
small  veins  rarely  contains  pigment,  in  sharp  contrast  to  the  condition 
existing  in  the  brain.  It  is  striking  that  the  areas  of  l)ronchopneu- 
monia,  which  are  not  infrequently  found,  contain  only  the  ordinary 
polymorj)honuclcar  leucocytes  and  alveolar  epithelial  cells,  pigmented 
elements  being  very  rarely  present.  The  capillaries  of  the  septa  may, 
however,  be  filled  with  pigment  and  macrophages.  Bignami  suggests 
that  this  fact  is  due  to  the  diminished  vitality  of  the  pigment  bearing 
cells,  which  have,  to  a  certain  extent,  lost  their  motile  power  and  are 
thus  less  able  to  pass  through  the  vessels. 

The  Kidneys. — The  changes  in  the  kidneys  in  acute  malaria  are 
usually  much  less  marked  than  in  the  liver  and  spleen.  Their  gross 
appearance  varies  but  little  from  the  normal.  Evidences  of  pigmenta- 
tion are  usually  wanting  on  gross  examination.  The  malarial  parasites 
and  phagocytes  are  usually  present  in  smaller  numbers,  the  quantity 
being  disproportionately  small  in  comparison  to  the  alterations  of  the 
parenchyma  which  are  sometimes  to  be  found.  The  glomeruli,  how- 
ever, are  ordinarily  considerably  pigmented,  the  pigment  at  times  being 
seen  within  large  white  cells  within  the  vessels,  sometimes  in  the 
glomerular  endothelium.  Endoglobular  parasites  are  rarely  seen  in 
the  capillaries  of  the  glomeruli  ;  they  are  more  common  in  the  inter- 
tubular  vessels,  but  are  rare  even  there.  The  most  important  lesions 
consist  in  exfoliation  and  degeneration  of  the  epithelium  lining  the 
capsules.  Albuminous  exudates  within  the  glomeruli  were  found  bv 
Bignami  only  in  algid  pernicious  fever.  At  times,  however,  there  may 
be  marked  alterations  in  the  parenchyma — to  wit,  focal  necroses  of  the 
epithelium,  especially  that  of  the  convoluted  tubules. 

The  changes  in  the  kidneys  in  cases  of  hsemoglobinuric  fever  have 
been  described  by  Pellarin,^  Benoit,-  Kiener,  and  Kelsch.'^  The  kid- 
neys are  somewhat  increased  in  size,  the  color  var^'ing  from  a  deep 
reddish  brown  to  a  light  yellowish  brown  coffee  color  in  more  ansemic 
individuals.  When  the  color  is  pale,  irregular  pinhead  points  and 
blotches  of  a  maroon  color  are  to  be  seen  upon  the  surface,  some  as 
large  as  several  millimetres  in  area.  They  are  also  scattered  through- 
out the  cortex.  These  have  been  shown  by  Kelsch  and  Kiener  to  be 
due  to  pigment  deposits ;  they  are  not  visible  in  more  congested  kid- 
neys. The  pyramids  are  of  a  deep  red  color  from  intratubular  hemor- 
rhages. The  capsule  is  easily  detached  ;  the  consistency  of  the  gland 
is  normal. 

Microscopically,  the  epithelium  of  the  convoluted  tubules  and  of  the 
large  branches  of  Henle's  loops  are  very  opaque,  the  nuclei  being 
scarcely  visible.  This  is  due  to  an  infiltration  of  the  protoplasm  with 
a  diffuse  coloring  matter  and  fine  pigment  granules  which  are  rendered 
more  evident  by  KOH.  These  granules  are  extremely  small,  and  sepa- 
rately appear  of  a  yellowish  color,  while  en  masse  they  have  a  brown 
shade.  The  epithelial  cells  are  swollen  and  bulge  into  the  lumen  of  the 
canal.     Occasionally  a  cell  shows  a  hyaline  protrusion  which  seems  on 

1  Arch.  deMed.  nav.,  1865.  -  Ibid.  ^  Arch,  de  Phys.,  1882. 


88  MALARIA. 

the  point  of  escaping.  In  some  tubes  the  epithelial  covering  is  repre- 
sented only  by  a  thin  protoplasmic  layer  with  a  homogeneous  surface, 
appearing  as  if  eroded  down  to  the  level  of  the  nuclei.  The  lumen 
of  the  tubule  is  filled  with  clumps  of  amorphous  material  or  casts 
mixed  to  a  greater  or  less  extent  with  this  pigment.  The  brown  specks 
and  blotches  seen  macroscopically  represent  groups  of  tubules,  the  epithe- 
lium and  lumina  of  which  are  crowded  with  similar  masses  of  pigment ; 
but  pigment  may  also  be  found  in  larger  granules — granules  nearly  as 
large  as  a  red  blood-corpuscle,  and  more  or  less  spherical ;  they  are  refrac- 
tive, of  a  color  varying  from  a  yellow  ochre  to  a  deep  brown,  and  are  some- 
times accumulated  in  epithelial  cells  which  bulge  so  as  to  almost  occlude 
the  lumen.  Sometimes  they  occupy  the  lumen  and  form  conglomerations, 
taking  the  shape  of  casts  ;  sometimes  they  are  fused  into  a  vitreoid  mass. 
Between  the  opaque  dark  casts  formed  by  the  fine  brown  granulations 
and  the  almost  vitreoid  casts  composed  of  the  large  orange  colored 
granulations  every  intermediate  stage  may  be  seen  in  the  same  prepara- 
tion. Generally  this  pigment  gives  no  reaction  for  iron,  though  Kelsch 
and  Kiener  have  obtained  this  reaction  from  certain  granules  in  one 
case.  The  finely  granular  substance  is  found,  according  to  these  authors, 
more  particularly  in  cases  where  death  has  occurred  in  a  pernicious 
paroxysm,  while  the  larger  forms  of  pigment  are  more  frequent  in 
cases  of  longer  duration.  In  the  glomeruli,  as  well  as  in  the  blood, 
Kelsch  and  Kiener  have  never  seen  the  large  variety  of  granules, 
though  the  finer  granules  are  numerous.  Between  the  glomerulus  and 
capsule,  usually  near  the  mouth  of  the  tubule,  there  is  often  quite  a 
collection  of  granules,  which  are  also  found  sometimes  in  epithelial 
cells,  sometimes  free.  In  the  glomerulus  itself  one  may  see  fine  gran- 
ulations disseminated  in  its  substance  and  apparently  included  in  the 
cells  of  the  capillary  walls.  More  rarely  granulations  may  be  accumu- 
lated in  a  capillary  loop.  In  some  cases  there  are  small  interstitial 
hemorrhages.  The  pyramids  show  few  changes.  The  same  varieties 
of  casts  as  noted  above  may  be  found,  and  the  same  pigment  collections. 
The  epithelium  is  usually  intact,  though  sometimes  protruding  and 
vesicular  cells  suggest  that  they  may  take  part  in  the  formation  of 
hyaline  material.  Almost  invariably  a  number  of  the  tubes  are  found 
filled  with  blood-corpuscles. 

The  Gastro-intestinal  Tract.  —  The  stomach  and  intestines 
show,  under  ordinary  circumstances,  few  changes  beyond  the  melanosis. 
It  is  to  be  remembered,  however,  that  the  intestinal  mucous  membrane 
may  be  of  a  dark  steel  gray  color  in  conditions  other  than  malaria. 
Microscopically,  one  may  see  a  considerable  number  of  parasites,  espe- 
cially of  the  full  grown  and  segmenting  varieties,  in  the  capillaries  of 
the  mucous  membrane,  together  with  numerous  pigmented  cells  and 
apparently  few  pigment  clumps.  In  most  cases,  however,  the  gastro- 
intestinal mucous  membrane  is  not  particularly  sought  by  the  parasites. 

In  other  instances,  as  pointed  out  by  Marchiafava  and  Bignami, 
this  region  may  be  the  seat  of  the  main  localization  of  the  afFection. 
Macroscopically,  there  may  be  intense  hypersemia  with  punctate  hemor- 
rhages in  the  gastro-intestinal  mucosa.  In  one  instance  observed  by  the 
author  there  was  a  distinct  dusky  slaty  tinge  as  well.  Here  the  capil- 
laries throughout  the  gastro-intestinal  tract  may  be  crowded  and  blocked 


'    PATHOLOGICAL   ANATOMY.  89 

with  parar^ites,  free  and  cnntainod  in  the  rod  corpuscles  or  in  phagocytes. 
As  in  the  case  of"  tlie  brain,  actual  tiironihoses  may  exist  witli  necrosis 
of  the  ejiithelial  coverinu-  and  uh-eration.  Cases  of  this  nature  are  asso- 
ciatetl  fre«(Ueutly  witli  niarUi-d  gastro-intestinal  syinj)tonis,  some  sliow- 
ing;  a  clinical  picture  very  similar  to  that  of  Asiatic  cholera. 

The  Bone  Marrow. — The  marrow  is  generally  of  a  dark  slaty 
color  ;  it  is  often  almost  black.  The  small  vessels  are  filled  with  endo- 
lilobular  j)iuincute(l  ])arasites,  while  numerous  macrophages  containing 
pigment  and  red  blood-corpuscles  may  be  found  about  the  periphery 
of  the  lumina  of  the  vessels.  At  times,  between  the  corpuscles,  Biguami ' 
found  numerous  ovt)id  or  round  bodies  which,  from  their  size  and  stain- 
ing ])ropensities,  he  believed  to  be  free  spores.  Not  only  in  the  vessels, 
but  also  outside  of  these,  the  pai'asites  are  to  be  found  in  greater  or  less 
number.  The  macrophages  are,  however,  especially  numerous,  even  in 
the  })ulp.  At  times  also  free  pigment  clumps  are  apparently  to  be 
made  out. 

The  ADRENAL  GLANDS  may  be  the  seat  of  pronounced  alterations. 
There  are  irregular  areas  of  vascular  dilatation,  parasites  being  numer- 
ous in  the  distended  vessels.  Macrophages  with  varying  contents  may 
be  present  in  considerable  numbers.  The  endothelial  cells  of  the  ves- 
.sels  may  be  phagocytic,  and  malarial  pigment  and  infected  corpuscles 
may  even  be  enclosed  by  true  adrenal  cells. 

In  the  other  organs  there  is  little  that  is  characteristic. 

(2)  Changes   following   Repeated   or   Chronic   Infections. — 
Chronic  Malarial  Cachexia. 

While  the  above  mentioned  changes  are  found  in  the  acutely  fatal 
cases  of  malaria,  interesting  pathological  changes  may  occur  in  various 
organs  as  the  result  of  long  continued  or  frequently  repeated  attacks. 
The  most  important  of  these  changes  occur  in  the  spleen,  the  liver,  the 
bone  marrow,  and  the  circulating  blood. 

The  Spleen. — The  spleen  is  ahvays  considerably  enlarged  ;  it  may 
be  enormous,  reaching  beyond  the  umbilicus  and  as  Ioav  as  the  pubes. 
It  is  firm  and  hard  ;  the  border  is  sharp.  The  capsule  is  usually  much 
thickened,  and  white  fibrous  cartilaginoid  plaques  occur  upon  the  surface. 
On  section  it  has  often  a  somewhat  slaty  color,  while  the  trabecule  are 
very  prominent. 

The  minute  anatomy  and  development  of  the  changes  in  the  viscera, 
follow^ing  repeated  malarial  attacks,  has  been  followed  w^ith  particular 
care  by  Biguami,^  upon  whose  valuable  work  we  shall  largely  trespass 
in  the  following  description.  The  acute  splenic  tumor  is  caused  chiefly 
by  the  aggregation  in  the  pulp  of  the  spleen  of  an  enormous  number 
of  red  corpuscles  which  have  become  either  shrunken  and  brassy  colored 
or  decolorized,  and  are  found  included  in  the  colorless  elements  of  the 
spleen  as  brassy  colored  fragments  or  hyaline  masses  ;  by  the  continuous 
aggregation  of  colorless  elements  containing  pigment,  red  corpuscles,  or 
parasites,  which  collect  from  all  parts  of  the  body,  and  many  of  Avhich 
are  necrotic  ;  and,  thirdly,  by  great  numbers  of  red  corpuscles  contain- 
ing parasites,  some  of  which  apparently  pass  through  the  vessel  walls 

1  Atti  d.  R.  Ace.  Med.  di  Roma,  Anno  xvi.  v.,  1890. 

«  Bull.  d.  R.  Ace.  Med.  di  Roma,  1893,  Anno  xix.  f.  4,  p.  186. 


90  MALARIA. 

by  diapedesis  and  seek  the  columns  of  the  pulp,  where  they  are  for  the 
most  part  enclosed  by  the  epithelioid  elements.  While,  as  a  result  of 
this  proceeding,  a  considerable  number  of  the  proper  elements  of  the 
spleen  become  necrotic,  others,  as  well  in  the  pulp  as  in  the  follicles, 
undergo  karyokinetic  division,  while  all  this  is  followed  by  a  marked 
hypersemia  and  acute  tumor  of  the  splenic  pulp.  Thus  the  spleen  is 
converted  into  a  place  for  the  deposit  of  cadavers,  wdiile  at  the  same 
time,  during  the  same  infection,  processes  of  regeneration  have  begun 
to  appear. 

When  the  actual  infection  is  at  an  end  and  the  acute  hypersemia  of 
the  spleen  has  ceased,  the  tissues  in  the  neighborhood  of  these  collec- 
tions of  necrotic  elements,  or  those  surrounding  the  necrotic  areas  of  the 
splenic  pulp,  show  certain  changes  which,  on  the  one  hand,  tend  to  pro- 
duce permanent  alterations,  and  on  the  other  to  lead  to  a  partial  repara- 
tion of  the  part.  In  those  parts  where  a  considerable  portion  of  the 
splenic  tissue  becomes  necrotic  or  disappears,  being  carried  away  by 
the  lymphatics,  the  splenic  vessels  become  considerably  dilated,  forming 
a  network  of  venous  lacunae  which  are  separated  by  thin  layers  of  pulp. 
This  results  in  a  tissue  simulating  that  of  an  angioma.  In  those  cases 
w^here  a  more  marked  destruction  of  the  splenic  tissue  has  occurred, 
and  where  every  trace  of  the  pulp  is  gone,  parts  become  represented  by 
extensive  areas  of  tissue  which  consist  of  wide  cavernous  sinuses,  the 
septa  of  which  are  composed  of  a  very  delicate  connective  tissue,  rich  in 
giant  cells,  similar  to  that  of  the  bone  marrow.  Some  of  the  follicles  be- 
come necrotic  and  fibrous.  While  this  occurs  a  process  of  regeneration 
yet  more  extensive  takes  place,  starting  for  the  most  part  from  the  fol- 
licles, but  also  sometimes  from  the  splenic  pulp.  The  follicles  become 
hyperplastic,  reaching  sometimes  three  or  four  times  their  normal  size. 
This  new  form  of  lymphoid  tissue,  starting  from  the  follicles,  may  be 
sometimes  seen  to  surround  necrotic  areas  of  splenic  tissue  Avhich  be- 
come smaller  and  smaller  and  finally  disappear.  In  the  neighborhood 
of  these  hyperplastic  follicles  occurs  a  hyperplasia  of  the  true  elements 
of  the  pulp,  while  the  reticulum  becomes  thickened  so  as  to  give  rise, 
in  preparations,  to  very  beautiful  and  clear  figures,  such  as  are  not  to 
be  seen  in  the  normal  spleen.  The  pigment  and  probably  the  greater 
part  of  the  necrotic  elements  are  carried  on  toward  and  collected  about 
the  periphery  of  the  follicles,  so  that  the  diffuse  melanosis  of  the  pulp 
is  followed  by  a  perifollicular  melanosis.  The  pigment  then  passes  on 
into  the  lymphatic  vessels  of  the  sheaths  of  the  arteries  and  of  the  con- 
nective tissue  of  the  septa.  This  results,  on  the  one  hand,  in  thickening 
of  the  vascular  sheaths  and  of  the  septa,  and,  on  the  other  hand,  in  the 
appearance  of  single  or  multiple  lymphatic  cysts,  giving  sometimes  the 
picture  of  a  lymphangioma  and  resulting  in  chronic  lymph  stasis. 

When  we  consider  that  after  each  new  infection  fresh  processes  simi- 
lar to  these  must  occur,  it  is  easy  to  understand  the  gradual  development 
of  the  enormous  splenic  tumors,  in  which,  sometimes,  it  is  dii!icult,  even 
histologically,  to  recognize  the  original  structure  of  the  organ. 

The  Livee. — The  changes  occurring  in  the  liver  in  chronic  malaria 
may  in  the  same  manner  be  traced  from  those  occurring  in  the  acute 
infection.  In  the  acute  infection  an  enormous  number  of  phagocytes, 
pigmentiferous  or  globuliferous,  coming  in  great  part  from  the  spleen, 


PATHOLOGICAL   AX  A  TOM  V.  91 

invades  the  caj)illarv  nctwctrk  of  tlic  liver,  wliile  the  parasites  are  gen- 
erally seanty.  The  eircuiatioii  is  slowed,  tiie  eapillary  network  heeomes 
dilated,  while  a  eertain  amount  of"  pigment  is  taken  up  l)y  the  endothe- 
lial eells  of  the  vessels,  and  later  by  Kupffer's  cells.  The  pigmented 
endothelium  becomes  swollen  and  in  part  necrotic.  These  vascular 
changes  are  followed  by  new  areas  of  blood  stasis.  At  the  same  time, 
as  has  been  noted,  many  of  the  liver  cells  suffer  alterations,  either 
undergoing  an  acute  atrophy  from  pressure  or  a  coagulative  necrosis. 
These  areas  are  sometimes  quite  extensive.  In  other  instances  many 
cells  are  found  to  be  filled  with  blocks  of  yellowish  iron-containing  pig- 
ment, resulting  from  the  early  death  of  many  red  corpuscles.  At  the 
same  time  a  certain  number  of  liver  cells,  Kupffer's  cells,  and  endothe- 
lial eells  multiply  by  karyokinesis.  The  result  of  all  this  is  the  acute 
hepatic  tumor  and  the  increase  in  functional  activity — polycholia. 

But  a  small  part  of  the  great  number  of  pigmented  elements  which 
enter  the  liver  escape,  passing  through  the  branches  of  the  supi'ahepatic 
veins.  The  greater  part  is  taken  up  by  endothelial  and  perivascular 
cells,  so  that  the  melansemia  is  followed  by  a  melanosis  of  the  vessels. 
The  pigment  then  passes  forward  out  of  the  capillary  net^vork  into  the 
perivascular  lymph  channels,  where  it  is  collected  in  large  blocks  en- 
closed in  white  cells.  These  carry  the  pigment  following  the  lymph 
channels  to  the  periphery  of  the  lobules,  and  perilobular  melanosis 
follows  thus  the  interlobular  melanosis.  This  process  then  extends, 
and  the  masses  of  pigment  are  to  be  found  three  or  four  months  after 
the  end  of  the  infection  in  large  blocks,  for  the  most  part  endocellular, 
in  the  perivascular  lymphatic  tissue  of  Glisson's  capsule. 

AVhile  this  migration  of  pigment  is  going  on  in  the  lobule  there 
occur,  on  the  one  hand,  permanent  alterations,  and  on  the  other  hand 
regenerative  processes.  Where  the  dilatation  of  the  lymph  and  blood- 
vessels and  the  degeneration  and  pigmentation  of  the  vascular  elements 
is  most  marked  and  extensive,  no  regeneration  may  follow  the  atrophy 
and  necrosis  of  the  endothelial  and  liver  cells.  The  dilatation  of  the 
vessels  increases  and  becomes  permanent.  The  greater  part  of  the  re- 
maining liver  elements  disappears ;  only  a  few  remain  in  an  atrophic 
condition,  the  tissue  showing  an  angioma-like  appearance  consisting 
of  ectatic  vascular  network,  about  which  may  be  recognized  a  stroma 
consisting  of  Kupffer's  cells.  AVhere  the  dilatation  of  the  lymph  vessels 
is  most  marked  there  may  occur  small  lymphatic  cysts. 

In  all  parts  of  the  liver,  when  the  normal  blood  current  has  been 
restored  after  the  disappearance  of  the  pigment  and  the  necrotic  masses 
in  general  from  the  endothelial  cells  of  the  vessel  walls,  an  active  regen- 
eration of  the  tissue  elements  occurs  about  the  atrophic  or  necrotic  liver 
cells.  The  young  hepatic  cells  become  arranged  with  great  regularity 
in  long  rows  on  both  sides  of  the  old  elements.  Thus,  when  the  stroma 
remains  intact,  an  interlobular  regeneration  may  occur.  These  regene- 
rative processes  are  accompanied  by  the  appearance  of  giant  cells  with 
budding  nuclei,  just  such  as  are  found  in  the  embryonic  liver.  The 
regeneration  never  appears  in  parts  of  the  liver  that  have  not  been 
entirely  freed  from  the  collections  of  pigment  and  parasites. 

The  migration  and  collection  of  the  pigment  in  the  perilobular  tissue 
is  followed  by  a  hyperplasia  of  tliis  tissue,  so  that  the  surroundings  of 


92  MALARIA. 

the  lobules  are  more  distinct.  These  de-  and  regenerative  changes  result, 
then,  in  a  marked  increase  in  the  size  of  some  lobules  and  a  diminution 
in  size  and  an  atrophy  of  others.  As  this  process  accompanies  each  acute 
infection,  one  can  readily  understand  the  chronic  perilobular,  mono- 
lobular  hepatitis  of  malaria,  which  is  characterized  by  the  presence  of 
zones  of  hyperplasia  or  of  atrophy  of  the  parenchyma,  by  chronic  blood 
and  lymph  stasis,  by  the  formation  of  areas  of  angiomatoid  tissue,  by 
lyniphectases  and  lymphatic  cysts.  In  this  manner  the  large  liver 
tumors  which  are  so  well  known,  with  smooth  surface  and  lobules  of 
irregular  size,  have  their  origin. 

Bignami  divides  the  processes  in  the  liver  into  four  stages  : 

(1)  The  liver  appears  congested,  while  the  lobules  are  not  sharply 
distinguishable  and  show  in  severe  cases  a  decreased  melanosis.  The 
macroscopical  characters  are  about  the  same  as  those  of  the  liver  in  acute 
malarial  infections.  Microscopically,  at  this  period,  a  little  after  the  ter- 
mination of  the  acute  infection,  it  may  be  noted  that  the  parasites  have 
disappeared  from  the  capillaries  of  the  liver,  the  pigmented  endovascular 
macrophages  have  in  great  part  gone,  and  the  pigment  is  entirely  col- 
lected in  the  endothelium  and  in  Kupffer's  cells.  Those  parts  of  the 
hepatic  lobules  in  which  necrosis  or  degeneration  has  occurred  undergo 
a  marked  atrophy  ;  the  necrotic  and  degenerate  elements  are  carried 
away  in  the  phagocytes,  while  the  vascular  network  becomes  dilated. 

(2)  In  a  more  advanced  stage  on  gross  examination  the  lobules  are 
distinct.  The  melanosis  continues  to  be  diflFuse  throughout  the  lobule, 
but  is  more  marked  at  its  periphery.  The  organ  is  still  congested.  The 
particular  features  of  this  stage  are  that,  on  the  one  hand,  the  hepatic 
lobule  frees  itself  from  the  accumulation  of  pigment  and  the  necrotic 
remains,  which  become  collected  toward  the  periphery  of  the  lobule, 
while,  on  the  other  hand,  an  active  process  begins  which  tends  toward  a 
partial  regeneration  of  the  parenchyma. 

(3)  In  this  stage  the  diffuse  melanosis  of  the  lobule,  with  the  greater 
prevalence  of  pigment  toward  the  periphery,  is  succeeded  by  an  exclu- 
sively perilobular  melanosis.  The  liver  is  enlarged,  the  consistency 
somewhat  increased,  the  surface  smooth.  On  section  one  may  see  that 
all  the  lobules  are  surrounded  by  a  slate  colored  line,  in  the  neighbor- 
hood of  which  the  coloration  of  that  part  of  the  lobule  is  somewhat 
brown.  In  general,  the  slaty  lines  marking  out  each  lobule  form  an 
exquisite  network.  The  size  of  individual  lobules  varies  greatly  :  some 
are  two  or  three  times  the  normal  size,  others  are  markedly  diminished. 
Microscopically,  it  may  be  observed  that  the  degenerative  alterations  of 
some  lobules  have  led  to  the  formation  of  false  angiomata  and  of  lacunae 
or  cysts  of  lymphatic  nature.  Other  lobules,  by  the  process  of  regene- 
ration already  described,  have  increased  notably  in  volume.  The  pig- 
ment has  become  extravascular ;  its  transport  through  the  capillaries 
and  perilobular  lymphatics  is  brought  about  by  white  mono-  and  poly- 
morphonuclear cells. 

(4)  In  cases  in  which  the  acute  infection  has  passed  for  several 
months  (in  one  case  three  months  only)  the  pigmentation  is  greatly 
diminished  and  scarcely  visible  to  the  naked  eye.  The  liver  is  notably 
enlarged  and  congested.  The  surface  is  smooth.  On  section  one  may 
see  the  lobules  distinctly  marked,  surrounded  by  a  most  delicate  red- 


PATHOLOGTCAL   ANATOMY.  93 

(lisli  brown  border;  (he  eonsi.stcnev  is  sonicwliat  increased.  Micro- 
scopical exaniiiiatioM  shows  tliat  the  inehiiiosis  has  Ix-coiiie  exchisivelv 
perivascular. 

(5)  Lastly,  on(>  arrives  at  the  defiiiite  terniiiiai  ibrin  of  the  cliroiiic 
malarial  hepatic  tumor.  The  macroscopical  charactei-s  are  the  tbllow- 
iuji,- :  The  liver  is  increased  in  size  and  in  weight,  sometimes  enormously  ; 
the  surface  is  smooth,  the  capsuU'  a  little  thickened.  On  section  the 
appearance  is  finely  granular,  tiie  lobules  are  distinct,  a  little  prominent, 
and  surrounded  by  a  zone  of  slightly  pinkish  tissue.  Microscopical  ex- 
amination shows  the  disap]X'aranee  of  all  malarial  pigment.  The  altera- 
ticMis  of  the  parenchyma  are  similar  to  those  described  in  the  last  two 
stages.  The  lobules  of  varying  size  are  surrounded  by  a  hyperplastic 
perilobular  connective  tissue.  The  connective  tissue  of  the  larger  septa 
is,  on  the  other  hand,  of  about  normal  volume.  A  notable  dilatation 
of  the  capillaries,  with  stasis  of  the  colorless  corpuscles,  persists.  The 
hepatic  cells  are  altered  in  form  in  the  zones  where  the  dilatation  is 
most  marked.  There  is  considerable  diiference  in  individual  cases 
in  the  extent  oi'  these  various  lesions.  There  are  cases,  for  example, 
in  which,  despite  the  enormous  increase  in  the  weight  of  the  organ, 
there  may  be  no  very  marked  dilatation  of  the  capillaries,  nor  are  false 
angiomata  or  lymphatic  cys1:s  to  be  found,  while,  on  the  other  hand,  the 
hyperplasia  of  the  perilobular  connective  tissue  and  the  increase  in  vol- 
ume of  many  lobules  may  be  more  marked  :  there  may  be  an  evident 
hyperplasia  of  the  parenchyma  (hepatic  cells  with  many  nuclei  and 
nuclei  rich  in  chromatic  substance).  lu  other  cases,  on  the  other 
hand,  the  cysts  and  false  angiomata  may  be  enormously  developed, 
so  as  to  constitute  one  of  the  chief  factors  in  the  enlargement  of  the 
liver. 

The  Boxe  jMaerow. — In  individuals  Avho  have  had  numerous  re- 
lapses of  malarial  fever  the  marrow  of  the  long  bones — for  example, 
of  the  femur  in  the  upper  and  louver  fourths — is  usually  red  and  of  a 
consistency  greater  than  is  generally  seen  in  acute  infections.  The 
microscopical  alterations  are  various ;  generally  the  signs  of  an  active 
proliferation  of  the  proper  elements  of  the  marrow  are  present.  This 
leads  to  an  increase  in  the  hematopoietic  activity.  There  are  factors, 
however,  such  as  the  degenerative  and  destructive  alterations  which 
take  place  in  the  bone  marrow  during  acute  infections,  which  injure,  to 
a  varying  extent  and  through  a  varying  length  of  time,  the  haematopoi- 
etic functions  of  the  marrow.  In  other  cases,  very  rare  indeed,  the  bone 
marrow  presents  the  macroscopical  and  microscopical  features  which 
exist  in  acute  pernicious  anaemia,  particularly  the  presence  of  a  consid- 
erable number  of  megaloblasts.  Lastly,  there  may  be  cases  in  which 
the  new  formation  of  the  hsematoblastic  marrow  is  wanting  or  entirely 
insufficient.  In  these  cases  the  post-malarial  anaemia  is  of  necessity 
progressive. 

The  Blood. — Corresponding  to  the  change  in  the  bone  marrow, 
Bignami  and  Dionisi  ^  distinguish  four  types  of  post-malarial  anjemia  : 

(1)  Ansemise  in  which  the  examination  of  the  blood  shows  alterations 
similar  to  those  observed  in  secondary  ansemise,  from  which  they  differ 
only  in  that  the  leucocytes  are  diminished  in  number.     The  greater  part 

1  Cent./.  Allg.  Path.  u.  Path.  Anat.,  1894,  V.  No.  10,  422. 


94  MALARIA. 

of  these  cases  go  on  to  recovery ;  a  few,  without  any  further  change  in 
the  hsematological  condition,  pursue  a  fatal  course, 

(2)  Ansemise  in  which  the  examination  of  the  blood  shows  alterations 
similar  to  those  seen  in  pernicious  anaemia — presence  of  gigantoblasts 
(megaloblasts).     These  cases  end  fatally. 

(3)  Ansemise  which  are  progressive,  as  a  result  of  lack  of  compen- 
sation by  the  marrow  for  losses  brought  about  by  the  infection.  At 
autopsy  the  marrow  of  the  long  bones  is  found  to  be  wholly  yellow, 
while  the  marrow  of  the  flat  bones  is  also  poor  in  nucleated  red 
corpuscles. 

(4)  Chronic  ansemise  of  the  cachectic,  which  diifer  from  the  above- 
mentioned  types  by  clinical  and  anatomical  characters  in  that  the  special 
symptoms  of  malarial  cachexia  prevail,  while  one  observes  post-mortem 
a  sort  of  sclerosis  of  the  bone  marrow.  The  marrow  of  the  long  bones 
is  red  and  of  an  increased  consistency  ;  the  giant  cells  are  very  numer- 
ous, and  many  are  necrotic ;  the  nucleated  red  blood-corpuscles  are  very 
rare,  and  the  colorless  polymorphonuclear  corpuscles  are  present  in 
small  numbers. 

The  Kidneys. — The  kidneys  in  chronic  malaria  show  usually  no 
great  changes.  Ki^ner,  however,  describes  two  forms  of  kidneys  met 
with  in  chronic  paludism  :  (1)  the  congested  form,  and  (2)  the  atrophic 
form. 

(1)  The  engorged  kidneys  are  voluminous,  increased  in  weight ;  the 
surface  is  smooth,  the  consistency  firm,  the  color  of  a  deep  red.  The 
congestion  is  especially  marked  in  the  pyramids.  All  the  vessels  are 
distended,  and  the  congestion  is  sometimes  so  extreme  that  interstitial 
hemorrhages  may  result  or  hemorrhages  into  the  interior  of  the  tubules. 
The  epithelium  of  the  tubules  is  granular ;  there  is  often  desquamation, 
and  hyaline  casts  may  be  found. 

(2)  The  atrophic  kidneys  are  small  and  irregular  in  surface.  The 
capsule  is  adherent,  the  consistency  increased.  The  kidneys  show  a 
maroon  or  mahogany  color  or  a  blotchy  appearance.  Small  cysts  are 
often  to  be  found.  The  microscope  shows  alterations  as  well  in  the 
connective  tissue  as  in  the  epithelium  of  the  tubules. 

Amyloid  degeneration  occasionally  follows  chronic  malaria.  This  has 
been  noted  in  the  kidneys  by  Laveran  ^  in  two  instances,  but  in  both 
of  them  the  malarial  cachexia  was  complicated  with  chronic  broncho- 
pneumonia and  bronchiectasis.  Frerichs^  describes  three  cases,  while 
Marchiafava  and  Bignanii^  have  carefully  studied  several  instances. 
The  clinical  history  of  these  cases  showed  that  after  a  long  period  of 
febrile  attacks  (sestivo-autumnal  or  obstinate  quartan)  there  followed 
the  symptoms  of  nephritis  and  a  rapid  cachexia,  in  which  the  patients 
died  in  a  few  months.  On  autopsy  the  principal  changes  that  were 
found  were  a  grave  anaemia,  a  marantic  condition  of  the  organs,  a 
chronic  nephritis,  and  a  diffuse  amyloid  degeneration.  The  distribution 
of  the  amyloid  substance  in  their  cases  was  as  follows  :  The  degenera- 
tion was  most  prevalent  in  the  kidneys,  where  not  only  the  vessels  of 
small  and  medium  size  and  glomeruli  were  affected,  but  also,  to  a  con- 
siderable extent,  the  walls  of  the  renal  tubules.     The  alteration  of  the 

^  Traite  des  Fievres  palustres,  p.  94.  ^  Lehrbuch  der  Leberkrankheiten. 

^  m/orma  Medica,  1891,  vol.  i.  p.  571. 


MALARIAL  CIRRHOSIS.  95 

interstitial  tissue  and   the  degenerations  of  the   renal  parenchyma  are 
very  grave. 

After  the  kidneys  the  amyloid  degeneration  is  most  severe  in  the 
intcstineff  and  the  upleen.  In  the  intestine  the  degeneration  aif'ects  chiefly 
the  vessels  of  the  villi,  but  also  the  vessels  of  the  submucosa,  and  to 
less  extent  those  of  the  other  intestinal  coats.  In  the  .yj/ecu  the  vas- 
cular network  of  the  pt'rij)herv  of  the  follicles  is  particidarly  affected. 
Here  one  sees  usually  the  deposition  of  great  blocks  of  amyloid  sub- 
stance, while  in  the  trabecuhe  of  the  pulp  the  process  is  in  its  beginning 
or  is  entirely  wanting.  In  the  liver  there  is  a  less  extensive  and  diffuse 
deposition  of  amyloid  substance  than  in  the  kidneys.  The  degeneration 
affects  islands  of  hepatic  tissue  which  are  irregularly  disseminated,  so 
that,  for  example,  one  may  see  an  island  of  the  size  of  a  lobule  or  larger 
from  which  the  hepatic  tissue  has  entirely  disappeared,  the  vascular  net- 
work showing  a  most  grave  amyloid  degeneration,  while  about  this 
the  hepatic  tissue  has  a  normal  apjDearance.  The  first  small  zones  of 
degeneration,  according  to  Bignami,  seek  by  preference  the  periphery 
of  the  hepatic  lobules,  from  whence  the  process  spreads. 

Malarial  Cirrhosis. — The  Relation  of  Chronic  or  Repeated 
Malarial  Infections  to  Cirrhotic  Processes. 

For  many  years  certain  authors  have  associated  cirrhosis  of  the  liver, 
certain  chronic  renal  changes,  and,  in  some  instances,  chronic  inflamma- 
tion of  the  lung,  endocardium,  and  central  nervous  system,  with  malarial 
fever.  Indeed,  in  almost  all  works  upon  medicine  malarial  fever  is  in- 
cluded as  one  of  the  etiological  factors  in  ordinary  atrophic  cirrhosis  of 
the  liver.  This  statement  has  been  based  almost  entirely  upon  rough 
clinical  observation,  no  one  having  definitely  traced  the  development 
of  the  cirrhosis  from  the  changes  following  acute  or  chronic  malaria. 
Frerichs '  noted  the  rarity  of  cirrhosis  in  patients  dying  with  chronic 
malaria,  though  in  five  instances  this  was  the  only  etiological  cause 
which  he  could  discover.  Laveran^  in  his  considerable  experience 
has  seen  but  two  cases  of  atrophic  cirrhosis  following  malarial  fever. 
Welch  has  seen  but  one  case  of  atrophic  cirrhosis  which  appeared  to 
follow  malaria. 

Kelsch  and  Ki§ner  give  a  longer  description  of  hepatitis  in  malaria, 
distinguishing  three  forms  of  chronic  malarial  hepatitis  and  two  groups 
of  malarial  cirrhoses  :  (1)  Insular  cirrhosis  with  nodular  hepatitis  and 
insular  cirrhosis  with  diffuse  parenchymatous  hepatitis ;  (2)  annular 
cirrhosis  with  nodular  or  diffuse  parenchymatous  hepatitis.  The  gen- 
eral appearance  of  the  liver  in  these  cases  is  that  of  ordinary  atrophic 
cirrhosis. 

Bignami  has  recently  discussed  this  subject  in  a  very  thorough  man- 
ner. He  concludes  that  there  is  little  evidence  to  show  that  ordinary 
atrophic  cirrhosis  is  a  frequent  follower  of  malarial  fever.  After  describ- 
ing the  development  of  the  ordinary  chronic  hepatic  tumor  of  malarial 
cachexia,  he  says  :  "  It  is  easy  to  understand  from  this  that  it  is  not 
difficult  to  make  a  differential  diagnosis  between  this  form  of  chronic 
tumor — or  of  chronic  hepatitis,  as  one  might  say — from  the  other  forms 

'  Loc.  cit.  ^  Traite  des  Fievres  palustres,  p.  90. 


96  3ialIria. 

of  cirrhosis.  There  are  not  facts  or  reasons  sufficient  to  cause  us  to 
believe  that  ordinary  cirrhosis  can  follow  a  chronic  tumor.  The  struc- 
ture in  the  two  cases  is  absolutely  different.  In  the  one  we  have  an 
extensive  new  formation  of  connective  tissue,  multilobular  in  nature, 
retracting  about  the  included  lobules  ;  in  the  other,  a  more  scanty  for- 
mation of  perilobular  connective  tissue  about  a  single  lobule,  not  con- 
tracting, together  with  grave  alterations  of  the  lobules  themselves, 
especially  of  their  vascular  and  lymphatic  system,  not  depending,  as 
we  have  seen,  upon  the  new  formation  of  perilobular  connective  tissue, 
but  due  to  lesions  primarily  local.  Atrophic  conditions  of  the  liver 
exist  in  malaria,  but  are  simple  atrophies,  and  occur  in  patients  who 
are  exhausted,  for  example,  by  profuse  diarrhoea,  etc.,  or  in  cases  which 
I  have  described  as  progressive  post-malarial  ansemia.  They  depend 
upon  the  complete  want  or  almost  complete  absence  of  any  process 
tending  toward  regeneration,  resulting  from  grave  and  diffuse  regressive 
alterations." 

Barker  ^  has  recently  ably  discussed  the  relation  of  malarial  infections 
to  cirrhotic  processes,  and  has  emphasized  the  fact  that  many  conditions 
exist  in  the  organs  in  malarial  fever  which  might  well  be  the  starting- 
point  for  extensive  growth  of  connective  tissue.  Flexner,^  after  the 
injection  of  blood  serum  from  one  animal  into  another,  has  seen  the 
development  of  characteristic  cirrhosis  of  the  liver  and  of  the  kidneys 
in  rabbits,  following  focal  necroses  not  dissimilar  to  those  found  in  the 
liver  in  acute  malarial  infections. 

In  conclusion,  then,  it  may  be  said  that  secondary  sclerotic  processes 
of  greater  or  less  degree  in  the  liver,  spleen,  and  bone  marrow  are  not 
uncommon  after  repeated  malarial  infections.  The  question  of  the 
possibility  of  the  development  of  a  true  atrophic  cin^hosis  of  the  liver, 
of  malarial  origin,  is  not  settled ;  the  development  has  never  been 
actually  traced  and  the  condition,  if  it  exist  at  all,  is  probably  rare. 
The  possibility  of  its  occurrence  cannot,  however,  be  denied. 

Symptoms. 

Period  of  IxcuBATio:sr. — In  the  absence  of  definite  knowledge  as 
to  how  malaria  is  acquired,  the  ideas  concerning  the  period  of  incuba- 
tion have  varied  very  greatly.  It  has  undoubtedly  been  observed  that 
characteristic  malarial  fever  may  appear  very  shortly  after  exposure  in 
a  malarious  district,  many  observers  believing  that  this  may  occur  with- 
in a  shorter  time  than  twenty-four  hours.  It  is  possible  that  the  febrile 
attacks  which  occur  sometimes  immediately  after  exposure  at  night  in 
damp,  marshy,  malarious  districts  may  have  some  other  cause  than 
malarial  infection.  Thus,  Plehn  describes  cases  where,  after  exposure 
at  night  in  very  malarious  districts  in  West  Africa,  there  was  an  imme- 
diate paroxysm  similar  to  a  malarial  attack,  which,  however,  did  not 
recur  until  the  appearance,  ten  days  later,  of  a  true  malarial  fever, 
which  doubtless  dated  its  infection  from  the  night  of  exposure.  At  the 
time  of  the  first  paroxysm  the  blood  was  negative,  the  parasite  (sestivo- 
autumnal)  not  appearing  until  ten  days  later.  The  hypothesis  of  Plehn 
that  the  initial  paroxysm  was  due  to  the  absorption  of  some  toxic  sub- 

^  Johns  Sopkins  Hospital  Reports,  vol.  v.  ^  The  Medical  Nev:s,  Philad.,  Aug.,  1894. 


SYMPTOMS.  97 

stance  pruduced,  j)erluips,  by  the  [)arasitc  oiit.-^ide  ol"  the  Ixjdy,  i.s  iiifreni- 
ous,  but  seems  a  little  far-fetched.  More  commonly  an  interval  of  one 
or  two  weeks  may  be  made  out  between  the  time  of  exj)o.-;ure  and  the 
time  of  tile  breakinj;  out  of  tlie  disease.  Maillot'  considered  the  mean 
period  of  incubation  to  l)e  from  ten  to  twelve  days,  while  Sorel '"  esti- 
mated it  at  from  seven  to  nine  days.  Hertz'  states  that  the  period  of 
incubation  is  commonly  reckoned  at  from  six  to  twenty  days,  but  be- 
lieves that  the  disease  may  appear  immediately  after  the  reception  of 
the  injurious  influence. 

A  number  of  instances  of  prolonged  incubation  have  been  reported, 
many  of  whicli  are  open  to  doubt.  Some  of  these,  however,  are  hard 
to  explain.  Such,  for  instance,  is  the  case  of  Blaxall,^  where,  after 
spending  five  days  in  the  harbor  of  Port  Louis,  two  of  the  crew  of  a 
man-of-war  were  attacked,  at  the  end  of,  respectively,  twelve  and  four- 
teen days,  with  quotidian  intermittent  fever,  while  two  others  developed 
tertian  fever  at  the  end  of,  respectively,  forty-eight  and  one  hundred 
and  eighty-four  days  after  em]>arkation.  It  is  probaljle,  in  view  of  our 
present  knowledge,  that  many  cases  of  prolonged  incubation  represent 
relapses  of  earlier  attacks,  the  manifestations  of  which  have  been  pres- 
ent and  would  have  been  evident  on  more  careful  examination. 

Of  recent  years,  since  the  discoveries  of  the  malarial  parasite  and 
the  inoculation  experiments  of  Gerhardt,'  Mariotti  and  Ciarrochi,"  Mar- 
chiafava  and  Celli/  Gualdi  and  Antolisei,*  Angelini,^  Di  Mattei,^'^  Calan- 
druccio,"  Bein,^-  Baccelli,'"  Sacharov,'*  the  suljject  has  been  considered 
in  a  much  more  intelligent  manner.  The  period  of  incubation  in  these 
cases  where  the  blood  of  one  malarial  patient  was  introduced  intravenously 
or  h^qjodermically  into  a  healthy  individual,  have  varied  greatly.  In  in- 
dividual cases  there  was  a  variance  in  the  period  of  incubation  of  from  six 
to  eighteen  days,  while  the  average  duration  was  from  eleven  to  twelve 
days.  Kecently,  Bastianelli  and  Bignami  ^'^  have  contributed  four  new 
cases  to  this  ILst  and  have  made  a  careful  study  of  this  subject.  In 
their  words,  the  period  of  incubation  in  these  cases  of  artificial  inocu- 
lation represents  "  the  time  necessars'  for  the  inoculated  parasites  to 
arrive,  by  multiplication,  at  the  quantity  necessary  to  determine  the 
fever,"  .  .  .  .  "  The  period  of  incubation  with  a  given  variets"  of  para- 
sites varies  inversely  to  the  quantity  of  material  inoculated."  .... 
"  The  mean  and  minimum  period  of  incubation  under  equal  conditions 
varies  with  the  various  groups  of  the  fever :  it  is  least  Avith  aestival 
fevers,  a  little  longer  with  tertian  fever,  and  yet  a  little  longer  with 
quartan  fever."  They  believe  that  they  are  justified  in  concluding  that 
"'  the  period  of  incubation  in  experimental  malarial  infections  is  not  a 
constant  quantity,  but  varies  in  the  same  group  of  fevers  and  in  differ- 
ent groups.     In  a  given  group  of  fevers  it  depends  primarily  upon  the 

1  Trailedes  Fihre-s,  p.  263.  ^  j,,^/,   ^^  Medecin  milit.,  1884,  t.  3,  p.  273. 

^  Ziemssen's  Cydopfjedia,  vol.  ii.  p.  588.  *  Quoted  from  Hertz,  loc.  cit. 

'"  Zeitsckr.  f.  klin.  3fed.,  1884,  375.  ^  Xo  Sperimeniale,  1884,  s.  iv.  t.  liv.  263. 

'  ForUchritte  d.  Med.,  1885,  iii.  Nos.  11  and  14.     *i2i/.  Mexl,  1889,  Xos.  225,  264,  274. 
«i?(>:  MeA.,  1889,  Nos.  226  and  227,  pp.  1352,  1.358. 
">/6(V/.,  1891,  p.  544,  and  Arch,  fiir  Hyr,.,  1895,  191. 
''  Cf.  Grassi  and  Feletti  ;  Cent,  fiir  Bach.,  1891,  ix.  403,  429,  461. 
'•■^  Charite  Annalen,  1891,  181.    "  ^^  Deatsch.  med.  Wock.,    1892,  Xo.  32,  721. 

"  Cent,  fur  Backt.,  1894,  xv.  p.  158. 

^  BuU.  d.  R.  Ace.  Med.  di  Bovia,  1893-94,  Anno  xv.,  v.  xx.  151. 
Vol.  I.— 7 


^linimum. 

Mean 

(days). 

(days). 

11 

13 

6 

10 

2 

3 

98  MA  LABIA. 

quantity  of  material  inoculated.  In  different  groups  of  fevers  it  varies 
with  the  rapidity  of  the  cycle  of  development  of  the  parasites  and  with 
the  special  capacity  for  reproduction  of  the  parasitic  variety." 

They  have  constructed  the  following  table  from  an  analysis  of  all 
cases  of  experimental  malarial  infection  which  they  could  collect : 

Period  of  Incubation.  Maximum 

(days). 

Quartan  fever 1-5 

Tertian  fever 12 

Ji^stivo-autumnal  fever 5 

These  researches,  especially  those  of  Bastianelli  and  Bignami  proving 
that  the  incubation  period  in  sestivo-autumnal  fever  may  be  as  brief  as 
two  days,  are  of  a  great  deal  of  interest.  It  is  striking  to  see  how 
well  their  conclusions  agree  with  the  deductions  which  have  been  drawn 
by  other  observers  before  the  discovery  of  the  malarial  parasite.  It  is 
with  the  sestivo-autumnal  variety  of  the  parasite,  that  variety  which  is 
associated  with  the  pernicious  fevers,  that  the  short  periods  of  incuba- 
tion have  been  observed,  while  the  older  clinical  observations  of  short 
periods  of  incubation  relate  usually  to  the  same  class  of  cases.  We  can- 
not, however,  positively  assume  that  these  figures  represent  the  period 
of  incubation  in  infection  as  it  ordinarily  takes  place,  for  we  do  not 
know  how  or  in  what  form  this  occurs. 

The  general  results,  however,  of  inoculations  in  tertian  and  quartan 
fevers  agree  quite  closely  with  what  might  have  been  expected  from 
clinical  observation,  while  the  demonstration  that  after  small  intra- 
venous inoculations  in  sestivo-autumnal  fever  the  disease  may  appear 
in  forty-eight  hours  makes  it  very  easy  for  us  to  believe  that,  however 
the  infection  may  occur,  the  true  incubation  period  in  some  very  malig- 
nant fevers  may  be  extremely  short. 

Plehn  ^  advances  an  ingenious  hypothesis  to  account  for  certain  early 
manifestations  of  fever.  He  asserts,  as  has  been  stated  above,  that  he 
has  noticed  in  several  instances  a  well  marked  febrile  reaction  occurring 
within  a  few  hours  after  exposure  in  a  malarious  locality  and  simulat- 
ing a  single  malarial  paroxysm.  The  examination  of  the  blood  was 
negative.  From  nine  to  twelve  days  later,  however,  characteristic  mala- 
rial fever  developed,  the  parasites  being  readily  found  in  the  blood.  He 
suggests  that  by  exposure  in  extremely  malarious  districts  the  individual 
may  absorb  a  sufficient  quantity  of  a  pyrogenic  toxine  to  cause  imme- 
diately a  single  paroxysm  days  before  the  true  incubation  period  has 
been  passed  through ;  there  is,  however,  little  which  can  be  advanced 
as  proof  of  such  an  hypothesis. 

Basing  our  conclusions,  then,  upon  the  comparison  between  clinical 
deductions  and  the  accurate  observation  of  inoculation  experiments,  we 
may  say  that  it  seems  likely  that  the  ordinary  period  of  incubation  in 
tertian  fever  is  about  ten  or  twelve  days,  in  quartan  fever  a  little  longer, 
while  in  sestivo-autumnal  fever  the  period  may  range  from  twenty-four 
hours  or  even  less  to  ten  days  or  two  weeks,  averaging  probably  a  some- 
what shorter  time  than  in  the  case  of  tertian  or  quartan  fever. 

Types  of  Fever. — The  malarial  fevers  may  be  divided  into  two 

1  Virch.  Archiv,  1892,  cxxix.  285. 


SYMPTOMS.  99 

main  classes  :  (1)  The  rc'i!:iilarly  iiitcniiittont  fevers,  occurring  throufrh- 
out  the  malarial  season;  (2)  the  more  irregular,  often  more  or  less  eon- 
tinned  fevers,  oecnrring  in  temperate  climates,  only  at  the  height  of  the 
malarial  season,  the  late  summer  and  early  fall. 

And  under  these  two  main  classes  one  may  sc])arate  three  distinct 
types  of  fever,  dependinfr  in  turn  upon  infection  with  one  of  the  three 
types  of  the  malarial  parasite  which  have  been  described  ])reviously. 
Thus,  the  first  class,  the  ret>:ularly  intermittent  fevers,  includes  («)  ter- 
tian fever,  with  its  combinations  (double  tertian  fever),  and  (/>)  quartan 
fever,  with  its  combinations  (double  and  triple  quartan  fever).  The 
second  class  of  fevers,  that  including  the  more  irregular  varieties,  de- 
jK'uds  upon  infection  with  the  third  variety  of  parasite  above  described. 
(Occurring,  as  it  does,  at  the  height  of  the  malarial  season  (August,  Sep- 
tember, October),  it  justly  deserves  the  name  (c)  cestivo-autumnal  fever 
applied  to  it  by  the  Italian  observers. 

Tertian  fever  is  common  in  almost  all  malarial  regions.  Quartan 
fever  is,  however,  rare  in  many  districts  where  the  other  forms  of  infec- 
tion are  frequent.  In  the  United  States  quartan  fever  appears  to  be 
rare  ;  in  the  last  seven  years,  out  of  nearly  a  thousand  cases  observed 
at  the  Johns  Hopkins  Hospital,  only  nine  cases  of  quartan  fever  have 
been  seen.  On  the  other  hand,  there  are  certain  regions  in  which  quar- 
tan fever  is  particularly  common,  as  the  neighborhood  of  Pavia  in  Italy 
and  in  certain  parts  of  Sicily.^ 

These  types  of  fever  are  the  same  wherever  they  exist.  In  tropical 
countries  the  severer  types  of  8esti^'o-autumnal  fevers  are  in  excess.  As 
one  passes  aw^ay  from  the  equator  only  the  milder  tertian  and  quartan 
fevers  are  to  be  seen  in  the  earlier  part  of  the  malarial  season,  while  the 
sestivo-autumnal  fevers  appear  in  the  later  summer  and  early  autumn. 
Lastly,  in  districts  where  malaria  is  very  uncommon  the  milder  forms, 
tertian  and  quartan  fever,  alone  prevail. 

Tertiax  Feyee. — (1)  Single  Infections — Tertian  Intermittent  Fever  ; 
(2)  Double  Infections — Quotidian  Intermittent  Fever. 

(1)  Single  Infections — Tertian  Intermittent  Fever. — This  tvq^e  of  fever 
depends  upon  infection  with  the  tertian  parasite,  an  organism  which, 
as  has  been  described,  possesses  the  remarkable  characteristic  of  existing 
in  the  blood  of  the  infected  individual  in  great  groups,  all  the  members 
of  which  are  approximately  at  the  same  stage  of  development  and  pass 

^  The  interesting  fact  that  districts  closely  adjoining  one  another  and  presenting  tlie 
same  general  physical  conditions  may  be  each  the  fof/er  for  a  distinct  t^-pe  of  malarial 
fever  was  noted  by  Trousseau  some  years  before  the  discovery  of  the  parasite.  In  dis- 
cussing the  types  of  regularly  intermittent  fevers  the  great  clinician  says  [Clinique  niedi- 
cale,  vol.  iii.  p.  42o,  2d.  ed.,  1S65):  "The  types  seem  to  depend  upon  the  nature  of 
the  miasm,  and  especially  upon  the  locality  which  it  infects,  rather  than  upon  con- 
ditions relative  to  the  individual  who  is  affected.  Tours  and  Saumur,  both  situated 
on  the  left  bank  of  the  Loire,  appear  to  me  to  present  the  same  climatic  and  teHuric 
conditions,  yet  one  observes  at  Tours  only  tertian  fevers,  while  the  several  cases  of 
quartan  fever  which  I  have  met  with  there  were  individuals  coming  either  from  Saumur 
or  Rochefort  or  from  other  regions  where  they  had  contracted  it.  One  of  the  examples 
which  has  most  impressed  me  in  connection  with  the  subject  is  the  following :  Fourteen 
soldiers  imprisoned  at  Saumur  came  to  Tours  to  testify  before  a  court-martial.  Tliey  had 
been  scarcely  ten  days  in  the  last  to\vn  when  nine  of  them  were  compelled  to  enter  the 
hospital,  affecied  with  quartan  fever,  the  germ  of  which  they  liad  evidently  contracted  at 
Saumur,  since  all  the  fevers  which  we  observed  with  the  inhabitants  of  Tours  and  the 
neighborhood  were  of  the  tertian  type." 


100  MALAEIA. 

through  their  cycle  of  existence  together,  all  the  organisms  composing 
the  group  undergoing  segmentation  within  a  period  of  several  hours  ;  it 
requires,  as  has  been  said,  approximately  forty-eight  hours  to  complete 
its  cycle  of  development.  In  infections,  then,  with  a  single  group  of 
parasites  segmentation  occurs  at  intervals  approximately  forty-eight 
hours  apart.  As  Golgi  so  clearly  showed,  the  febrile  paroxysm  is 
always  associated  with  the  segmentation  of  a  group  of  malarial  para- 
sites, and,  as  one  might  expect,  the  chief  characteristic  of  this  type  of 
fever  consists  in  intermittent  febrile  paroxysms  occurring  every  other  day. 
The  regularity  with  which  these  paroxysms  recur  is  truly  remarkable, 
the  onset  sometimes  taking  place  at  almost  exactly  the  same  hour  day 
after  day.  More  frequently  there  are  slight  differences,  generally,  how- 
ever, of  not  more  than  two  hours,  between  the  time  at  which  succeeding 
paroxysms  recur.  Our  observations  of  nearly  a  thousand  cases  would 
lead  us  to  believe  that  slight  anticipation  in  the  hour  of  onset  is  more 
common  than  retardation. 

The  Paroxysm. — The  paroxysm  is  usually  divided  into  three  clas- 
sical stages  :  (a)  the  chill ;  (6)  the  fever ;  (c)  the  defervescence  or  sweat- 
ing stage. 

(a)  The  Chill. — This  may  begin  without  any  premonitory  symptoms. 
More  commonly,  however,  for  a  period  of  from  a  few  minutes  to  half 
an  hour  the  patient  complains  of  uneasy  sensations,  a  slight  headache, 
or  perhaps  a  little  giddiness  or  fatigue.  Not  infrequently  the  onset  is 
preceded  by  yawning.  If  the  temperature  is  carefully  noted  during 
this  period,  it  will  usually  be  found  that  a  slight  elevation  has 
already  begun  to  appear.  Immediately  after  this  the  patient  begins  to 
complain  of  chilly  sensations,  usually  up  and  down  the  back ;  these 
increase,  the  patient  begins  to  shiver,  and  soon  a  general  shaking  chill 
follows.  The  chill  is  often  extremely  violent :  the  teeth  chatter ;  the 
whole  body  is  thrown  into  so  violent  a  tremor  that  the  bed  and  often 
surrounding  objects  in  the  room  are  shaken.  The  skin  is  pale  or  often 
somewhat  cyanotic  and  cool,  though  wholly  disproportionately  so  in 
comparison  to  the  intense  feeling  of  cold  complained  of  by  the  patient. 
It  is  often  moist,  while  the  erection  of  the  hair  follicles  gives  rise  to  the 
characteristic  "goose  flesh."  The  pupils  are  usually  dilated.  The 
patient  complains  often  of  headache,  buzzing  in  the  ears,  vertigo,  and 
sometimes  of  troubles  of  vision.  The  pulse  is  small  and  rapid  and 
often  of  rather  high  tension.  There  may  be  nausea  and  vomiting. 
The  duration  of  the  chill  varies  materially  in  different  cases ;  it  may 
last  as  long  as  an  hour,  though  usually  the  period  is  considerably  shorter 
— from  ten  minutes  to  half  an  hour.  Not  infrequently  no  actual  shak- 
ing occurs,  the  patient  complaining  only  of  chilly  sensations.  Occa- 
sionally, though  very  rarely  in  this  type  of  fever,  the  chill  may  be 
entirely  absent.  Thus  out  of  339  cases  classified  by  Hewetson  and  the 
author  at  the  Johns  Hopkins  Hospital,  chills  or  chilly  sensations  were 
present  in  95.5  per  cent,  of  the  cases.  During  the  period  of  the  chill 
the  temperature  of  the  patient  rises  rapidly,  and  at  the  end  of  the  chilly 
sensations  may  have  reached  almost  its  height.  Generally,  almost  the 
maximum  point  of  temperature  is  reached  within  two  hours  after  the 
onset  of  the  paroxysm. 

(6)  The  Febrile  Stage. — After  a  certain  length  of  time  the  chilly  sen- 


SYMPTOMS. 


101 


sations  beconio  less  marked 
and  are  intcrriiiitt'd  by 
flushes  of  heat,  wliioh  be- 
come more  trefpient,  and 
finally  wholly  replace  the 
chill.  Then  begins  the 
second  or  febrile  stage  of 
the  ])aroxysm.  The  patient 
complains  of  an  intense 
burning  heat ;  the  skin  is 
flushed,  hot,  and  dry,  the 
conjunetivre  injected,  the 
pulse  becomes  fuller,  but 
remains  rapid ;  it  may  be 
dicrotic.  The  patient  com- 
plains bitterly  of  headache 
and  often  of  vertigo  and 
buzzing  in  the  ears.  The 
coverings  for  which  but  a 
short  time  ago  he  had 
begged  are  now^  thrown 
aside.  Often  there  is  in- 
tense thirst.  The  patient 
is  frequently  restless,  throw- 
incr  himself  from  one  side 
of  the  bed  to  the  other. 
In  some  instances  there  is 
active  delirium.  A  case  ob- 
served by  the  author  jumped 
from  the  window  of  the  ward 
during  the  febrile  stage  of  a 
double  tertian  paroxysm, 
killing  himself  by  the  fall. 
In  other  instances  the  pa- 
tient is  dull,  drowsy,  and 
typhoidal  in  appearance, 
complaining  upon  inquiry 
only  of  intense  headache 
and  aching  pains  in  the 
back  and  the  extremities. 
Xot  infrequently  there  is  a 
slight  cough.  Sometimes 
there  is  vomiting  or  diar- 
rhoea. Bleeding  from  the 
nose  occasionally  occurs. 

On  physical  examination 
the  face  is  flushed,  the  con- 
junctivae are  injected ;  the 
tongue  is  often  dry  and 
coated.  There  is  often  a 
dusky,  yellowish-gray  color 


m   c 

<DC0<£>Oc>COOOO2 

II 

.1 

^                1          1           !           . 

T 

] 

1         ■                               . 

/ 

1     - 

> 

- 

y 

■1  .  ■ 

■' 

;, 

It  '■' 

f 

; 

L  , 

1-   :■■• 

!       '                             ■  .  .■ 



> .  1 

— 

--  j 

,           1 

r— -^— -' 

f^  1    ^:-  . 

13 

90 

v*'"^'*"^ 

/ 

■j'^.  ■,• 

20 

70 

V 

^ 

V 

'■ 

2U 

72 

r 

'■-',''' 

i 

1 

^ 

i 

20 

72 

=r- 

.  l.._^ 

A.  M  . 

■^ 

! 

fcj 

A.M. 

IT 

72 

\ 

■     ]"" 

8 

A.M. 

1   1 

\ 

\ 

10^ 

A.M. 

IS 

72 

' 

t 

1 

rsj 

N. 

1 

1  1  ! 

i  1 

I 

'.        2 

P.M. 

13   72 

l! 

1  i 

' 

4 

P.  M  . 

1 

IN 

'  ! 

:'      ' 

6 

P.  M. 

JiJJW 

i  1 

8 

P.  M. 

1 

1 

1 

10 

P.  M. 

:■;  '-3 

^ 

12 

M. 

/ 

2 

A.  M 

^ 

2-  ■;, 

V 

4 

A.  M  . 

^ 

b 

A.  M- 

16,72 

' 

w 

8 

A.  M  . 

j 

1 

' 

10 

A.  M. 

21 1": 

: 

■ 

^ 

12 

1 

1  • 

^ — 

■ 

2 

P.  M. 

24,S-J 

4 

p.  M. 

h 

* 

6 

P.  M. 

20   60 

[  1 . 

~ 

K 

8 

P.  M. 

1 

> 

10 

P.  M 

20  61 

1 1 

:  1 

V 

i  1 

in 

12 

M. 

t 

1 

^ 

■ 

!  ' 

' 

!  ' 

h : 

2 

A.  ,V 

20|64 

:< 

,  ; 

i  i 

.  j 

4 

A.  M. 

1 

.,*» 

1 

1  1 

6 

A.  M 

20JfiS 

1  ! 

! 

8 

A.  M 

1 

■  1 

,  • 

10 

A.  M 

ts 

' 

12 

N. 

1 

2 

P.  Mi 

/ 

4 

P.  M. 

i 

/ 

6 

P.  M. 

2'l.K 

> 

/ 

8 

P.  M. 

r^l 

10 

P.  M. 

20  ■  n 

12 

M 

1 

\ \' ' 

2 

A.  M. 

^ 

1?  00 

1 ' 

V 

1  1 

, 

4 

A.  M. 
A.  M. 

^ 

6 

IT    72 

^*^ 

II 

'8 

A.M. 

i 

1 ' 

, 



10 

A.  M. 

! 

> 

12 

N. 

1 

ill 

__•- 

"    "^ 

2 

P.  M 

20  -JJ 

T^ 

4 

P.  W  . 

> 

6 

P.  M. 

V 

8 

P.  M  . 

< 

10 

P.  M. 

70 

/ 

12 

M. 

y 

2 

A.  M  . 

IS 

13  >J1 

V 

4 

A.  M  . 

1 

> 

6 

A.  M 

13' « 

\ 

3 

A.  M. 

> 

|0 

A.  M 

13  72 

12 

N. 

< 

2 

P.M|. 

1:    -i 

^ 

4 

P.M 

6 

P.M. 

20   'JO 

i 

8 

P.M 

10 

P.  M 

20  •;! 

i 

12 

M- 

[ 

2 

A.  M 

i 

li'.l 

K 

' 

^1 

4 

A.  M. 

j 

^, 

; 

6 

A.M. 

18   00 

\ 

* 

8 

A.M. 

1 

1  ■ 

> 

1 

13 

A.M. 

.6  7, 

!  ,  : 

/ 

12 

N. 

102  MALARIA. 

to  the  skin,  while  the  lips  and  mucous  membranes  are  pale.  Herpes 
on  the  lips  and  nose  is  very  common.  Various  cutaneous  eruptions 
have  been  noted,  usually  erythematous  in  nature.  In  several  instances 
the  author  has  observed  an  extensive  general  urticaria.  The  respi- 
ration is  not  particularly  accelerated,  though  the  pulse  is  often  rapid 
and  sometimes  dicrotic.  The  lungs  are  generally  clear  on  auscul- 
tation and  percussion,  though,  not  infrequently,  evidences  of  a  general 
bronchitis — sonorous  and  sibillant  rales — may  be  heard  throughout  the 
chest,  more  frecjuently  in  the  back.  The  heart  sounds  are  usually  clear, 
though  a  soft  systolic  murmur  may  be  heard  over  the  body  of  the  heart. 
The  abdomen  is  generally  natural  in  appearance.  The  area  of  hepatic 
dulness  is  often  somewhat  increased.  There  is  frequently  tenderness  on 
pressure  in  the  region  of  the  spleen,  while  the  area  of  the  splenic  dulness 
is  almost  invariably  increased.  In  most  cases  the  spleen  is  easily  pal- 
pable. This  has  been  the  case  in  73.4  per  cent,  of  our  cases  in  which 
notes  were  made.  In  fresh  cases  the  border  is  rounded  and  soft ;  in 
older  cases,  where  there  have  been  numerous  previous  attacks,  the  bor- 
der is  often  sharp  and  firm,  reaching  sometimes  a  considerable  distance 
below  the  costal  margin.  The  splenic  tumor  is  particularly  striking  in 
children.  The  most  marked  splenic  enlargements  occur,  however,  in 
the  more  irregular  sestivo-autumnal  fevers.  Massuriany^  noted  the 
presence  of  a  soft  souffle  over  the  splenic  area,  v.'hich  Bouchard  has 
compared  to  the  uterine  bruit.  During  this  period  the  temperature 
reaches  its  maximum  point.  Temperatures  as  high  as  108°  F.  have 
been  noted.  The  duration  of  the  febrile  period  is  usually  four  or  five 
hours,  though,  not  infrequently,  considerably  longer. 

(c)  The  Sicecding  Stage. — After  the  stage  of  fever  has  existed  for  four 
or  five  hours  it  is  usually  followed  quite  suddenly  by  the  third  or  sweat- 
ing stage  of  the  paroxysm.  The  patient  begins  to  feel  relief  from  the 
sensation  of  oppressive  heat  from  which  he  has  been  suffering,  and  then, 
quite  suddenly,  breaks  into  a  profuse  sweat.  The  sweating  is  often 
excessive ;  the  night-clothes  and  bedding  may  be  soaked.  In  asso- 
ciation with  this  the  temperature  falls,  usually  quite  rapidly.  The 
pulse,  which  has  been  rapid,  becomes  slow  and  full,  and  the  patient 
often  passes  into  a  refreshing  sleep.  The  temperature  falls,  almost  in- 
variably to  a  subnormal  point.  The  duration  of  the  sweating  stage 
varies  considerably.  The  defervescence  is  generally  somewhat  longer 
than  the  rise  of  temperature,  though  it  may  be  very  short  and  sudden ; 
it  commonly  lasts  from  two  to  four  hours,  though  often  somewhat  longer. 

The  average  length  of  the  entire  paroxysm  from  the  time  the  tem- 
perature passed  99°  F.  until  it  reached  this  point  again  averaged,  in  173 
cases  observed  by  the  author,  about  eleven  hours.  The  paroxysms  occur 
more  frequently  during  the  day  than  during  the  night,  the  onset  being, 
perhaps,  more  commonly  noted  between  midnight  and  noon,  though  it 
may  occur  at  any  hour  of  the  day  or  night ;  indeed,  jDaroxysms  begin- 
ning in  the  afternoon  are  not  at  all  uncommon. 

In  children  the  paroxysm  differs  often  from  that  observed  in  adults. 
Very  commonly  in  young  children  both  the  first  and  third  stages,  the 
chill  and  the  sweating,  may  be  absent  or  abortive.  The  first  stage  is 
then   generally  represented   by  a   slight    restlessness.     The   face   looks 

1  St.  Pet.  med.  WocL,  1884. 


SYMPTOMS.  103 

pinched,  the  eyes  aro  sunken  ;  the  fingor-tips  and  toes  bocomo  cyanotic 
and  cold,  while  the  child  may  yawn  and  stretcii  itself.  Nausea,  vomit- 
in<2:  and  diarrlKca  are  particularly  common.  These  may  be  the  only 
manifestations  of  the  lirst  sta<>;e.  Commonly,  however,  these  sym[)toms 
are  followeil  by  <>rave  nervous  phenomena.  The  chill  in  malaria,  as  in 
other  acute  diseases,  is  not  infre(piently  represented  in  the  youn^  child 
by  g;eneral  convulsions.  These  begin  usually  with  a  slight  spasmodic 
twitching  of  the  eyelids  or  of  the  extremities,  the  spasm  soon  becoming 
general.  The  febrile  stage  and  the  whole  paroxysm  are  often  shorter 
in  the  child  than  in  the  adult.  The  sweating  stage  may  be  wholly 
absent.  In  many  instances,  besides  a  slight  coldness  of  the  hands  and 
blueness  of  the  finger-tips,  and  a  somewhat  pinched  expression  of  the 
face  in  the  first  stage,  the  first  and  third  stage  of  the  paroxysm  may  be 
entirely  lacking. 

The  Intennifoiion. — In  the  period  of  intermission  the  patient  often  feels 
quite  well,  so  much  so  that  it  is  not  uncommon  for  patients  to  pass  through 
a  number  of  paroxysms  before  consulting  a  physician,  believing  after 
each  that  the  disease  is  at  an  end.  The  temperature  after  the  sweating 
stage  becomes  almost  invariably  subnormal,  and  often  remains  so  during 
the  greater  part  of  the  next  day.  About  forty-eight  hours  after  the  onset 
of  the  first  paroxysm  the  fresh  group  of  parasites  proceeding  from  the 
segmentation  of  two  days  before  having  reached  maturity  and  entered 
again  upon  segmentation,  a  fresh  paroxysm  begins.  Often,  as  has  been 
said,  the  time  of  onset  of  several  successive  paroxysms  is  almost  exactly 
the  same.  More  commonly,  though,  there  are  slight  variations  of  an 
hour  or  two,  anticipation  or  retardation.  In  these  instances  the  parasite 
passes  through  its  cycle  of  existence  a  little  quicker  or  a  little  slower 
than  in  the  typical  forty-eight  hours.  Slightly  anticipating  paroxysms 
are  very  common,  more  so  than  retardation. 

The  Blood.  —  The  blood  shows  the  presence  of  one  group  of  the 
characteristic  tertian  parasites.  These  organisms  are  to  be  followed 
through  all  the  stages  of  their  development.  They  are  most  striking 
and  most  readily  observed  several  hours  before  the  paroxysm,  when 
they  are  large  and  contain  most  pigment.  At  the  time  of  the  par- 
oxysm and  immediately  before  this  the  picture  may  not  be  so  striking, 
as  many  of  the  parasites  which,  earlier  in  development,  are  to  be  found 
w4th  great  frequency  in  the  general  peripheral  circulation,  become 
accumulated  in  certain  of  the  internal  organs,  where  they  remain  during 
the  period  of  segmentation.  Segmenting  parasites  are  usually  to  be 
found  in  the  peripheral  circulation,  the  first  being  seen  several  hours 
before  the  onset  of  the  paroxysm ;  at  times  they  may  be  present  in 
large  numbers.  Large  swollen  forms  of  the  organism  with  very  active 
pigment  granules,  or  deformed  and  vacuolated  forms,  are  also  common 
during  this  period.  Often  the  fragmentation  of  these  bodies  may  be 
seen,  and  numerous  small  pigmented  extracellular  forms  resulting  from 
this  fragmentation  may  be  found.  These  swollen  vacuolated  and  frag- 
mented forms  appear  to  be  more  common  where  recovery  is  taking 
place,  and  there  is  every  reason  to  believe  that  they  represent  full- 
grown  parasites  which,  failing  to  undergo  segmentation,  have  become 
degenerate  and  sterile.  During  and  just  after  the  paroxysm  the  pro- 
cess of  phagocytosis  may  often  be  observed  under  the  microscope,  and 


104 


MALARIA. 


pigmented  leucocytes  are  always  present.  The  elements  taken  up  are 
for  the  most  part  the  free  pigment  clumps  from  segmenting  forms,  the 
segmenting  form  itself,  fragmented  extracellular  bodies,  and  flagellate 
forms. 

(2)  Double  Infections. —  Quotidian  Intermittent  Fever. — Single  tertian 
infections  are  among  the  mildest  forms  of  malarial  fever  which  are 
observed  in  temperate  climates ;  more  commonly  the  individual  shows 
an  infection  with  two  groups  of  the  tertian  parasite.  These  groups 
reach  maturity  on  alternate  days.  Segmentation,  then,  of  a  group  of 
parasites  occurs  every  day,  and,  as  one  might  expect,  daily  paroxysms, 
quotidian  intey^mittent  fever,  result.  The  paroxysms  in  these  instances 
are  similar  in  every  way  to  those  of  single  tertian  infections.  The 
manner  of  onset  and  duration  are  the  same,  while  during  the  periods 
of  intermission  the  temperature  is  likewise  almost  always  subnormal. 
It  is  common,  however,  for  the  paroxysms  on  successive  days  to  show 
slight  constant  differences  in  their  hours  of  onset,  one  group  of  para- 
sites arriving  at  maturity  at  an  hour  slightly  different  from  that  of 
the  other.  These  differences  are  usually  not  great,  though  they  may  be 
considerable,  one  paroxysm  beginning  in  the  morning,  that  upon  the 
following  day  in  the  afternoon.  Very  commonly  one  set  of  organisms 
is  more  numerous  than  the  other,  causing  thus  a  more  severe  paroxysm. 
The  chart  then  shows  alternate  mild  and  severe  attacks.  These  facts 
alone  might  lead  us  to  recognize  the  dependence  of  this  quotidian  fever 
upon  a  double  infection  without  the  confirmation  obtained  by  examina- 
tion of  the  blood. 

The  blood  shows  the  presence  of  two  groups  of  the  tertian  parasite 
in  different  stages  of  development.     Thus  at  the  time  of  the  paroxysm, 

Fig.  2. 


Double  tertian  infection  (quotidian  fever). 

while  one  group  is  full  grown  and  in  the  stage  of  segmentation,  the 
other  is  represented  by  smaller,  slightly  pigmented,  actively  amoeboid 
bodies.  The  question  of  the  origin  of  these  double  tertian  infections  is 
interesting  and  by  no  means  wholly  clear.  Very  commonly  the  first 
several  paroxysms  are  tertian  in  nature,  daily  chills  appearing  only 
later  on  in  the  course.  This  may  well  be,  and  probably  is  due  to  the 
fact  that  at  the  time  of  the  original  infection  there  were  two  groups  of 


SYMPTOMS.  105 

parasites,  one  of  which  was  so  nmch  sinaller  than  the  other  as  to  take 
materially  lon<i;er  to  reaeh  a  size  sutlieient  to  [»ro(liiee  a  paroxysm.  On 
the  other  hand,  some  observers  have  suii'^ested  that  the  origin  of"  donhle 
int'eetions  may  be  due  to  the  lagging  beiiind  of"  eertain  parasites  out  oi' 
an  originally  single  group,  these  retarded  forms  eventually  forming  a 
group  of  their  own.  If  this  be  the  case,  however,  it  is  remarkable  that 
the  retardation  should  be  almost  exactly  twenty-four  hours  behind  that 
of"  the  original  grouj).  Indeed,  the  remarkai)le  similarity  in  the  hours 
of  the  paroxysms  due  to  two  difi'erent  groups  of  the  parasite  is  striking 
and  not  easily  explained. 

Infections  with  multiple  groups  of  parasites  have  been  described. 
These  result,  naturally,  in  more  irregular  subcontinuous  fever.  This 
is,  however,  extremely  rare.  Only  one  doubtful  case  of  this  nature  has 
been  observed  by  the  author.  The  examination  of  the  blood  in  these 
instances  shows  organisms  in  all  stages  of  development ;  there  is  great 
difficulty  here  in  distinguishing  separate  groups. 

Quartan  Fever. — (1)  Single  Infections. —  Quartan  Intennittent 
Fever ;  (2)  Double  Infections. — Double  Quartan  Intermittent  Fever ;  (3) 
Triple  Infections. —  Quotidian  [Triple  Quartan)  Intermittent  Fever. 

(1)  Single  Infections. —  Quartan  Intermittent  Fever. — This  type  of 
fever  depends  upon  the  presence  in  the  blood  of  the  quartan  parasite, 
an  organism  which,  just  as  in  the  case  of  the  tertian  parasite,  possesses 
the  remarkable  characteristic  of  existing  in  the  blood  in  great  groups,  all 
the  members  of  which  are,  approximately,  at  the  same  stage  of  develop- 
ment. The  cycle  of  development  of  the  quartan  parasite  lasts  approx- 
imatelv  seventv-two  hours,  segmentation  occurrino;  everv  fourth  dav. 
The  characteristics,  then,  of  single  quartan  infections  are  quartan  inter- 
mittent paroxysms,  two  days  of  complete  intermission  existing  between. 
The  paroxysm  in  quartan  fever  resembles  in  all  its  features  that 
observed  in  tertian  infection.  The  duration  in  the  cases  seen  by  the 
author  averaged  between  ten  and  eleven  hours.  The  same  periods 
of  subnormal  temperature,  lasting  often  during  the  greater  part  of  the 
two  days  of  intermission,  are  observed.  The  regularity  of  the  par- 
oxysms in  quartan  infection  is  the  most  remarkable  characteristic  of  the 
disease.  A  tendency  toward  anticipation  or  retardation  in  the  par- 
oxysms is  less  often  noted  than  in  tertian  infection. 

The  blood  shows  the  presence  of  a  quartan  parasite.  The  develop- 
ment of  the  organism  may  be  readily  followed.  It  is  most  clearly 
demonstrated  just  before  and  during  the  paroxysm  when  the  parasites 
are  full  grown.  The  tendency  of  the  full  grown  and  sporulating  forms 
to  accumulate  in  the  internal  organs — a  tendency  which  has  been  noted 
in  tertian  fever,  and  exists,  as  will  be  stated  later,  to  a  greater  extent  in 
sestivo-antumnal  fever — is  not  to  be  observed  in  the  case  of  the  quartan 
organism ;  all  stages  of  development  may  be  seen  -with  equal  frequency 
in  the  peripheral  circulation.  At  the  time  when  the  parasite  reaches 
maturity  swollen,  fragmented,  and  vacuolated  forms  may  be  seen  as  in 
tertian  fever.  They  are,  however,  less  frequent,  as  are  also  the  flagellate 
bodies. 

(2)  Double  Infections. — Double  Quartan  Fever. — Often  more  than  one 
group  of  quartan  parasites  may  be  present  in  the  blood  at  the  same  time. 
When  two  groups  are  present  segmentation  usually  occurs  on  two  sue- 


106 


MALARIA. 


cessive  days,  with  a  day  of 
intermission  following.  Clin- 
ically, therefore,  these  double 
infections  are  characterized  by 
chills  upon  two  successive 
days,  with  a  day  of  complete 
intermission  following.  The 
paroxysms  in  these  instances 
are  exactly  similar  to  those 
observed  in  single  infection. 
The  examination  of  the  blood, 
however,  shows  the  presence 
of  two  groups  of  the  quartan 
parasite. 

(3)  Triple  Infection's. — 
Triple  Quartan  Fever. — ^Very 
commonly  three  groups  of  the 
quartan  parasite  may  be  pres- 
ent in  the  blood  at  the  same 
time.  These  groups  reach 
maturity  on  successive  days, 
and  cause,  therefore,  quo- 
tidian intermittent  fever.  The 
symptoms  of  quotidian  fever 
depending  upon  a  triple  quar- 
tan infection  differ  often  in 
no  wise  from  those  depending 
upon  a  double  tertian  infec- 
tion. Daily  paroxysms,  ex- 
actly similar  in  nature,  occur 
in  both  instances.  The  same 
period  of  subnormal  temper- 
ature may  be  noted,  and  the 
diagnosis,  without  the  exam- 
ination of  the  blood,  may  be 
impossible.  Examination  of 
the  blood  in  these  instances 
shows,  however,  the  presence 
of  three  groups  of  the  quartan 
parasite,  each  in  different 
stages  of  development. 

Jj^  S  T  I  VO- A  U  T  U  M  N  A  L 

Fever.— This  type  of  fever 
differs  materially  from  the 
regularly  intermittent  fevers 
of  the  early  part  of  the  malarial 
season.  It  depends  upon  the 
presence  in  the  blood  of  the 
smaller  organism  first  de- 
scribed by  Marchiafava  and 
Celli,     the     sestivo-autumnal 


SYMPTOMS.  107 

parasite.  This  parasito,  as  lias  been  j)r('vi()usly  stated,  possesses  to  a 
luiieli  less  marked  degree  the  eharaeteristie  of  existiiig  in  large  sharj)ly 
detined  groiii)s,  while,  as  has  also  been  noted,  the  length  (»!'  the  cycle  of 
existence  apjx-ars  to  vary  considerably.  At  the  beginning  of  many 
infections  an  arrangement  in  groups  may,  however,  be  made  out,  and 
this  arrangement  may  exist  for  a  certain  length  of  time.  Usually, 
however,  befoi'e  the  process  has  lasted  very  long  organisms  in  different 
stages  of  development  may  be  found  at  any  time  during  the  fever.  In 
some  instances  groups  of  parasites  with  a  cycle  lasting  about  twenty- 
four  hours  have  apparently  been  made  out,  while  in  others  fairly  distinct 
groups  appear  to  pass  through  a  cycle  lasting  considerably  longer,  as  long 
as  fortv-eijrht  hours  or  even  more.  Clinicallv,  aestivo-autumnal  fever 
appears  in  very  varied  forms. 

Xot  infrequently  it  may  be  f^ecn  in  the  form  of  quotidian  inteiiniftent 
fever.  Here  the  paroxysms  may  resemble  very  closely  those  of  tertian 
or  quartan  fever,  and  in  some  instances,  without  the  examination  of  the 
blood,  the  distinction  from  double  tertian  or  triple  quartan  infections 
cannot  be  made.  In  these  instances  the  process  begins  with  a  sharp 
chill  and  ends  with  a  well  marked  sweating  stage,  the  duration  of  the 
paroxysm  being  perhaps  exactly  similar  to  that  in  the  regularly  inter- 
mittent fevers.  ^lore  commonly,  however,  the  paroxysms  are  longer 
and  more  drawn  out,  lasting  perhaps  as  long  as  twenty  hours.  Here 
the  first  stage  often  differs  greatly  from  that  in  tertian  or  quartan  fever. 
While  in  the  regularly  intermittent  fevers  the  onset  is  rajjid  and  usually 
associated  with  a  chill,  in  these  instances  the  rise  may  be  much  more 
gradual,  while  the  chill  is  not  infrequently  altogether  lacking.  Often 
a  slight  transient  chill  may  be  observed  some  time  after  the  beginning 
of  the  rise  in  temperature.  The  chill  in  sestivo-autumnal  fever  can  by 
no  means  be  called  the  initial  symptom  in  the  paroxysm  ;  the  fever  has 
often  Ijecome  well  marked  before  the  onset  of  the  rigor.  Usually,  after  a 
certain  number  of  paroxysms,  a  distinct  irregularity  in  the  fever  becomes 
evident.  Either  from  the  lengthening  out  of  one  of  the  paroxysms  or 
from  the  anticipation  of  the  following  paroxysm  the  intermission  between 
the  two  becomes,  perhaps,  completely  obliterated  or  indicated  only  by  a 
slight  drop  in  temperature,  until  finally  there  results  an  irregular  con- 
tinued fever  in  which  all  trace  of  the  paroxysm  has  disappeared. 

Xot  infrequently  the  early  paroxysms  recur  at  greater  intervals  one 
from  the  other.  These  intervals  are  frequently  forty-eight  hours,  more 
or  less  ("^Esfiro-aufumnal  tertian  fever;  malignant  tertian  fever'' — 
Marchiafava  and  Bignami).  In  these  instances  the  paroxysms  are  usu- 
ally particularly  long,  lasting  sometimes  as  much  as  thirty-six  hours. 
The  very  gradual  rise  in  temperature,  which  is  often  unaccompanied 
by  a  chill,  and  the  slow  fall,  are  in  striking  contrast  to  the  chart  of  an 
ordinary  tertian  fever.  Marchiafava  and  Bignami,  who,  as  has  been 
before  stated,  believe  that  they  can  distinguish  two  separate  types  of 
the  sestivo-autumnal  parasite,  the  quotidian  and  the  tertian,  have  de- 
scribed minutely  the  fever  curve  in  these  cases  with  longer  intervals. 
This  class  of  cases  they  term  "  malignant  tertian  fever,''  in  contradis- 
tinction to  the  milder  regularly  intermittent  tertian  fever.  They  de- 
scribe what  they  believe  to  be  a  characteristic  fever  curve,  the  more  or 
less  sudden  onset  of  the  s}Tnptoms,  a  pseudo-crisis,  a  precritical  elevation 


108 


MALARIA. 


of  temperature,  which  often  reaches  a  point  higher  than  has  been  pre- 
viously attained,  and,  finally,  the  actual  crisis.     Charts  similar  to  this 


have  been  observed  by  the  author  and  reproduced  in  a  recent  publica- 
tion (see  Fig.  6),  though  he  has  not  seen  a  sufficient  number  of  in- 
stances to  justify  him  in  believing  that  such  a  curve  is  characteristic 
of  a  particular,  separate  type  of  parasite.     It  is  certainly  true,  however, 


SYMPTn.US. 


109 


that  invgular  osc-illatiDus  in  the  ciii-vc  of  the  it-vcr  produced  l)y  these 
parasites ^u-e  very  coninioii.     The  ])eri()ds  of  intermission  between  par- 


^   ^\         CD        (D         (D        tD         OoOO         90         0 

°   0 

~~ 

'  1  i 

■i 

:i-i]iin«4mif' 

'VI' 

..__.. 

ic"i 

.      '    ! 

ill 

T.- 

^J;i.. 

' /I, 

ffKV  1 

■-' 

soT 

«     T 



rTTT'i 

^-- 

^„^       Iff    m 

--4--  i 

^ 

1 

i"a.'/"^ 

----- 

— 

i 

i 

■ 

-- 

1 

— 

■i 

\'y 

\ 

-m-' 

•» 

r 

T  >^ 

4-,^                  '  -\ 

3Wf- 

■* 

■"* 

1 

■  ']'  "1^ 

"i 

\    y~— L   I 

;  I 

6  p.M- 

^      -^ 



"N" 

-  M_p^ 

.J 

5.^     H 

—  -  — 

— 

— 

— 

"-"i 

\ 

-r 

; 

<      - 

i 

2  A.    .1. 

/ 

4  A.  «. 

— -t- 

£       1 

6  A.^.l. 

.'  .'i 

S-; 

8  A.  [.1- 

^^ 

3       il 

i3        i  '  ' 

^ 

■  1 

^■^y|,.. 

■ :  K 

1 

^, 

iir^i-- 

~ 

c?      =' 

; 

> 

^.^-I*'- 

<       ~ 

1  ;  : 

_^ 

V 

6,  P.M. 

i;    d 

;r,    1 

8  P.  k 

..-•^ 

lOP.  |M. 

P        V 

>• 

■-^ 

1 

2   M  . 

^        — 

y 

2  A.  »1. 

^       TT 

/•^ 

*f 

6  A.  M. 

g            IS 

!^ 

SA.fvl. 

p 

N 

~~^)i\ 

\.Sl. 

LPH. 

GRS. 

K 

1  0  A:  M  . 

,-.              l! 

V  2-4 

H. 

2  :.. 

»j 

\ 

2  P.  [1I . 

,  :   ~ 

0                'J, 

i  i ; 

V^ 

-±M!L_ 

il 

< 

ill 

■^ 

e  P.  M. 

;| 

\ 

! ! 

m        — 

.   : 

, 

,  ■  : 

i 

OP.    -1-: 

-^      3u 

T-^T- 

1  i '  ' 

/ 

2    M. 

o"      ~ 

1    : 

c 

2..M. 

' 

S'       '* 

.„      ,    J 

/ 

-^ 

4  A.  [.!• 

1            ^i- 

< 

6  A.  iM  . 

!  i 

2.          Cl 

3  A.  M. 

1 

"-;>• 

i            iOA.M. 

. 

^          2i 

'  .V-.      1,1 

'"■■■\ 

!    Of 

0 

1       :'■'. 

r 

2  P.  M. 

!       ~ 

;  S3     i ' 

i 

4  P.M. 

' 

1 

6P.J.1. 

1 

^    'QU 

;,.SL 

LPH 

grs.t|t.  1 

P' 

!^J1^ 

f 

1  , 

it' 

7 

.> 

4 

M  1  1 

1  i  ' 

I2M.I 

-r 

2A.f.. 

1 

< 

' 

4  A.    A. 

\ 

6  A.   .1. 

V 

8  A.  VI. 

s 

10  A.  [^. 

'  : ; 

=  ; 

1  2   \  .     ; 

l_^  -5 

~ 

1 

\ 

2  P.  .1. 

- 

" 

1 

4  P.M. 

' 

j 

;i 

6  P.M. 

'   L 

_  ^r^ 

0P.I.I. 

ill 

1 

_ — =_ 

j  0  P.  M 

■1     ',  !  1  i 

1 

12  M. 

-ST 

2  A.   H. 

1 

'-^ 

" 

~ 

^^. 

6  A.  J\. 

iln+- 

1 

5  &3    1 

^, 

8'a;  'I- 

li  hi!   1 

oxysms  show,  usually,  a  subnormal  temperature.  The  periods  of  apy- 
rexia  are,  however,  very  brief,  as  one  may  readily  conceive  when  he 
considers  the  length  of  the  paroxysm,  lasting,  as  it  often  does,  tliirty-six 
hours  or  over. 


110 


MALAEIA. 


In  those  cases  in  which  the  paroxysms  occur  at  intervals  of  approx- 
imately forty-eight  hours, 
one  from  another,  the  irreg- 
ularity in  the  hour  of  onset 
of  the  paroxysms  is  partic- 
ularly striking.  In  some 
cases  there  is  marked  re- 
tardation, intervals  of  con- 
siderably more  than  forty- 
eight  hours  occurring  be- 
tween the  beginning  of  one 
paroxysm  and  that  of  its 
successor.  More  frequent- 
ly, however,  there  is  antici- 
pation, the  paroxysms  re- 
curring at  intervals  of  less 
than  forty-eight  hours. 
Now,  if,  as  already  stated, 
the  individual  paroxysm 
should  last  thirty-six  hours 
or  more,  it  may  be  readily 
seen  how  short  the  period 
of  intermission  in  these 
cases  would  be.  Often,  then, 
there  is  an  almost  continu- 

^    s|-|w|-jj|g||||||ii|.iMi.    ijiirii  I  ||||||||||||||||||||P'"r'l    >     ^^^^  high  temperature,  with 

occasional  remissions  or  in- 
termissions lasting,  per- 
haps, less  than  an  hour — 
"  malarial  remittent  fever." 
In  many  instances  the 
new  paroxysm  begins  be- 
fore the  previous  one  has 
finished,  owing  either  to  an 
excessive  prolongation  of 
the  first  paroxysm  or  to  an 
anticipation  of  the  succeed- 
ing one.  In  these  cases  the 
result  is,  of  course,  a  eow- 
tinuous  fever.  Usually,  the 
continuous  fevers  resulting 
from  sestivo-autumnal  in- 
fections, though  the  tem- 
perature may  never  reach 
the  normal  point,  yet  show 
indications  of  the  parox- 
ysms and  sometimes  occa- 
sional abortive  chills.  In 
some  instances,  however, 
all  evidence  of  paroxysms  may  be  absent,  the  chart  closely  simulating 
that  of  typhoid  fever.     Such  cases  are  probably  often  due  to  infections 


s 

W-h 

0 

'" 

■■■| 

EZ 

■\n('d 

8 

). 

ti 

Zl 

wa 

9 

'< 

V. 

zz 

■_w;d 

Ho6t\ 

* 

\ 

9i 

\z 

Z 

< 

06 

13 

s, -.4^11111111111111111111111 

H 

65 

•w 

•V 

0 

91 

n 

■in 

■V 

R 

-• 

91 

K 

■li, 

■V 

h 

'^ 

7,% 

i-z 

■w-v 

* 

t  1  , 

A\ 

m 

n 

•wv 

Z 

" ::::::::::::_'. ' -c-  ^^ 

es 

95 

o 

|W 

z 

'l-t'OA'SlSiNNind^l!     ;     ||     |j 

n 

« 

■wjj 

0 

..4. 

58 

65 

•wa 

8 

L.l.--- 

86 

n 

•W|-d 

e 

3-. 

IS 

95 

■M 

t 

...;;! 

1-6 

95 

•w-lj 

z 

./:.. 

6S 

85 

^ocj^ 

k 

"    X. 

1... 

ts 

85 

•W|-y 

0 

t* 

88 

95 

•WfV 

8 

> 

86 

95 

■\^ 

•V 

9 

J 

i8 

0£ 

^ 

■V 

t 

1* 

06 

Of 

■1^ 

■V 

'z 

Ti    |_^ 

i 

S6 

5£ 

i 

l| 

IN 

z 

i^-t 

90 

5t 

Wtl 

0 

"T"                                  1    E 

001 

Si 

WH 

i  V" i[_ 

60 

Zt 

WH 

9':r" "■::::::.._. 5. 

88 

85 

Wd 

*l!i                                  1 

\ 

\ 

001 

t5 

Wd 

tX 

L 

K 

86 

5f 

\IOO|f 

SI 

i 

68 

95 

w-v 

0 

1 

86 

85 

•w 

■y 

8 

__, 

ii- 

f6 

65 

w 

■V 

9 

vr 

toi 

LZ 

w 

V 

* 

:<t- 

801 

85 

wj-v 

S 

.^? 

811 

85 

s 

•w 

SI 

/■ 

SOI 

ze 

iMi-k 

A 

Ml 

5£ 

i"?  r 

8 

\ 

MI 

0£ 

w 

9 

001 

95 

m-'d 

* 

r^ 

fOI 

96 

ra-ti 

Z 

■^ 

p, 

¥>\ 

Of 

M.^ 

SI 

001 

ZE 

m 

•V 

n 

001 

5S 

n 

•V 

8 

/ 

88 

t5 

m 

y 

? 

> 

Ml 

Of 

11 

V 

i 

> 

001 

5£ 

^ 

{^ 

z 

r:. 

1 

001 

85 

5 

\- 

^ 

SI 

7  1 

i 

roi 

5£ 

Vf 

k 

0 

^^ 

801 

85 

W 

8 

'  ^   ^     1  ITIIIIIIIIIII II 

MI 

OE 

t\y 

9 

- 

Ml  1 

oni 

85 

'^\f 

t 

1 

^■~-?..;  '1 1 

r.6 

85 

^\k 

S 

r "1  iiT:    "  r<.  riiiiJiiini 

Ml 

f5 

OOK 

z\ 

1  II  iMi  iiiiIiiil: 

1* 

66 

85 

IM  -V 

o<    lilllllJIIIIIIIIIIIIIIIIIL 

•- 

90 

83 

■wv 

8 

T               <^ 

MI 

9£ 

'm-v 

9 

:          " ;' 

on 

S£ 

M 

1' 

::::::::.>. 

Ml 

5E 

wv 

S 

,...-. 

MI 

S£ 

1 

i-M 

SI 

T               _...?'        ____ 

001 

5E 

n'd 

-^T"v ;;;;;;- 

Kl 

n 

W  'd 

i^i  1""""" 

OZI 

01- 

w  -d 

iNr^i""""     

ON  E 

NO 

ds  a 

aijv 

911 

01 

m-d 

v^ 

-^  \     -y-- 

1 

1   1 

9!.l 

3£ 

|Wi-d 

z 

5^: 

We 

Nods  a 

3  1dV 

on 

9E 

I'l?!^ 

z 

> 

T 

1^^  II '  1 

fdi 

OE 

M 

0 

'A: 

3N  E 

NOdS  d3idV 

oil 

95 

WfV 

R 

1                    ■■('             ON  ONO 

s  aaliiJvi 

W!-v 

9 

'IM"V 

*■!  i    ' ' '  ' '  1 

■     y    :::::::. 

MI 

95 

im-v 

si  1 1   :■ '        M 

V\         .T__t___^ 

i 

■m 

S 1  1 1                <  ■ ' 

■III 

WI 

65 

,W'd 

01  ■                        ~"^^^ 

1  : 

:wd 

e'                               "~>L 

1 

1  '  ' 

+wrd 

9'          .  '          '  , 

"^-^ 

'     1 

HI  'd 

t  '  I    ,    1 1    .  L     '•    '. 

~~---». 

:jj 

95 

q; 

i'%         o         o        'o        'i         S          o        1          S         S 

n 

CC 

SYMPTOMS.  1 1 1 

with  nu)iv  than  one  oroup  ot"  pai'asites.  It  is  [)r()hahly  tiMic  that  the 
long  duration  of  some  of  the  paroxysms  is  accounted  for  by  the  fact 
tliat  tlie  sei2;inentation  of  a  given  group  of  jiarasites  occurs  through  an 
appreciably  greater  length  of  time  than  iu  the  regularly  intermittent 
fevers. 

The  result  of  all  this  is  that  the  chart  of  {estivo-autunuuil  fever 
presents  very  connnouly  somewhat  the  foll<»\\ing  ])icture  :  At  the  onset 
there  are  several  intermittent  paroxysms  occurring  at  intervals  of  from 
twentv-four  to  forty-eight  hours  or  a  little  more.  After  a  few  of  these 
attacks  the  fever  becomes  irregular  or  continued.  This  may  occur,  as 
has  been  said,  in  several  ways  :  (1)  Throuf/li  iiiudlJicatioiif<  of  the  carve 
in  the  iiulii-idKal  paroxysni ;  (2)  bjj  modification  in  HucceHnion  of  the 
paroxysms. 

(1)  The  important  modifications  of  the  curve  are  the  following :  (a) 
The  lack  of  a  sharp  initial  elevation,  so  that  the  curve  rises  in  a  slow 
and  continuous  manner ;  (6)  the  occurrence  of  a  pseudo-crisis,  so  that 
the  attack  tends  to  lose  its  individuality  ;  (c)  the  prolongation  of  the 
paroxysm,  which  is  usually  associated  with  an  exaggeration  of  the 
thermic  oscillations  during  the  fastigium. 

(2)  The  modifications  in  the  succession  of  the  paroxysms  may  be  («)  the 
anticipation  of  the  paroxysms ;  (6)  the  retardation  of  the  paroxysms ; 
(c)  the  prolongation  of  the  paroxysms,  by  which  apyrexia  is  made 
incomplete ;  {d)  the  occurrence  of  slight  oscillations  in  temperature 
during  the  period  which  ought  to  be  one  of  apyrexia ;  {e)  the  redupli- 
cation of  the  attack. 

Very  often  when  the  case  first  comes  under  observation  it  is  already 
one  of  "  remittent "  or  continued  fever.  The  chills  are  frequently  ab- 
sent ;  the  patient  complains  bitterly  of  headache  and  general  pain  in 
his  back  and  extremities.  He  is  usually  dull,  drowsy,  and  apathetic, 
though  there  may  be  marked  delirium.  The  face  is  flushed,  the  con- 
junctivae are  injected,  the  tongue  dry  and  coated ;  there  is  sordes  upon 
the  lips  and  teeth  ;  the  patient  remains  continuously  in  a  condition 
similar  to  that  described  in  the  febrile  stage  of  the  ordinary  paroxysm. 
In  these  instances  it  is  often  absolutely  impossible,  without  examination 
of  the  blood,  to  distinguish  the  case  from  one  of  typhoid  fever.  The 
writer  has  repeatedly  seen  patients  with  sestivo-autumnal  malaria 
placed  under  treatment  as  cases  of  typhoid  fever,  the  attention  being 
first  drawn  to  the  true  condition  of  things  by  a  sudden  fall  of  the  tem- 
perature to  normal,  or  by  the  discovery  of  the  small  amoeboid  hyaline 
parasites  within  the  red  corpuscles.  Grave  cerebral  or  abdominal  symp- 
toms develop,  often  early  in  the  course  of  these  subcontinuous  fevers, 
which  frequently  tend  to  become  pernicious.  Careful  observations  may 
show  that  these  symptoms  are  paroxysmal.  Delirium,  drowsiness, 
stupor,  coma,  grave  cerebral  symptoms,  local  spasms,  general  convul- 
sive seizures  may  occur,  or  perhaps  profuse  vomiting  or  a  choleriform 
diarrhoea  with  collapse.  In  fact,  any  of  the  symptoms  which  will  be 
discussed  under  the  Pernicious  Fevers  may  suddenly  develop  in  the 
course  of  subcontinuous  sestivo-autumnal  infection. 

These  instances  of  more  or  less  continued  fever  are  occasionally 
referred  to  as  "  malarial  remittent  fever. ^'  They  have  been  admirably 
described  by  Baccelli,  who  recognized  their  true  malarial  nature,  under 


112 


MALARIA. 


"TTOir:::::::::::::::::: 

■"■''■                   

-.    -                       "3 

^     iw-flt 

■  ' "                m   n 

^    3i''     -    -__    - 

L 

■w 

■WiV.  o^t 

.  1                           ZL     02 

■  WiV  8, 

---   .     -/     _  .  - 

'Wiv  91 

:«j»lt ::  :::  : 

■j^t- --- 

.J                                        fli     8Z 

J  ''                                               ZL     9£ 

_3p2i.  ::  :::::::::  :: 

•wid  e 

-  -  -  .                                  S9    ot; 

•w'd  9 

~  1 

-.,  =  ::?'                       "i   zc 

■W|d  s 

.;; 

CO 

_   iSIl ___   . 

...                     3                                         08     t5 

•Wi»  01 

'         "  -  "" 

•W"|V  9 

.. .                                            89     92 

--'' 

J  - !                 _  _                             08     ZE 

•WiV  Z 

..   '( 

\-Vt  Z  L 

•fl'"" 

. .                                        f8     82 

W  |d  9 

S>-    -  -      .-    ... 

W*|d  t 

-_''s,_._                                            88     K 

■f'l"'   2                                                                   ,.       - 

!l.    _.    "    " 

w 

-     lSy_ _..     _     _ 

'    _         _      .                                 OS     K 

t 

■Wl'O                                                             .      _ 

08  n 

•W|V  1' 

-  .         J  k,                                                      26     82 

'W|V  z 

1  "W  Zl 

•W|d  oy                                              .^' 

■fci 

t™  I''  «                             ...  J 

t                                                                         >8     28 

* 

•W;d  9                                                  ,  '' 

•Wdt 

Tl'"                                        "^..      -      -- 

_  M-z T:_._i.  

&I 

•W|V  CI                                               5 

IWJV  S             _                            _  .  J  ,      _ 

-f 

•W|V  9                                                         1 

WIV  t                                                         J 

S8     2C 

■Wivz                                    j<- 

_J-wz-         _           __     ^  'S 

OS     2S 

-jffiai                    ^.  _ 

J*ljd8             __         __             _Ji      _      _ 

88     Of 

-     ■'CJi'^    ^    ..          __            -"^^ 

_  34dt                ^...civirr^ 

-  im'  _  __  _  ::::::  ::  : 

'li:::::::"""  ""    " 

^1 

_  nz'jzi  _  __  _  

'  k  .                                                               9i     9E 

•W|V  9| 

08     28 

•W  V  9 

•H  V  t 

,.jC"      !)i     OE 

'W  V  d                                                            J  r  - 

-  335^    :::  ::::::::!_: 

_      MJjd  CJ_      _^         1 

•wl<<.£       _    : [__ 

•H  d  £                                               i' 

■Wdt                                               ,. 

08     82 

--Tk^                           X"  " 

--TE^___     _-   _  ^±-J 

OG     82 

__-kv(n___    __    _    ,i 

Ti^T               T  ";2- 

08     82 

_     -Wivsl,     .     .                   -L,> 

•HjVt^                                          J- 

fa    82 

..^11. .j;  .  ... 

.-Zfei/. )•_■.   ___ 

OG     82 

■w-do'i                             J-' 

•P'-MiL       _         ^ 

88     92 

•Wd9^     +__JC 

■Wdtl                            V 

21    n 

•W-d2|                                .:>., 

■Livc'l                                          :  =  i 

88    n 

•(M-,V8                                           ir- 

88    n 

■«:^i  _-                  J-_- 

•VMiVt                            jr 

t8     K 

•wivj                   ^<; 

l-wsi                           ■>' 

18     f2 

Sdof          .': 

"^r..  _.  _;_      

06     t2 

•w-;d  r             ,  ' 

•s 

26    n 

X 

— rT?i 1  ^^" 

2G     »2 

•wiv  o:i 

~  -  =  ■' 

•wjvo     -J  t  A -JO  >cn  IS  i\  nci   _- 

001  n 

"WiV  9                                           ^'' 

•WiV  t                                           ( 

m  t5 

■WVJ 

-Ti^ifc       :        ::!!:;:_ 

hOI    92 

■■L 

.^                                                                  f8     92 

■wd9        ---    ---    -    --    ---i 

' 

fS 

•wjU  t 

96     02 

t^ 

•W';d  Z 

--XSst            

5'                                             t6   re 

'W'lV  8 

*  >-  _                                                              96     82 

•WiV^ 

~;».           "        " 

^  ■-  '                                                             001    t2 

•w-vz|                                            .c- 

■J-'WBI                                                                        ^ 

2G     t2 

■Wjd  01 

F 

^ZKJdjt,    ...    _ 

W     02 

__^9t_      ___      __ 

m. 

__T!r5F^_  ___  _   _.._ 

96     82 

■W 

( 'f  2^f 

tOl    82 

I 

■W  V  si 

1                                                               96     82 

■W  V  9| 

J 

•wvt 

001     OS 

•wvz                                              / 

J 

-  JiiSL  ...  ...  .  --,?..- 

on     08 

•W,dO.                                                 ,£,. 

■Wd9                                                              --,, 

f8     92 

■wjds 

i, 

■Wjd    . 

^  ■■  =  ,  ^  _  ^      -                            801     98 

3 

w-jd  s 

-             T                     ---i                   021-98 

^ 

]_'N   El                     NOISS  WC  V  NO 

<o 

°-"       °10          V           °m          'm          "t; 

goo       o       22 

100" 
99° 
98° 

PULSE 
RESP. 

SYMPTOMS.  113 

the  name  o^  ^'  .snhconf In u(i  Ij/plioidai."  As  has  hceii  previously  stated, 
the  tendency  of  the  regidarly  intermittent  fevers,  when  left  to  them- 
selves, is  toward  spontaneous  recovery  after  a  certain  number  of  par- 
oxysms, and,  while  relapses  are  common  and  productive,  perhaps,  of 
grave  secondary  disturl)ances — antemia,  nej)hritis,  etc. — the  tendency  to 
become  ])ernici()us  is  rarely  observed.  This  is  not  true  of  sestivo- 
autumual  infections  as  a  class.  In  many  instances,  to  be  sure,  when 
placed  under  hygienic  conditions  the  same  tendency  toward  sponta- 
neous recovery,  usually  with  relapses,  is  to  be  observed.  Often,  how- 
ever, an  untreated  infection  becomes  steadily  more  aggravated,  until, 
finally,  so-called  "pernicious"  symptoms  appear  and  a  fatal  result 
ensues. 

In  other  instances  an  sestivo-autumnal  infection  may  be  associated 
with  but  slight  irregular  rises  in  temperature ;  there  may  be  no  sharp 
paroxysms,  the  patient  complaining  only  of  languor,  anorexia,  head- 
ache, pains  in  the  back  and  limbs.  Such  instances  may  easily  lead  to 
errors  in  diagnosis.  There  is  usually,  if  the  case  has  existed  for  any 
length  of  time,  a  certain  degree  of  anaemia,  with  the  characteristic 
sallow  hue  to  the  skin,  while  the  spleen  is  almost  always  enlarged. 
Such  cases  probably  often  pass  into  the  condition  which  will  be  later 
described  as  "  chronic  malarial  cachexia." 

Pernicious  Malarial  Fevers. — These  very  malignant  forms  of 
malarial  fever  have,  in  this  and  other  languages,  generally  acquired  the 
name  "  the  j^ernicious  fevers.''  It  is  quite  true  that  the  term  "  malig- 
nant fevers"  used  by  the  translators  of  Marchiafava  and  Biguami's^ 
work  is,  in  the  abstract,  better,  but  the  word  "  pernicious  "  is  so  firmly 
implanted  in  the  general  usage  that  its  eradication  appears  to  the  writer 
injudicious. 

Pernicious  fever  depends,  almost  invariably,  upon  infection  with  the 
aestivo-autumnal  parasite.  In  temperate  climates  these  fevers  are  rare, 
but  in  the  tropics  they  are  extremely  common.  The  pernicious  nature 
of  an  attack  depends,  generally,  as  has  been  shown  in  the  section  on 
Pathological  Anatomy  (page  83),  upon  several  causes :  (1)  The  great 
numbers  of  parasites  present  and  their  capacity  for  rapid  multiplication ; 
(2)  the  special  involvement  of  certain  vital  organs  by  the  parasites, 
which,  as  has  been  pointed  out,  show  a  remarkable  tendency  toward 
accumulation  in  certain  definite  organs,  varying  in  different  cases ;  (3) 
possibly  upon  the  greater  or  less  virulence  of  the  parasite.  This  latter 
statement  is  based  upon  the  assumption  that  the  malarial  parasites  pro- 
duce a  specific  toxic  substance.  Certain  authors  thus  believe  that,  in 
the  case  of  infection  with  a  very  malignant  parasite,  pernicious  symp- 
toms may  result,  while  but  a  small  number  of  parasites  are  present, 
particularly  if  the  chief  seat  of  development  of  the  parasite  be  localized 
in  a  particularly  vital  spot.  This  is,  however,  doubtful.  While  it  is 
probable  that  a  specific  toxic  substance  may  be  produced  by  the  para- 
site, and  while  there  is  very  good  reason  to  believe  that  there  is  a  dif- 
ference between  the  malignity  of  the  parasites  in  different  instances,  yet, 
in  a  general  way,  the  severity  of  the  symptoms,  as  demonstrated  long 
ago  by  Golgi,  appears  to  depend  largely  upon  the  number  of  parasites 
present.     And  in  a  general  way  it  may  be  definitely  stated  that  per- 

^  The  Parasites  of  Malarial  Fevers,  New  Sydenham  Society,  1894. 
Vol.  I.— 8 


114  MALABTA. 

nicious  fever  never  occurs  without  the  presence  of  a  considerable  number 
of  parasites,  though  in  some  of  these  instances  very  few  organisms  may 
be  found  in  the  peripheral  circulation. 

Bastianelli  and  Bignami  in  a  recent  article  ^  well  say  :  "  The  con- 
ditions through  which  a  malarial  infection  becomes  pernicious  are  :  (1) 
That  the  infection  be  produced  by  one  of  the  varieties  of  the  sestivo- 
autumnal  parasite.  On  this  condition  all  today  are  agreed,  and  we 
shall  not  insist  further.^  (2)  The  second  condition  relates  to  the  abun- 
dance of  the  parasites,  and  it  may  be  stated  as  follows  :  In  pernicious 
fevers,  if  one  takes  into  consideration  not  only  the  examination  of  the 
blood  from  the  finger,  but  also  the  condition  in  the  vessels  of  the  various 
organs  (Marchiafava,  Celli,  Bignami),  it  is  a  striking  point  that,  how- 
ever the  distribution  of  the  parasites  may  vary  in  individual  cases,  their 
total  number  is  always  considerable.  As  regards  the  distribution,  one 
may  make  the  following  distinctions  :  There  exist  (1)  cases  in  which  the 
number  of  parasites  is  most  abundant,  yes  enormous,  while  all  the  organs 
are  uniformly  invaded.  These  are  the  most  common  forms  of  pernicious 
fever,  and  are  usually  accompanied  by  coma.  There  are  some  cases  in 
this  category  in  which  the  number  of  parasites  in  the  blood  of  the  finger, 
of  the  spleen,  of  the  bone  marrow,  etc.  is  enormous,  while  the  number 
in  the  brain  is  scanty ;  clinically,  the  absence  of  cerebral  phenomena  is 
noted.  (2)  Cases  in  which  the  number  of  parasites  is  absolutely  and 
relatively  scanty  in  the  bone  marrow,  in  the  spleen,  in  the  liver,  while 
there  may  be  relatively  few  in  the  blood  of  the  finger,  yet  other  organs 
are  crowded  with  parasites.  Among  these  the  following  localizations  are 
to  be  made  out :  (a)  The  brain  and  the  meninges  are  filled  with  parasites 
either  in  sporulation  or  in  all  their  stages  of  development ;  in  such  cases 
it  is  difficult  to  find  not  only  sporulating  forms,  but  even  young  parasites 
in  the  spleen.  Clinically,  there  are  cerebral  phenomena.  (6)  The  stomach 
and  intestine  are  chiefly  invaded ;  in  these  organs  the  mature  forms  of 
the  parasite  are  usually  found ;  these  are  the  cases  of  pernicious  fever 
which  present,  clinically,   ....  intestinal  phenomena." 

The  pernicious  symptoms  may  come  on  quite  early  in  the  course  of 
the  infection,  though  usually  several  paroxysms  have  existed  before 
their  appearance.  In  very  malarious  districts,  however,  almost  the  first 
paroxysm  observed  may  be  pernicious  in  nature. 

The  Comatose  Type. — The  commonest  form  of  pernicious  malaria 
is  that  accompanied  by  coma.  Here,  in  the  earlier  part  of  the  paroxysm, 
the  patient  may  be  slightly  delirious,  but  he  soon  becomes  drowsy  and 
somnolent,  passing  finally  into  a  condition  of  profound  coma.  Not  in- 
frequently, in  grave  malarious  districts,  the  patient  comes  for  the  first 
time  to  the  observation  of  the  physician  while  in  this  condition.  He  is 
profoundly  unconscious ;  the  respiration  is  often  stertorous,  and  occa- 
sionally of  the  Cheyne-Stokes  type.  The  pupils  may  be  contracted  or 
dilated,  sometimes  perhaps  unequal.  There  is  often — a  not  unimportant 
point — a  slight  jaundice.     Not  infrequently  there  is  hiccough  ;  the  pulse 

1  Bull.  d.  B.  Ace.  Med.  di  Boma,  1893-94,  Anno  xv.,  v.  xx.  186. 

-  There  are  exceptions,  though  rare,  to  this  rule.  Dr.  Walter  Eeed  of  the  Army 
Medical  Museum  in  Washington  has  recently  communicated  to  me  his  observation  of 
specimens  from  a  case  of  characteristic  comatose  pernicious  fever  due  to  a  double  tertian 
infection.  This  case  has  since  been  reported  by  Dr.  Wm.  B.  French  of  Washington 
{N.  Y.  Med.  Journal,  1895,  vol.  Ixiii.  p.  674). 


SYMPTOMS.  115 

iniiy  be  t'ull  and  slow  ami  of  lii<i'h  tension,  tlioii<^h  toward  the  end  it  is 
often  rapiil,  irregular,  and  feeble.  Local  spasms  of  certain  nmscles  may 
oeeur.  Thus,  in  one  of  the  author's  cases  there  was  a  well  marked 
spasm  of  the  lower  facial  muscles  on  one  side,  which  disappeared  with 
the  paroxysm.  Recovery  may  result  after  the  gravest  symptoms,  but 
Avitlu)Ut  treatment  the  jKa\>xysm  is  usually  followed  rapidly  by  a  second, 
which  generally  ])roves  tiital. 

Othhij  Ckhebkal  Manifestations. — In  other  instances  most 
decideil  cerebral  symptoms  of  a  different  nature  may  occur.  Delirium 
which  may  be  maniacal  may  be  observed.  Active  delusion.^  and  halluci- 
iKifioiis  are  not  uncommon,  while  in  some  instances  tetanic  convultiions 
have  been  noted.  In  a  number  of  instances  hemiplegia,  has  been 
associated  with  the  paroxysm,  disappearing  after  the  attack.  At 
times  distinct  symptoms  of  bulbar  paralysis  may  occur.  In  one  of 
these  cases  carefully  studied  by  Marchiafava  ^  the  special  localization 
Df  the  parasites  in  certain  foci  in  the  medulla  was  confirmed  post- 
mortem. 

Hemorrhagic  Type, — In  some  instances  of  pernicious  fever  grave 
hemorrhagic  symptoms  may  occur — epistaxis,  haemoptysis,  extensive 
cutaneous  hemorrhages.  Several  of  these  cases  are  described  by  Mar- 
chiafava and  Bignami.^ 

Algid  Type. — This  is  sometimes  extremely  insidious  and  fatal. 
After  several  paroxysms  which  are  in  no  way  remarkable  the  patient 
very  suddenly  passes  into  a  condition  of  extreme  collapse.  This  does 
not  occur  at  the  beginning  of  the  paroxysm,  but  at  the  time  when  the 
stage  of  fever  should  exist.  The  temperature  may  be  but  slightly  elevated  ; 
indeed,  in  some  instances  it  is  subnormal.  The  condition  is  not  unlike 
that  in  Asiatic  cholera.  The  mind  is  clear,  there  is  little  suffering,  ])ut 
extreme  colla])se.  The  eyes  are  sunken ;  the  features  drawn  and 
jiinched  ;  the  face  expressionless ;  the  tongue  dry ;  the  skin  moist  and 
covered  with  a  cold  sweat.  The  patient  may  be  so  quiet  and  uncom- 
plaining that  it  may  be,  as  Laveran  states,  only  through  an  accidental 
examination  of  the  pulse  that  the  true  state  of  affairs  may  be  discovered. 
The  pulse  is  very  rapid  and  feeble  and  thready,  almost  impalpable,  be- 
coming imperceptible  at  the  wrist  before  death.  Physical  examination 
of  the  thorax  is  negative  excepting  for  the  feeble  action  of  the  heart. 
The  second  sound  at  the  base  may  be  quite  inaudible.  The  abdomen  is 
usually  retracted ;  there  is  often  tenderness  on  pressure  in  the  region  of 
the  spleen,  which  is  palpable. 

Sudoriferous  Type. — A  sudoriferous  type  of  paroxysm  has  been 
•described,  in  which,  during  the  last  stage,  the  sweating  becomes  exces- 
sive and  the  patient  passes  into  a  condition  of  collapse  with  a  thready 
pulse  and  cold  extremities.  Without  vigorous  interference  the  case  may 
end  fatally. 

Bilious  Type. — A  ty^Q  of  paroxysm  has  been  described  by  cer- 
tain observers,  the  chief  symptom  of  which  is  the  vomiting  of  large 
quantities  of  bile-stained  fluid  ;  this  is  usually  associated  with  stools  of  a 
similar  nature. 

Gastralgic  and  Cardialgic  Types. — Severe  gastralgic  parox- 
ysms associated  ^\i\^l  profuse  vomiting,  and  often  with  hsematemesis, 

^  Lav.  d.  III.  Cong.  d.  soc.  It.  d.  Med.  Int.,  Eoma,  1890,  142.  ^  i^^.  p,^_ 


116  MALARIA. 

may  occur  without  the  existence  of  striking  intestinal  symptoms.  An 
attack  of  this  nature  is  well  described  by  Laveran.^ 

Choleeiform  Type. — In  certain  instances  in  which  the  chief 
localization  of  the  parasite  is  in  the  stomach  and  intestines  the  patients 
present  a  clinical  picture  strongly  resembling  that  of  Asiatic  cholera. 
These  cases  have  been  particularly  studied  by  Marchiafava.^  The 
paroxysm  usually  begins  with  profuse  vomiting  and  diarrhoea ;  the  dis- 
charges may  resemble  those  of  cholera.  The  skin  is  cold,  moist,  and 
clammy.  There  is  cyanosis  of  the  lips  and  extremities ;  the  pulse  is 
rapid  and  thread-like.  There  may  be  cramps  in  the  extremities.  The 
condition  closely  resembles  the  algid  stage  of  Asiatic  cholera.  If  the 
paroxysm  be  not  fatal,  profuse  sweating  may  follow,  with  an  intermis- 
sion in  the  symptoms.  Anatomically,  the  mucous  membrane  of  the 
stomach  and  intestines  is  found  to  be  filled  with  malarial  parasites. 
These  may  produce  actual  thrombosis  of  the  vessels  of  the  mucous 
membrane  with  superficial  necroses  and  ulceration. 

Pneumonic  or  Dyspnceic  Type. — Baccelli^  and  others  have  de- 
scribed a  type  of  paroxysm  the  symptoms  of  which  suggest  strongly  a 
pneumonia.  This  admirable  observer,  however,  as  long  ago  as  1866 
recognized  this  condition  to  be  distinct  from  a  true  complicating  pneu- 
monia. There  is  intense  thoracic  pain,  great  dyspnoea,  and  a  painful 
cough.  There  may  be  moderate  dulness  over  the  affected  lung  with 
coarse,  sonorous,  and  sibilant  and  finer  moist  rales.  Laveran  *  has  seen 
a  fairly  abundant  hsemoptysis  following  an  acute  dyspnoeic  paroxysm. 
In  other  instances,  despite  the  extreme  dyspnoea,  physical  examination 
may  be  quite  negative.  The  sputum  is  mixed  with  dark  fluid  and 
clotted  blood.  The  condition  is  certainly  not  a  pneumonia ;  it  is  more 
probably  an  active  congestion  of  the  pulmonary  vessels.  In  the  absence 
of  autopsy  records  in  cases  of  this  nature  one  can  but  suspect  that  they 
represent  a  special  localization  of  the  parasite  in  the  pulmonary  capil- 
laries. 

H^MOGLOBixuRic  Type — "  Malarial  hcematuria." — Hsemoglobi- 
nuria  is  a  not  uncommon  symptom  in  the  graver  fevers  in  cer- 
tain malarious  districts.  In  temperate  climates  it  is  rarely  seen. 
The  ultimate  cause  of  its  production  is  not  yet  settled.  A  con- 
tinual destruction  of  the  red  blood-corpuscles  is  going  on  throughout 
every  malarial  infection.  This  occurs  in  various  ways  :  (1)  The  para- 
sites, developing  within  the  corpuscles,  form  the  black  pigment, 
melanin,  at  the  expense  of  the  corpuscles  in  which  they  grow,  the 
corpuscles  becoming  gradually  decolorized  and  destroyed.  (2)  In  many 
instances  the  red  blood-corpuscles  containing  the  parasite  undergo  a  pre- 
mature necrosis,  becoming  brassy  colored  and  shrunken.  (3)  Sometimes 
the  decolorization  of  the  corpuscles  containing  the  parasite  occurs  quite 
suddenly,  the  corpuscles  bursting,  as  it  were,  and  setting  free  their  haemo- 
globin in  the  blood  current.  Thus,  during  an  ordinary  malarial  attack 
there  is  always  a  certain  amount  of  haemoglobin  set  free  in  the  serum, 
but,  as  this  amount  does  not  pass  beyond  the  limit  of  the  quantity 
which  can  be  disposed  of  by  the  liver,  it  does  not  appear  in  the  urine. 

^  Traite  des  Fievres  -palui^tres,  Obs.  xxxviii. 

''  Gent.  J.  Allg.  Path.  u.  Path.  Anat.,  1894,  V.  No.  10,  418. 

^  Studien  iiber  Malaria,  Berlin,  1895.  *  Traite  des  Fiewes  palustres. 


sYJirroMS.  117 

It  is  doubtless,  in  part,  to  this  constant  destruction  of  the  red  corpuscles, 
with  the  liberation  of  their  luemoglobin,  that  the  polycholia  and  slight 
jaundice  so  coninionly  observed  in  malaria  are  due.  Ponfick  estimates 
that  uj)  to  one  sixth  the  total  number  of  the  red  blood-corpuscles  may 
be  destroyed  and  disposed  of  in  the  economy  without  the  haemoglobin 
appearing,  as  such,  in  the  urine.  If  this  destruction  of  the  red  blood- 
corpuscles  becomes  unusually  great,  and  the  quantity  of  haemoglobin 
separated  from  the  disco-plasma  of  the  red  blood-corpuscles  exceeds  the 
amount  which  can  be  taken  care  of  by  the  liver,  hemoglobinuria  will 
result.  It  is  not,  however,  only  the  infected  corpuscles  which  lose  their 
lifemoglobin  in  these  instances ;  great  numbers  of  their  uninfected  fel- 
lows are  equally  aifected,  just  as  in  the  ordinary  paroxysmal  hsemoglo- 
binuria.  Some  substance  excessively  toxic  to  the  disco-plasma  of  the 
red  blood-corpuscles  must  be  present  in  the  circulation,  or  some  change 
has  taken  place  in  the  blood  serum  by  which  it  has  lost  its  isotonicity, 
but  what  these  changes  are  and  to  what  they  are  due  are  by  no  means 
clear.  There  is  much  which  might  lead  us  to  believe  with  Baccelli 
that  some  toxic  substance,  produced  perhaps  by  the  parasite  itself,  may 
be  at  the  bottom  of  these  changes.  Why,  however,  heemoglobinuria 
should  be  so  common  in  certain  regions — as,  for  instance,  Greece  and 
West  Africa — and  so  infrequent  in  many  other  more  malarious  dis- 
tricts is  quite  inexplicable  in  the  present  state  of  our  knowledge. 

Clinically,  these  cases  are  among  the  severest  forms  of  malarial 
fever.  The  same  condition  is  known  in  Western  Africa  as  "  black 
water  feverJ'  By  many  observers,  particularly  by  the  French,  the 
term  bilious  hcenioglobinuric  fever  has  been  used.  Not  infrequently  the 
term  "  hcematuric  "  is  used,  and,  indeed,  as  the  interesting  researches  of 
Joseph  Jones  show,  actual  heematuria  often  occurs.  The  hsemoglo- 
binuric  attack  is  rarely  the  initial  symptom  of  the  infection.  Usually 
the  patient  has  had  repeated  attacks  of  malaria,  the  haemoglobinuria 
appearing  suddenly  with  a  relapse,  or,  if  it  be  the  first  infection,  the 
hsemoglobinuric  attack  is  preceded  by  several  intermittent  paroxysms. 
In  cases  w^here  either  in  a  relapse  or  in  a  primary  infection  the  hsemo- 
globinuria  appears  with  the  first  actual  paroxysm,  there  are  often  pro- 
dromal symptoms  lasting  for  from  several  hours  to  sometimes  several 
days.  It  is  probable  that  these  are  associated  with  moderate  fever  and 
often  represent  abortive  paroxysms.  There  are  loss  of  appetite,  head- 
ache, indefinite  pains  in  the  extremities  and  back.  It  may  be  remem- 
bered that  in  many  paroxysms  of  the  more  ordinary  types  of  sestivo- 
autumnal  fever  the  gradual  onset  of  the  paroxysm  without  chill  is  fre- 
quent :  this  is  not  true  in  the  case  of  the  hsemoglobinuric  paroxysm, 
which  begins  almost  invariably  with  a  severe  shaking  chill.  This  is 
followed  by  intense  pain  in  the  back,  head,  and  extremities,  and  by  pro- 
fuse vomiting ;  the  vomitus  consists  of  a  deeply  bile-stained  fluid.  The 
face  is  flushed ;  the  conjunctivae  are  injected ;  the  pulse  is  rapid;  the  patient 
is  usually  in  a  condition  of  great  anxiety  and  apprehension.  There  is  a 
well  marked  icteric  hue  to  the  skin.    There  is  usually  profuse  diarrhoea. 

The  first  urine  that  is  passed,  in  the  early  stage  of  the  paroxysm,  has 
a  somewhat  rosy  reddish  hue.  This,  however,  rapidly  becomes  deeper, 
and  is  finally  an  intense  brownish  black  color  with  something  of  a 
greenish  tinge,  and  a  greenish  yellow  foam  on  shaking.     The  vomitus 


118  31  A  LABIA. 

becomes  of  a  deeper  color,  at  first  yelloAV,  then  green,  finally  sometimes 
almost  black.  There  may  be  diarrhoea,  the  dejecta  being  green  or 
brown  in  color,  while  in  other  instances  there  is  constipation.  During 
the  stage  of  fever  the  patient  generally  becomes  jaundiced.  There  is 
usually  little  delirium,  the  patient  being  quite  conscious  and  in  a  con- 
dition of  great  anxiety  and  agitation.  He  often  complains  of  severe 
epigastric  pain,  which  is  possibly  associated  with  repeated  vomiting  ;  in 
other  instances  the  pains  in  the  loins  may  be  extremely  severe,  bearing, 
possibly,  as  Kelsch  and  Kiener^  suggest,  some  relation  to  the  intense 
renal  congestion.  The  fever  is  often  high,  the  temperature  touching,  in 
some  instances,  41°  C.  (106°  F.)  or  even  higher. 

The  urine  at  the  height  of  the  process  is  of  a  deep  brownish  black 
color,  and  deposits  on  standing  an  abundance  of  reddish  brown  sediment. 
The  amount  varies  considerably  in  different  instances,  in  some  being 
extremely  scanty,  in  others  amounting  to  as  much  as  1000  or  1500  c.c. 
The  specific  gravity  varies  inversely  to  the  amount  of  urine  passed.  As 
the  amount  is  generally  somewhat  reduced,  the  specific  gravity  averages 
above  normal.  The  reaction  varies  ;  it  is  generally  feebly  acid.  There  is 
usually  an  abundance  of  albumin.  In  some  instances  a  test  for  the  biliary 
coloring  matters  may  be  obtained.  Kelsch  and  Kiener  assert  that  this 
is  the  rule  at  the  height  of  the  process,  while  Plehn^  in  eight  instances 
was  unable  to  obtain  this  test.  The  sediment  consists  of  mucus,, 
bladder  epithelium,  numerous  granules  and  masses  of  pigment,  renal 
epithelial  cells,  and,  almost  invariably,  hyaline  and  granular  casts  with 
epithelial  cells  adherent.  In  many  instances  blood-corpuscles  may  also 
be  found,  actual  hemorrhages  taking  place  into  the  kidney.  Often, 
however,  besides  the  profuse  sediment  of  a  brownish  granular  material,, 
occasional  epithelial  cells,  and  casts,  not  a  sign  of  a  red  corpuscle  may 
be  found,  the  condition  being  a  true  hsemoglobinuria. 

In  the  simplest  and  mildest  attacks  the  temperature  remains  elevated 
nine  or  ten  hours,  and  then  falls  quite  suddenly  to  normal,  the  urine  at 
the  same  time  clearing  up,  excepting  for  a  slight  trace  of  albumin  with 
occasional  casts.  In  some  instances  a  paroxysm  of  this  nature  is  the 
last  manifestation  of  the  process,  complete  recovery  following.  In 
other  instances  there  may  be  repeated  intermittent  hsemoglobinuric  par- 
oxysms, ending  perhaps  in  recovery.  Very  frequently,  however,  the 
condition  is  more  severe.  The  fever  lasts  much  longer ;  the  vomiting 
and  diarrhoea  continue  ;  the  jaundice  becomes  more  intense ;  there  are 
perhaps  occasional  slight  intermissions,  but  in  the  main  the  attack  is 
continuous.  The  urine,  as  well  as  the  fever,  may  show  occasional  tem- 
porary changes  for  the  better,  but  these  are  of  short  duration,  fresh  ex- 
acerbations rapidly  following.  The  urine  becomes  often  scanty  and 
more  albuminous ;  the  patient  becomes  emaciated  and  pale ;  the  eyes 
are  sunken,  the  tongue  is  dry,  the  pulse  rapid  and  feeble,  and  eventually 
a  fatal  result  follows.  In  some  instances,  however,  recovery  may  occur 
when  the  patient  is  a])parently  almost  beyond  hope. 

Certain  cases  pursue  an  extremely  rapid  fatal  course.  The  initial 
chill,  fever,  vomiting,  and  diarrhoea  are  associated  with  almost  complete 
suppression  of  urine ;  that  which  is  passed,  often  but  a  few  drops,  is  in- 
tensely bloody.     There  is  great  agitation,  intense  prostration,  the  patient 

1  Maladies  des  Pays  chauds.  '^  Beulsch.  nied.  Woch.,  1895,  Nos.  25,  26,  27. 


SYMPTOMS.  119 

lulling  into  a  condition  of  profound  c-olUipsc  and  dying  witiiin  several 
days.  Nephritis  almost  invariably  follows  the  hfenioglobinuric  attack. 
In  the  milder  cases  it  is  transient  and  slight.  In  many  more  severe 
cases,  however,  the  end  of  the  paroxysm  is  followed  by  the  symjjtoms 
of  a  well  marked  nej)hritis,  lasting  sometimes  for  weeks  and  j)ossiblv 
even  for  months.  In  a  certain  number  of  instances  this  condition  pur- 
sues a  rapidly  fatal  course.  The  albuminuria  and  casts  persist ;  the 
quantity  of  urine  remains  steadily  below  normal ;  the  jiatient  becomes 
unemic ;  and  delirium,  coma,  and  convulsions  ensue  with  a  fatal  result. 

Malarial  ha?moglobinuria  does  not  occur  in  all  malarious  districts. 
In  some  regions  where  pernicious  fevers  are  relatively  conuiKjn  luemo- 
globinuria  is  rarely  seen.  The  cause  for  this  is  not  apparent.  In 
Rome,  for  instance,  the  disease  is  uncommon.  It  is  not  very  frequent 
in  most  of  the  malarious  districts  of  the  United  States.  In  Greece  it 
seems  to  be  unusually  common,  while  in  certain  parts  of  Africa  it  is 
seen  in  its  most  fatal  forms. 

The  hlood  generally  shows  the  pestivo-autunnial  parasite.^  Predispos- 
ing causes  appear  to  be  any  over-exertion  or  exposure,  indeed  anything 
which  reduces  the  vitality'  of  the  individual.  Extremely  interesting  is 
the  widespread  idea  in  certain  regions  that  quinine,  which  has  so  specific 
an  action  upon  the  parasites,  may  yet  have  an  unfavorable  influence, 
indeed  be  the  determining  cause  of  the  hsemoglobinuric  paroxysm.  In 
Joseph  Jones'  interesting  memoirs-  a  number  of  assertions  of  this  nature 
appear.  More  recently  Plehn^  in  a  valuable  article  upon  the  black 
water  fever  of  Cameroon  records  his  belief  that  in  that  climate,  at  least, 
the  development  of  haemoglobinuria  is  often  l^rought  about  by  the  ad- 
ministration of  quinine,  while  the  records  of  his  cases  of  hsemoglobinurie 
fever  treated  with  and  without  the  specific  malarial  remedy  show  that 
the  more  favorable  course  was  pursued  by  those  cases  which  v>-ere  treated 
expectantly.  This  view,  however,  is  not  held  by  the  majority'  of  ob- 
servers. The  tendency  toward  spontaneoiLs  recovery  in  many  of  these 
cases  suggests,  certainly,  that  the  presence  of  the  haemoglobinuria,  de- 
pendent on  whatever  it  may  be,  may  have  an  injurious  eifect  upon  the 
life  of  the  parasite. 

The  Blood  ix  the  ^EsTivo-ArTUMXAL  Fevers. — The  blood  in  the 
sestivo-autumual  fevers  shows  the  presence  of  the  small  form  of  the  para- 
site described  first  by  Marchiafava  and  Celli  ("  Haematozoon  falciparum," 
Welch).  As  already  noted  in  the  description  of  the  parasite,  only  the 
earlier  forms  in  its  cycle  of  existence  are  generally  found  in  the  per- 
ipheral circulation.  These  are  the  ring-like  or  amoel^oid  hyaline  liodies, 
which  are  often  quite  free  from  pigment.  As  the  later  stages  in  the 
development  of  the  organism  are  rarely  found  in  the  peripheral  circu- 
lation, it  is  natural  that  the  period  shortly  before  and  during  the  early 
part  of  the  paroxysm  should  be  that  in  Avhieh  the  smallest  number  of 
parasites  is  to  be  found  on  clinical  examination  of  the  blood ;  and  this 

^  This  has  been  the  case  in  those  instances  observed  bv  the  Roman  authors,  and  the 
descriptions  of  Plehn  and  others  seem  to  point  in  the  same  direction.  Owing,  however, 
to  the  remarkable  distribution  of  these  fevers,  to  which  reference  has  been  made  above,  we 
should  perhaps  bear  in  mind  the  possibility  that  there  may  be  certain  fine  differences 
between  the  parasites  of  the  ordinary  irregular  fevers  and  those  of  the  haemoglobiniiric 
variety,  which  may  be  brought  to  light  by  furtlier  study. 

^  Medical  and  Surgical  Memoirs,  vol.  ii.,  New  Orleans,  1887.  ^  Loc.  cit. 


120  MALARIA. 

is  the  case.  There  are  cases  of  sestivo-autumnal  fever  where,  at  this 
period,  a  prolonged  search  must  be  made  before  parasites  are  to  be 
found.  Always,  howev^er,  in  the  experience  of  the  writer,  parasites 
are  present  after  a  few  hours  have  passed  by.  And  I  believe  that 
it  may  be  emphatically  stated  that  there  are  no  dangerous  forms  of 
malaria  in  which  the  parasite  is  not  to  be  found  after  reasonably  care- 
ful search. 

After  the  infection  has  existed  for  a  week  or  two  the  crescentic  and 
ovoid  pigmented  forms  of  the  organism  are  usually  observable.  Phago- 
cytosis is  very  commonly  to  be  noted,  and  pigment-bearing  leucocytes 
are  to  be  found  throughout  almost  ail  periods  of  the  fever.  The  period- 
icity in  the  phagocytic  action  is  much  less  marked  than  in  the  ordinary 
intermittent  fevers.  This  is  due  in  part  to  the  presence  at  all  times  of 
parasites  in  diiferent  stages  of  development,  and  in  part  to  the  early 
necrosis  of  the  red  blood-corpuscles  which  is  so  common  in  these  fevers 
the  dead  fragments  are  speedily  engulfed  and  carried  away  by  the  color- 
less elements.  Occasionally,  true  macrophages,  such  as  are  seen  in  the 
spleen,  may  be  found  in  the  peripheral  circulation ;  these  may  be  enor- 
mous, ten  times  the  size  of  an  ordinary  leucocyte.  They  sometimes 
contain  coarse  granules,  much  larger  than  any  ordinarily  seen  in  the 
blood,  having  somewhat  the  appearance  of  eosinophilic  granules.  These 
cells  may  contain  not  only  parasites,  but  red  corpuscles,  usually  shrunken 
and  brassy  colored,  including  a  parasite,  and  also  entire  smaller  phago- 
cytes with  their  included  pigment  or  parasites  or  corpuscles. 

Fevees  with  Long  Intervals. — From  the  earliest  times  there 
have  been  described,  besides  the  ordinary  quotidian,  tertian,  and  quartan 
intermittent  fevers,  other  fevers  with  intermissions  considerably  longer ; 
thus  fevers  with  intervals  of  five,  six,  seven,  eight,  nine,  ten,  eleven, 
and  twelve  days,  or  even  longer,  have  been  believed  to  exist.  Celsus, 
who  distinguished  quotidian,  tertian,  and  quartan  fevers,  referred  to  the 
occasional  occurrence  of  fevers  with  longer  intervals,  but  noted  their 
rarity.^ 

After  Golgi's  first  researches  concerning  the  life  history  of  the  quar- 
tan and  tertian  parasites,  and  after  the  fact  became  settled  that  a  third 
variety  of  parasite  existed,  whose  cycle,  under  some  circumstances,  lasted 
but  twenty-four  hours,  the  fever  in  every  instance  being  definitely  con- 
nected with  the  segmentation  of  a  group  of  parasites,  it  is  but  natural 
that  many  observers  should  have  suspected  the  existence  of  other  varie- 
ties of  parasites  which  in  turn  might  be  related  to  these  rare  fevers  with 
longer  intervals.  And  Golgi  in  1889^  advanced  the  hypothesis  that  the 
crescentic  bodies  which  we  know  to  be  connected  with  the  sestivo- 
autumnal  parasite  might  bear  a  definite  relation  to  these  forms  of  fever. 
He  believed  that  they  represented  a  form  of  parasite  which  underwent 
a  long,  slow  development,  lasting  from  seven  to  twelve  days — that, 
finally,  segmentation  of  the  crescentic  forms  occurred  and  paroxysms 
followed,  just  as  in  the  case  of  the  regularly  intermittent  fevers.  This 
variety  of  parasite,  however,  differed  in  the  greater  length  and  the 
irregularity  of  the  cycle  of  development,  while  the  paroxysms,  in  like 
manner,  recurred  at  irregular  intervals,  from  seven  to  twelve  days  apart 

^  ' '  Tnterdum  etiam  longiore  circuitu  quaedam  redeunt,  sed  id  raro  evenit." 
^  Ziegler's  Beitrdge,  1890,  vii.  647. 


SY^Ml'TUMS.  121 

or  even  more.  Canalis '  lioliovcd  that  the  festivo-autumnal  parasite 
possessed  two  so])arate  evclcs — a  shorter,  lastiii<;'  from  one  to  two  days, 
and  a  longer,  associated  Avith  the  crescentic  and  ovoid  bodies,  lastin*;-  an 
indetinite  lengtli  of  time,  three  or  four  days  at  least.  Antolisei  and 
Ang;elini  -  also  believed  that  this  variety  of  parasite  was  associated  with 
fevers  with  loni::er  intervals. 

Clinically,  however,  one  very  rarely  observes  cases  showing  a  regular 
recurrence  of  paroxysms  at  intervals  lonoer  than  every  fourth  day.  On 
the  other  hand,  it  is  not  so  very  unusual  to  meet  with  cases  where  a  lunn- 
ber  of  paroxysms  have  recurred  at  intervals  of,  approximately,  six  to  four- 
teen days.  In  all  these  instances  one  is  generally  compelled  to  depend 
largely  upon  the  statements  of  the  patient.  An  analysis  of  those  cases 
which  have  been  observed  since  the  recognition  of  the  parasite  and  its 
diU'erent  varieties  shows  that  these  fevers  with  long  intervals  may  be 
associated  with  any  of  the  varieties  of  parasite  which  we  now  know. 
Golgi  noted  the  existence  of  such  paroxysms  in  patients  whose  blood 
showed  the  sestivo-autumnal  parasite.  Bignami^  and  Pes*  described 
eases  occurring  in  connection  with  the  tertian  parasite,  while  Vincenzi  ^ 
has  shown  that  they  may  be  associated  with  the  presence  of  any  of  the 
varieties  of  parasites  which  we  now  know,  alone  or  in  combination. 

The  manner  in  which  these  fevers  arise  was  described  first  by 
Bignami.  As  stated  in  the  description  of  the  parasite,  the  mere 
presence  of  the  organism  in  the  circulating  blood  is  not  sufficient  to 
produce  subjective  symptoms.  These  appear  first  only  when,  from 
steady  multiplication,  the  number  of  parasites  contained  in  the  circu- 
lation has  reached  a  certain  necessary  quantity.  With  every  period  of 
segmentation  their  number  appreciably  increases.  Not  every  fresh 
segment,  however,  continues  to  develop.  Were  this  the  case,  every  in- 
fection would  become  pernicious  within  a  short  period.  With  each  par- 
oxysm a  very  considerable  number  of  young  parasites  is  destroyed — so 
great  a  number,  in  fact,  that  many,  indeed  the  majority,  of  cases  of  ter- 
tian and  quartan  fever  tend  toward  spontaneous  recovery,  though,  to  be 
sure,  relapses  often  occur.  To  what  this  destruction  is  due  is  as  yet 
a  matter  of  doubt.  In  how  far  it  may  depend  upon  the  protective 
power  of  the  blood  serum  or  upon  an  active  defensive  phagocytosis 
on  the  part  of  the  leucocytes,  or,  possibly,  upon  the  deleterious  effects 
of  some  toxic  substance  produced,  perhaps,  by  the  parasite  itself  at  the 
time  of  segmentation,  is  as  yet  wholly  a  matter  of  speculation.  It  is, 
however,  not  an  infrequent  occurrence  to  see,  more  particularly  in  tertian 
or  quartan  infections,  a  severe  paroxysm  followed  by  a  complete  disap- 
pearance of  the  symptoms,  while  the  blood  shows  a  disappearance  of  the 
group  of  parasites.  The  author  has  previously  published  charts  of  this 
nature.*'  In  such  instances,  through  some  means  or  other,  the  greater 
part  or  an  entire  group  of  parasites  is  destroyed  at  the  time  of  segmen- 
tation. In  these  cases  the  result  is  usually  complete  apyrexia  for  a 
certain  length  of  time,  from  several  days  to  two  weeks  or  even  more, 
and  then,  after,  perhaps,  a  little  warning,  a  repetition  of  the  paroxysms. 

1  Fortschritte  d.  Med.,  1890,  Nos.  8  and  9.  ^  Eifonna  Medica,  1890,  320,  326,  332. 

^Ibid.,  1891,  No.  165,  p.  169.  *  Ibid.,  1893,  vol.  ii.  p.  759. 

^Bull.  R.  Ace.  Med.  di  Roma,  1891-92,  p.  631  ;  Arch,  per  le  Sc.  Med.,  vol.  xix.  f.  3, 
p.  263.  ^  The  Malarial  Fevers  of  Baltimore,  loc.  eit. 


122  MALARIA. 

In  some  instances  the  first  paroxysm  may  be  followed  by  a  period  of 
apyrexia,  lasting,  as  in  one  of  the  author's  cases,  eight  days  before  the 
development  of  a  second  febrile  attack,  and  that,  in  turn,  by  another 
intermission  of  approximately  the  same  length  of  time,  and  so  on,  the 
chart  thus  showing  an  intermittent  fever  with  intervals  of,  perhaps, 
eight  or  ten  or  twelve  days.  And  yet  the  examination  of  the  blood 
shows  the  characteristic  parasites  of  tertian  or  of  quartan  fever. 

The  explanation,  then,  of  these  fevers  with  long  intervals  is  not  to 
be  found  in  a  parasite  whose  cycle  of  development  lasts  an  unusually 
great  length  of  time,  but  in  the  fact  that  the  first  sharp  paroxysm  is 
followed  by  the  destruction  of  so  great  a  number  of  the  parasites  that 
a  long  period — sometimes  practically  that  of  the  period  of  incubation 
of  the  disease — must  be  passed  through  before  the  group  again  reaches 
a  size  sufficient  to  produce  symptoms.  The  recurrent  attacks  repre- 
sent, as  Bignami  pointed  out,  recrudescences  from  attacks  from  which 
complete  recovery  has  not  taken  place.  Single  paroxysms  with  long 
intervals,  or,  more  commonly,  one  or  two  paroxysms  occurring  to- 
gether with  long  intervals  between  them,  may  exist  for  a  very  consider- 
able length  of  time  in  tertian  or  quartan  infections.  Thus,  the  author 
has  had  occasion  to  observe  an  individual  who  for  over  two  years  had 
had  occasional  chills  at  irregular  intervals  of  two  or  three  weeks,  more 
or  less,  due  to  an  untreated  tertian  infection.  One  or  two  paroxysms 
were  almost  invariably  followed  by  an  apparent  complete  spontaneous 
recovery,  only  to  be  succeeded  in  the  course  of  from  two  to  four  weeks 
by  another  relapse. 

In  another  class  of  cases  the  paroxysms  with  long  intervals  are  due 
to  imperfectly  treated  malarial  fever.  Many  patients  living  in  mala- 
rious districts  are  in  the  habit  of  taking  large  single  doses  of  quinine 
immediately  following  any  outbreak  of  fever.  Thus  in  an  instance 
observed  by  the  author  a  lady  asserted  that  she  had  had  paroxysms  at 
intervals  of  ten  days.  The  third  or  fourth  paroxysm  occurred  under 
his  observation,  the  blood  showing  the  characteristic  tertian  parasites. 
In  this  instance  the  patient,  by  taking  a  single  dose  of  quinine  after 
each  paroxysm,  had  accomplished  the  same  end  which  nature  accom- 
plishes in  the  other  class  of  cases — ^viz.  the  destruction  of  the  greater 
part  of  the  group  of  parasites ;  and  in  each  instance  a  relapse  occurred 
about  ten  days  after  the  previous  attack.  The  same  explanation  is 
probably  true  in  the  cases  occurring  in  sestivo-autumnal  infections. 
There  is  no  evidence  to  show  that  there  is  any  such  thing  as  a  regular 
type  of  fever  occurring  at  intervals  longer  than  every  fourth  day.  The 
paroxysms  in  these  instances  differ  in  no  way  from  those  in  tertian, 
quartan,  or  sestivo-autumnal  fevers  according  to  the  variety  of  infection. 

Combined  Infections  with  Different  Varieties  of  Parasites. 

Combined  infections  with  two  or  more  varieties  of  the  malarial  para- 
sites may  occur,  though  they  are  rather  uncommon.  In  542  cases  of 
malarial  fever  classified  by  He wetson  and  the  author  there  were  only  1 1 
such  instances.  Clinically,  these  cases  present  usually  the  features  of 
an  ordinary  tertian,  quartan,  or  sestivo-autumnal  infection,  and  without 
examination  of  the  blood   the  presence  of  two  varieties   of  parasites 


LXFECTIOXS    WtTlI  nfFFERKXT  VAIIIKTIES   OF  PAIiASFfFS.      123 

wcnild  oftoii  ivmtiin  iiususjx'clcd.  This  is  duo  to  the  fact  that  the  two 
(litlcTcnt  varieties  of  tlie  oroanisin  are  rarely  present  each  in  sufficient 
number  to  proihiee  symptoms  at  the  same  time.  One  type  of  the  para- 
site ahnost  always  predominates,  and  is  responsible  for  the  clinical 
symptoms.  Certain  cases  have  been  noted  where  a  distinct  alternation 
of  symptoms  has  occurred  ;  a  period  of  quartan  fever,  for  instance, 
beinji'  followed  by  spontaneous  recovery,  and  succeeded  by  a  period  of 
tertian  fever,  which,  if  untreated,  pursues  the  same  course,  and  crives 
way  tinally  to  a  relapse  of  the  quartan  infection  ;  the  parasites  of  l)oth 
varieties  are  present  at  the  same  time.  In  rare  instances  complicated 
fever  curves  may  arise  from  a  combined  infection.  This  is,  however, 
very  unusual.  The  commonest  combination  in  this  climate  is  sestivo- 
autumnal  and  tertian  fever. 

The  Urixe. — The  urine  in  the  malarial  fevers  has  no  special  diag- 
nostic features.  There  are  no  constant  changes  in  the  amount  or  in  the 
.specific  gravitf/  of  the  twenty-four  hours'  urine.  The  color  of  the  urine  is 
somewhat  increased,  due  probably  to  the  increased  quantity  of  urobilin 
which  is  derived  from  the  haemoglobin  of  the  red  blood-corpuscles 
destroyed  by  the  parasites.  The  amount  of  urea  excreted  during  the 
paroxysms  is  increased,  just  as  it  is  during  any  other  acute  febrile  con- 
dition. Albumin  is  usually  present  in  serious  cases.  Thus,  out  of  284 
cases  examined  by  Hewetson  and  the  author,  albumin  was  present  in 
133  instances,  nearly  one-half.  In  many  of  these  instances  casts  of  the 
renal  tubules  may  be  found.  Actual  acute  nephritis  may  occur.  Thus 
in  4  instances  out  of  335  of  our  cases  evidences  of  a  severe  acute 
nephritis  were  present — a  nephritis  which,  apparently,  owed  its  origin 
directly  to  the  malarial  infection.  In  3  of  these  instances  the  nephritis 
was  hemorrhagic  in  nature ;  in  the  other  case,  which  resulted  fatally, 
there  was  an  extensive  acute  diffuse  nephritis.  Ehrlich's  diazo  reaction 
may  be  present;  it  was  found  in  5.5  per  cent,  of  our  cases. 

The  Toxicity  of  Malarial  Urine. — Extremely  interesting  researches 
have  lately  been  made  concerning  the  increased  toxicity  of  the  urine 
during  malarial  fever.  Brousse,^  studying  the  effects  following  the 
injection  of  the  urine  of  cases  of  malarial  fever  into  animals,  arrived 
at  the  following  conclusions :  "  (1)  The  urotoxic  coefficient  calculated 
by  Bouchard's  formula,  the  mean  coefficient  being  0.464,  rises  during 
the  paroxysm,  and  the  physiological  effects  observed  are  those  which 
usually  follow^  the  injection  of  urine — dyspnoea,  myosis,  falling  of  tem- 
perature, exophthalmos,  and  furthermore  convulsions  ;  (2)  this  toxicity 
is  diminished  during  the  period  of  convalescence  in  intermittent  fever, 
very  much  below  that  of  the  urine  during  the  paroxysm,  and  moreover 
below  that  of  the  normal  urine."  ^ 

Roque  and  Lemoine  ^  studied  the  urine  in  3  cases  of  malarial  fever — 
one  a  case  of  tertian  fever  and  two  cases  of  pernicious  comatose  mala- 
ria. Their  conclusions  were  as  follows  :  "  (1)  The  pathogenic  agents  of 
paludism  form,  in  the  blood,  a  large  quantity  of  toxic  products,  a  great 
part  of  which  is  eliminated  by  the  urine.  This  elimination  is  at  its 
maximum  immediately  after  the  paroxysm,  and  lasts,  generally,  twenty- 

^  Quoted  from  Laveran,  Du  Paludistne,  etc.,  Paris,  1891. 

^  Societe  de  Med.  et  de  Chir.  pratiques  de  3fontpellier,  14  Mai,  1890. 
=*  Bemie  de  Med.,  1890,  p.  926. 


124  MALARIA. 

four  hours,  at  least  in  the  paroxysms  of  tertian  fever.  (2)  Sulphate  of 
quinine  acts  by  favoring  the  increase  of  this  elimination.  (3)  Certain 
pernicious  fevers,  showing  a  complete  absence  of  toxicity  in  the  urine, 
depend  probably  upon  alterations  in  the  kidneys  and  liver,  and  the 
return  of  the  urinary  toxicity  should  be  considered  a  good  prognostic 
sign,  (4)  Finally,  it  may  be  noted  that  in  two  cases  recovery  has  fol- 
lowed a  more  increased  elimination  of  toxines  than  that  observed  after 
the  preceding  paroxysms."  In  discussing  this  paper  Lepine  justly 
remarked  that  injections  should  be  made  not  only  with  the  pure  urine, 
but  also  with  a  solution  of  the  salts  of  the  urine  made  after  calcination. 
This  alone  can  give  a  reliable  idea  of  the  toxicity  of  the  urine  dependent 
upon  organic  compounds. 

More  recently  Botazzi  and  Pensuti  ^  have  made  an  elaborate  control 
research,  and,  while  finding  the  same  general  results  as  Roque  and 
Lemoine,  dispute  their  conclusions.  Their  studies  were  carried  out  in 
ten  cases.  They  collected  urine  during  and  after  the  febrile  periods. 
They  found  that  during  the  paroxysm  the  urine  showed  a  less  intense 
color  than  afterward.  During  the  febrile  periods  examination  of  the 
urine  with  the  ordinary  reagents  which  are  used  in  qualitative  analysis 
showed  always  a  diminished  amount  of  alkaline  and  earthy  phosphates, 
Avhile  that  voided  after  the  paroxysm  showed  sometimes  a  considerable 
quantity.  The  specific  gravity  of  the  urine  passed  after  the  paroxysm 
was  higher  than  that  during  the  paroxysm.  They  state  that  under  other 
conditions  the  urotoxic  coefficient  has  been  shown  to  run  parallel  to 
the  elimination  of  the  potassium  salts,  while  the  presence  of  peptones 
in  the  urine  increases  appreciably  its  toxicity.  Both  these  substances 
they  found  present  in  increased  quantities  in  the  urine  passed  after  the 
paroxysm.  The  urobilin,  as  already  stated,  is  present  in  increased 
quantities  in  the  urine  of  malarial  fever,  and  especially  so  in  that  fol- 
lowing the  paroxysm.  The  toxicity  of  this  substance  has  been  demon- 
strated by  these  authors,  who  found  that  the  urine  passed  after  the  par- 
oxysm, when  decolorized,  lost  half  its  toxicity.  They  assert,  in  opposition 
to  Boque  and  Lemoine,  that  "  there  is  no  need  to  suppose  the  presence 
of  special  toxic  substances  of  the  nature  of  leucomaines  to  account  for 
the  toxicity  of  malarial  urine  "  [after  the  paroxysm]  ;  "  the  potassium, 
the  phosphoric  acid,  the  peptones,  the  urinary  pigments,  and  especially 
urobilin,  which  are  found  in  this  urine  in  markedly  increased  quantities 
relatively  to  the  normal  urine  and  to  that  of  the  febrile  period,  are  of 
themselves  a  sufficient  explanation."  The  cause  of  the  increased  presence 
of  these  substances  is  not  difficult  to  appreciate.  The  potassium  salts  and 
the  jDigments  which  they  believe  to  be  the  chief  cause  of  the  hypertoxicity 
result  from  the  destruction  of  the  red  blood-corpuscles,  and  the  phos- 
phoric acid  and  peptones  are  doubtless  due  to  the  disintegration  and  com- 
bustion of  the  albumins  and  nucleins  of  the  cellular  elements  of  the  tis- 
sues. They  have  not  found  evidence  of  a  marked  retention  of  toxic  sub- 
stances owing  to  disease  of  the  kidneys,  as  asserted  by  Roque  and  Lemoine. 

In  conclusion,  they  state  :  "  We  think  that  we  have  demonstrated 

(1)  that  in  the  malarial  fevers  the  febrile  urine  is' less  toxic  than  that 

emitted  during  the  apyretic  stage ;  (2)  that  the  urine  emitted  during 

the  period  of  apyrexia  is  more  toxic  than  normal  urine ;  (3)  that  the 

^  Lo  Sperimentale,  Firenze,  1894,  xlviii.  232,  254. 


INFECTIONS   Wrni  DIFFERENT  VARIETIES  OF  PARASITES.      125 

toxicity  of  the  urine  of  malarial  i)atieiit.s  aui>iiients  constantly  with  the 
succession  of  febrile  attacks,  though  in  some  cases  this  augmentation 
appears  in  the  form  of  unex])eete(l  and  irregular  exacerbations  ;  (4)  that, 
as  tiiere  is  nt)thing  sj)eeitie  in  the  course  of  the  intoxications  produced  in 
rabbits  with  malarial  urine,  there  is  no  need  to  suppose  the  ])resence  of 
specific  toxins  or  substances  of  the  nature  of  leucomaines,  for  the  salts 
of  potassium,  phosphoric  acid,  the  urinary  pigments,  the  peptones,  all  of 
which  substances  are  eliminated  in  increased  quantities,  are  a  sufficient 
explanation  ;  (5)  that  the  injection  of  febrile  urine  is  followed  by  a 
slower  intoxication,  characterized  by  sopor,  by  increased  diuresis,  by 
diarrha?a,  and  mydriasis,  while  the  apyretic  urine  produces  a  more  acute 
effect,  sometimes  fulminating,  characterized  by  clonic  and  tonic  spasms 
and  myosis,  '  exhorbitisine,'  spastic  expiration  ;  (6)  that  to  explain  this 
different  picture  one  may  suppose  that  with  febrile  urine  the  polyuria 
and  diarrhoea  are  due  chiefly  to  the  increased  richness  in  the  urea, 
while  the  peptones  may  contribute  to  the  production  of  sopor.  In 
the  afebrile  urines  the  salts  of  potassium,  the  phosphoric  acid,  the  uri- 
nary pigments,  and  especially  the  urobilin,  manifesting  themselves  as 
substances  essentially  convulsive,  determine  hypertoxicity.  (7)  Finally, 
besides  the  hsemocytolysis  and  the  destruction  of  the  cellular  elements 
of  the  tissues,  and  the  formation  and  elimination  of  toxic  substances, 
there  must  exist  intermediate  factors  wdiich  account  for  the  absence  of 
increased  toxicity  after  the  first  febrile  paroxysms  and  the  irregular  ele- 
vation and  diminution  in  the  urotoxic  coefficient  in  some  other  cases." 
Laveran  speaks  also  conservatively  concerning  these  experiments  as  a 
proof  of  the  existence  of  a  specific  toxin. 

In  conclusion,  then,  one  may  say  that  while  a  distinct  increase  in 
the  toxicity  of  the  urine  has  been  shown  to  be  present  after  malarial 
paroxysms,  there  is  as  yet  no  proof  that  this  is  dependent  upon  specific- 
products  of  the  action  of  the  malarial  parasite. 

The  Blood. — Besides  the  presence  of  the  parasites,  the  examination 
of  the  blood  in  malarial  fever  reveals  certain  other  changes  which  are  at 
times  valuable  from  a  diagnostic  point  of  view. 

{A)  TJie  Regularly  Intermittent  Fevers. — An  actual  ancemia  always 
occurs  in  malarial  fever.  Kelsch/  Kalindero,^  Dionisi/  all  noted  that 
a  considerable  fall  in  the  number  of  red  blood -corpuscles  to  the  cubic 
millimetre  occurred  after  each  paroxysm,  while  similar  results  were 
obtained  by  Dr.  Kirkebride  in  some  counts  made  under  the  author's 
observation  in  1893.  The  fall  in  the  number  of  red  corpuscles  may  be 
quite  considerable,  though  in  tertian  and  quartan  fever  the  restitution 
to  normal  is  very  rapid.  Always,  however,  after  several  paroxysms 
have  occurred  there  is  a  certain  degree  of  anaemia,  which,  if  the  disease 
be  allowed  to  continue,  may  become  quite  marked. 

The  percentage  of  hcemoglobin  falls  with  the  number  of  corpuscles, 
but  usuallvto  a  somewhat  greater  extent,  while  the  return  to  the  normal 
point,  as  noted  by  E,ossoni/  takes  place  more  slowly  than  that  of  the- 
red  corpuscles. 

1  Arch,  de  Phys.,  1876,  ii.  s.,  t.  iii.  490. 

■-'  Jour,  de  Med.  et  de  Pharm.  d'Ah/erie,  1889,  xiv.  123. 

^  Lo  Sperimentale,  1891,  t.  iii.  and  iv.  284. 

*  Lav.  d.  Cong.  d.  Soc.  Ital.  d.  med.  Int.,  IF  Congresso,  Eoma,  Oct.,  1889,  121. 


126  IIALABIA. 

The  behavior  of  the  colorless  corpuscles  in  malarial  fever  has  been 
noted  especially  by  Kelsch/  Kalindero/  Bastianelli,^  and  Billings.*  It 
has  been  shown  that  the  number  of  leucocytes  in  malarial  fever  is 
almost  invariably  subnormal.  The  smallest  number  of  leucocytes  is 
seen  just  after  the  paroxysm  when  the  temperature  is  subnormal.  From 
this  time  there  is  a  gradual,  slight  increase,  which  becomes  accentuated 
just  before  the  paroxysm.  A  rapid  diminution  in  number  occurs  again 
during  the  paroxysm.     At  no  time  is  there  leucocytosis. 

[B)  The  Estiva-autumnal  Fevers. — The  changes  in  the  blood  in  the 
«stivo-autumnal  fevers  are  very  similar  to  those  in  the  regularly  inter- 
mittent forms,  differing  only  in  their  intensity.  The  red  corpuscles 
show  a  marked  diminution  ^vith  each  paroxysm.  When  the  parasites 
are  numerous  this  reduction  amounts,  sometimes,  to  as  much  as  a  million 
corpuscles  during  a  single  paroxysm.  Between  the  attacks  the  corpus- 
cles do  not  show  the  same  tendency  to  return  to  the  normal  number 
which  is  observed  in  the  regularly  intermittent  fevers.  The  restitution 
is  imperfect  and  incomplete.  The  number,  however,  rarely  falls  below 
one  million  to  the  cubic  millimetre,  although  Kelsch  has  seen  as  small 
a  number  as  five  hundred  thousand.  The  colorless  corpuscles  are  almost 
invariably  reduced  in  number.  The  changes  in  number  follow  the  same 
course  here  as  in  the  regularly  intermittent  fevers.  There  is  a  diminu- 
tion after  the  paroxysm,  a  slight  rise  just  before  the  beginning  of  the 
succeeding  attack,  with  a  fall  again  later  on.  The  hcemoglohin  follows 
the  same  curve  as  do  the  red  corpuscles,  falling,  however,  generally  to  a 
slightly  greater  extent. 

In  certain  instances  a  well  marked  leucocytosis  has  been  noted  in 
pernicious  paroxysms.  Bignami  has  noted  the  unfavorable  inferences 
that  one  may  draw  from  this  symptom.  In  some  instances  this,  very 
possibly,  depends  upon  a  secondary  mixed  infection.  In  other  instances, 
boAvever,  it  may  occur  where  cultures  from  the  organs  are  quite  nega- 
tive. Thus,  in  one  of  the  author's  cases  of  the  pernicious  algid  type  the 
blood  contained,  one  hour  before  death,  sixty  thousand  leucocytes  to  the 
cubic  millimetre.  The  leucocytes  in  malarial  fever  show  certain  other 
changes  which  are  quite  characteristic  and  interesting.  Just  as  in  the 
case  of  typhoid  fever,  where  the  number  of  leucocytes  is  ordinarily  sub- 
normal, so  in  malarial  fever,  one  finds  upon  a  differential  count  a  well 
marked  reduction  in  the  percentage  of  the  polymorphonuclear  neutro- 
philes,  with  a  corresponding  relative  increase  in  the  percentage  of  the 
large  mononuclear  forms.  Thus  the  average  numerical  proportions  of 
the  various  forms  of  leucocytes  in  sixteen  cases  analyzed  in  this  clinic 
by  Billings  were  as  follows  : — 

Small  mononuclear 16.9 

Large  mononuclear 16.9 

Polymorijhonuclear 65.04 

Eosinophilic 0.96 

In  the  pernicious  case  above  referred  to,  observed  by  the  author,  the 
relative  proportions  of  the  different  varieties  of  leucocytes,  notwithstand- 
ing the  leucocytosis,  were  as  follows  : 

1  Arch,  de  Phys.,  1876,  ii.  s.,  t.  iii.  490.  ^  j^g^^  ^^^^ 

3  Bull.  d.  B.  Ace.  Med.  d.  Boma,  1890,  Anno  xviii.,  f.  v.  297. 
*  Johns  Hopkins  Hospital  Bidleiin,  1894,  No.  43,  105. 


SEQUELS  AND  COMPLICATIONS.  127 

Small  iiiiinoniu'lcar 23    per  cent. 

Lar<;e  numomu-k'ar  and  transitional  tornis 18.4      " 

Polyniorithonuc'lear 58.  G      " 

The  ohaiinc's  in  the  l)loo(l  in  malarial  luemoglobinuria  have  been 
alivatly  ivt'cnvd  to. 

Tlu'  oravc  aiijoniiio  wliicli  luay  follow  malarial  fever  will  be  eoii- 
sidered  later  among  the  sequelae. 

Sequels  and  Complications. 

There  is  no  one  point  in  the  history  of  the  development  of  our  know- 
ledji'e  eoncernino'  the  malarial  fevers  where  so  much  confusion  and  mis- 
apprehension  has  existed  as  in  the  appreciation  of  the  nature  of  the 
se(|uehe  and  complications.  The  relation  of  chronic  cachexia  and  grave 
ansemia  to  malaria  has  long  been  recognized,  as  well  as  the  existence  of 
jui  acute  post-malarial  nephritis.  The  grave  cerebral,  nervous,  gastro- 
intestinal symptoms  which  may  occur  with  acute  malaria  have  been 
already  referred  to.  Many  observers,  however,  do,  even  today,  ascribe 
to  the  malarial  poison  the  capacity  of  producing  of  itself  a  considerable 
numl>er  of  other  complicating  processes  ordinarily  dependent  on  other 
t^pecitic  causes.  These  observers  have  in  particular  described  a  charac- 
teristic "  malarial  pneumonia,"  "  malarial  dysentery,"  etc.  That  such 
misapprehension  should  have  arisen  is  not  remarkable  when  we  consider 
the  many  ways  in  which  the  simple  malarial  process  may  be  masked  or 
complicated. 

Ascoli  ^  states  clearly  the  main  possibilities  in  this  direction  as  follows  : 
"  Finally,  in  conclusion,  we  may  distinguish  the  following  clinical 
forms  :  (1)  INIalaria  which  simulates  another  pathological  process.  (2)  A 
disease,  the  [ordinary]  course  of  which  is  known,  which,  in  an  indi- 
vidual suifering  with  chronic  malaria,  progresses  and  develops  anomalies 
in  its  course  according  to  the  stage  of  the  cachexia.^  (3)  A  fresh  malaria 
develops  in  a  subject  who  is  at  that  time  in  an  apyretic  stage  of  the 
disease  or  suifering  from  the  remains  of  a  former  infection  {combinata). 
(4)  Different  varieties  of  the  hsematozoa  exist  in  the  blood  of  a  patient 
suffering  from  malaria  alone  (mista).  (5)  Two  febrile  diseases  exist 
together  and  contemporaneously  (concomitanti) :  («)  exerting  a  recipro- 
cal influence  detrimental  to  the  organism  { proporzionate) ;  in  certain  of 
these  cases  the  reciprocal  influence  is  not  manifest  throughout  the  entire 
course  ;  (6)  each  preserving  its  more  constant  and  common  symptom- 
atology [cissociata).  (6)  The  malaria  may  prepare  the  ground  for  the 
development  of  another  acute  infection,  or  it  may  follow  after  another 
infection  has  run  itself  out  (consecutiva).'^ 

The  sequelae  and  complications  of  malarial  fever  may  be  divided  into — 
(1)  Those  sequelae  or  complications  due  directly  to  changes  produced  by 
the  malarial  parasites  or  their  toxic  products ;  (2)  true  complications, 
mixed  infections. 

1.  Sequelse  and  Complications  due  directly  to  Changes  produced 
by  the  Malarial  Parasites  or  their  Toxic  Products. — In  the  section 
upon  the  pernicious  fevers  the  acute  symptoms  produced  by  the  special 

1  Bull.  dellaSoc.  Lane.  d.  Osp.  di  Boma,  An.  xii.,_1891-92,  103. 

^  "  Una  malattia  di  processo  morboso  noto  che,  attacando  un  malarico  chronico,  assume 
andaniento  e  parvenze  variabili  secondo  lo  stadio  della  cachessia." 


128  3IALABIA. 

localization  of  the  parasites  in  the  brain,  Inngs,  or  gastro-intestinal  tract 
have  already  been  discussed.  It  is  therefore  unnecessary  to  refer  again 
to  the  acute  choleriform  and  comatose  cases  which  might  so  readily  sug- 
gest a  mixed  infection. 

Relapses. — The  extreme  frequency  with  which  relapses  are  met  in 
malarial  fever  has  been  referred  to  in  the  section  on  fevers  with  long 
intervals.  Most  cases,  unless  treatment  be  thoroughly  carried  out,  show 
recrudescences  in  the  course  of  one  or  two  or  three  weeks.  These  are 
clearly  proven  to  be  due  to  the  fact  that  all  the  parasites  have  not  been 
destroyed  by  the  treatment.  The  few  which  escape  form  a  nucleus  for 
the  development  of  new  groups,  which  in  the  course  of  a  week  or  two 
arrive  at  a  degree  of  development  sufficient  to  result  in  a  fresh  outbreak 
of  the  symptoms.  The  recrudescences  are,  ordinarily,  in  every  way  simi- 
lar to  the  original  attacks.  There  is,  however,  another  variety  of  relapse 
which  has  been  recognized  for  many  years — viz.  the  reappearance  of  an 
infection  many  w^eks  or  months  after  all  symptoms  have  disappeared. 
Undoubtedly,  many  such  cases  are  fresh  infections.  There  are,  however, 
cases  'where  a  fresh  infection  can  be  definitely  ruled  out,  while  the 
malarial  nature  of  the  process  is  undoubted.  An  interesting  example 
of  the  reappearance  of  fever  after  a  long  period  of  perfect  health  is  the 
case  of  a  friend  of  the  author,  a  physician  himself,  wholly  familiar  with 
malarial  fever,  clinically  and  pathologically.     During  the  fall  of  1880 

Dr. suffered  from  a  prolonged  attack  of  tertian  fever  which  reduced 

him  to  rather  a  cachectic  condition.  Recovery  followed  full  doses  of 
c-[uinine.  For  twenty-one  months  after  this  the  health  was  perfectly 
good,  the  patient  living  in  non-malarious  districts.  On  a  hot  afternoon 
of  August,  1882,  while  making  a  pedestrian  tour  in  the  Tyrol,  after  a 
prolonged  walk,  during  which  the  patient  was  subjected  to  great  changes 
of  temperature,  there  was  a  well  defined  characteristic  malarial  parox- 
ysm. The  true  nature  of  the  attack  was  not  suspected,  but  on  the  third 
day,  at  the  same  hour,  while  travelling  in  a  railway-carriage,  there  was 
a  second  paroxysm.  On  the  fifth  day,  again,  at  the  same  hour,  a  third 
characteristic  paroxysm  occurred.  Convinced  then  of  the  malarial 
nature  of  the  attacks,  treatment  with  quinine  was  begun,  which  resulted 
in  the  immediate  and  permanent  disappearance  of  the  paroxysms.     In 

the  words  of  Dr. ,  "  In  this  case  there  can  be  no  question  of  a  second 

infection.  I  had  not  been  in  a  country  where  there  was  any  malaria 
for  two  years,  and  for  three  weeks  before  the  appearance  of  the  first 
chill  I  had  been  in  the  mountains  of  the  Tyrol." 

The  absolute  proof — the  discovery  of  the  parasite — is  here  wanting ; 
there  can  be  little  doubt,  however,  as  to  the  nature  of  the  case.  The 
explanation  of  these  cases  is  difficult.  It  is  highly  improbable  that  the 
parasite  has  remained  present  in  the  blood,  passing  through  its  ordinary 
cycle  of  development,  and  yet  some  form  of  the  parasite  must  exist 
throughout  this  time.  Bignami,  as  was  noted  in  the  description  of  the 
parasite,  suggests  that  some  form  of  the  organism — which  perhaps  we 
have  not  yet  been  able  to  discover,  possibly  a  non-staining  spore — may 
persist  in  some  of  the  internal  organs,  possibly  within  the  protoplasm 
of  some  of  the  cellular  elements. 

Cheoxic  Malarial  Cachexia. — The  commonest  sequel  to  mala- 
rial fever  is  that  which  is  generally  known  as  chronic  malarial  cachexia. 


SEQUELS  AND   COMI'LlCATIoyS.  129 

111  malarious  districts  many  patients  allow  an  infection  to  continue  for 
weelcs,  months — nay,  in  some  instances,  even  for  years — without  ever 
attemptiuii-  a  systematic  or  thorough  treatment.  Tlic  result  is,  natu- 
rallv,  a  serious  (.Irain  upon  the  vital  resources  of  tiie  individual.  The 
course  of  such  a  case  is  commonly  as  follows  :  The  i)atient  has  several 
paroxvsms,  and  takes  a  few  doses  of  quinine,  which  are  followed  by 
a  disaj)pearance  of  the  fever,  or  after  a  week  or  so  of  paroxysms 
which  have  been  untreated  the  fever  disappears  spontaneously,  Fre- 
tpient  relapses  occur  which  are  improperly  treated  or  allowed  to  take 
their  own  course.  In  some  instances  of  iX'stivo-autumnal  fever  a  j)atient 
may  remain  for  a  long-  period  of  time  with  a  slight,  irregular  fever,  no 
sharp,  definite,  malarial  paroxysms  being  observed.  The  first  result 
of  a  continued  process  of  this  nature  is  the  gradual  development  of  an 
ansemia  which  usually  becomes  marked,  and  is  sometimes  extremely 
grave.  The  patient  has  a  sallow,  grayish  yellow  color ;  the  li[)s  and 
mucous  meral)ranes  are  blanched  ;  the  tongue  is  often  coated  ;  there  is 
frequently  oedema  of  the  dependent  parts.  The  spleen  is  usually  greatly 
enlarged,  sometimes  reaching  to  the  right  of  the  median  line.  Indeed, 
some  of  the  largest  splenic  tumors  which  occur  may  be  seen  in  these 
cases.  The  hepatic  flatness  is  increased  in  extent ;  the  border  is  often 
palpable,  reaching  sometimes  a  considerable  distance  below  the  costal 
margin.  The  patient  suffers  greatly  from  exhaustion,  severe  headache, 
pains  in  different  regions  of  the  body.  Severe  supraorbital  neuralgia 
may  exist.  Sudden  motion  or  exertion  is  followed  by  vertigo  or  faint- 
ing. The  gait  is  tottering  and  unsteady  ;  there  may  be  a  marked  general 
tremor. 

The  examination  of  the  blood  during  an  afebrile  stage  mav  be  quite 
negative,  excepting  for  the  anaemia.  More  commonly  occasional  para- 
sites or  pigmented  leucoc}i:es  may  be  found,  while  in  £estivo-autmnnal 
infections  the  characteristic  crescentic  or  ovoid  j)igmented  bodies  are 
usually  to  be  seen.  Chronic  cachexia  may  follow  any  variets'  of  infec- 
tion. In  the  majority  of  instances,  however,  it  represents  an  untreated 
sestivo-autumnal  infection,  and  in  these  instances  the  crescentic  and 
ovoid  forms  of  the  parasite  may  be  found.  The  same  condition  also 
follows  frequently  repeated  attacks,  even  though  the  individual  attack 
has  been  actively  treated.  The  tendency  toward  dropsical  transuda- 
tions is  generally  decided,  and  at  times  may  give  rise  to  confusion. 
Thus,  in  several  instances  the  author  has  observed  cases  of  moderate 
anaemia  with  quite  marked  oedema  of  the  dependent  parts  and  complete 
absence  of  fever,  where,  owing  to  an  unsatisfactory  history  and  the  fail- 
ure to  find  parasites  in  the  blood,  the  true  nature  of  the  process  was 
wholly  unsuspected  until  the  appearance,  within  several  weeks,  of  a  re- 
lapse. Gastro-intestinal  disturbances  are  verr  common  in  malarial 
cachexia,  and  the  grave  anaemia,  with  diarrhoea,  oedema  of  the  dej^endent 
parts,  the  enormous  splenic  tumor,  reduce  the  patient  to  a  most  distress- 
ing condition  of  marasmus,  where  he  is  an  easy  prey  to  complicating 
infections  of  all  sorts. 

Chronic  malarial  cachexia  is  not  uncommon  in  children,  where, 
owing  to  the  irregularity  of  the  symptoms,  the  true  nature  of  the  pro- 
cess is  often  unsuspected.  It  may  lead  to  the  most  intense  grade  of 
infantile  atrophy.     The  child  becomes  greatly  emaciated  ;    the  sallow. 

Vol.  I.— 9 


130  MALARIA. 

grayish  vello^v,  parchment-like  skin  hangs  in  fokis ;  the  mucous  mem- 
branes are  blanched.  There  are  occasionally  slight  febrile  attacks,  the 
child  becoming  cold  and  blue,  or,  perhaps,  showing  now  and  then  a 
slight  eclamptic  attack.  There  are  persistent  gastro-intestinal  disturb- 
ances, vomiting,  diarrhoea,  as  well  as,  perhaps,  diffuse  bronchitis.  The 
spleen  is  always  enormously  enlarged. 

PosT-^iALARiAL  Ax^MiA. — The  ausemia  associated  with  malarial 
fever  may  assume  various  forms.  Thus,  Bignami  and  Dicmisi^  have 
distinguished  four  types  of  post-malarial  anaemia. 

(1)  Anaemia,  in  which  the  examination  of  the  blood  shows  alterations 
similar  to  those  observed  in  ordinary  secondary  ansemia,  differing  from 
these  cases  only  in  that  the  leucocytes  are  diminished  in  number.  These 
cases  often  show  well  marked  oligocythsemia  ;  oligochromsemia  relatively 
greater ;  more  or  less  poikilocytosis ;  nucleated  red  corpuscles  (normo- 
blasts). The  leucocytes,  as  already  stated,  are  diminished  in  number, 
while  the  relative  proportion  of  the  large  mononuclear  forms  is  increased 
at  the  expense  of  the  polymorphonuclear  cells.  The  greater  number 
of  these  cases  go  on  to  recovery ;  a  few,  however  without  any  change  in 
the  haematological  condition,  pursue  a  fatal  course. 

(2)  Anaemia  in  which  the  blood  shows  changes  or  alterations  similar 
to  those  common  in  pernicious  anaemia — /.  e.  marked  oligocythsemia ; 
oligochromsemia  relatively  less ;  marked  poikilocytosis ;  nucleated  red 
corpuscles,  for  the  most  part  gigantoblasts  ;  leucocytes,  diminished  in 
number  with  an  increase  often  in  the  small  mononuclear  forms,  and  a 
diminution  in  the  polymorphonuclear  varieties.    These  cases  end  fatally. 

(3)  Anaemia  showing  the  ordinary  characteristics  of  secondary 
anaemia,  excepting  for  the  complete  absence  of  regenerative  forms 
(nucleated  red  corj^uscles).  These  cases  are  progressive  and  fatal,  the 
marrow,  at  autopsy,  showing,  as  has  already  been  stated,  no  evidence  of 
regenerative  activity. 

(4)  Chronic  secondary  anaemiae  occur  in  prolonged  cases  of  malarial 
cachexia,  and  are  remarkable  for  the  small  number  of  nucleated  red 
corpuscles  present  and  the  marked  reduction  in  the  number  of  the  leu- 
cocytes, particularly  of  the  polymorphonuclear  variety.  There  are, 
however,  post-malarial  anaemias  which  do  show  after  the  clearing  up  of 
the  infection  a  leucocytosis  similar  to  that  in  ordinary  secondary  anaemia. 
This  is  probably  a  favorable  sign,  pointing  to  a  rapid  regeneration. 

Malarial  Xephritls. — The  grave  damage  which  the  kidneys  may 
suffer  in  certain  acute  malarial  infections,  either  from  the  direct  action 
of  some  toxin  produced  by  the  haematazoa  or  from  the  presence  in  the 
circulation  of  injurious  substances,  due  indirectly  to  the  action  of  the 
parasite,  is  most  strikingly  brought  to  one's  notice  in  the  intense  acute 
nephritis  which,  as  described  in  a  previous  section,  may  follow  mala- 
rial haemoglobinuria.  The  kidney,  however,  rarely  escapes  a  certain 
amount  of  damage  in  any  severe  malarial  infection.  Thus,  out  of  284 
cases  analyzed  by  Hewetson  and  the  author,  albumin  was  found  in 
nearly  one-half,  while  severe  acute  nephritis  was  present  in  4  instances. 
The  nephritis  following  malarial  fever  is  usually  a  mild  acute,  diffuse 
process  similar  to  that  observed  in  any  infectious  disease.  In  some 
instances,  as  stated  in  the  section   on  malarial  haematuria,  the   course 

^  Loc.  cit. 


SEQUELAE  Ay  J)  COMPLICATIONS.  131 

may  l)i'  rapid  and  fatal  ;  in  the  majority,  however,  the  projrnosis  is 
favoral)le  and  eom|)K'te  reeovery  oeeurs.  It  is  not  impossihU'  tliat,  in 
some  instances,  a  fatal  chronic*  dilfnse  nephritis  may  owe  its  origin  to 
the  malarial  poison  ;  however,  detinite  proof  of  this  is  as  yet  wanting;. 
There  is  nothing  absolutely  characteristic,  clinically  or  pathologically,  in 
these  instances  of  malarial  nephritis. 

Amyloid  De(;knei{AT1()X. — Amyloid  degeneration  is  an  occasional 
.sequel  to  malarial  fever.  Two  cases  were  reported  by  Frericlis,'  and 
several  others  have  recently  been  studied  by  Marchiafava  and  Dignami.- 
These  eases  have  followed  after  a  long  series  of  febrile  attacks,  those 
which  have  been  carefully  studied  having  been  aestivo-autumnal  or 
obstinate  quartan  fever.  The  clinical  symptoms  are  those  of  nephritis 
accompanied  by  an  extremely  ra])id  cachexia,  ending  fatally,  as  a  rule, 
within  several  months.  The  blood  in  these  cases  may  show  the  condi- 
tion first  notetl  by  Ehrlich  as  of  grave  portent — viz.  complete  absence 
of  nucleated  red  corpuscles  and  eosinophilic  cells,  and  reduction  in  the 
number  of  the  leucocytes,  with  an  excess  of  lymphocytes,  while  at 
autopsy  the  marrow  of  the  long  bones  is  found  to  be  entirely  fatty, 
showing  no  evidence  of  an  attempt  at  proper  regeneration. 

Atrophy  of  the  Gastro-ixtestixal  Mucosa. — Pensuti^  has 
reported  a  case  of  extensive  atrophy  of  the  gastro-intestinal  mucosa  fol- 
lowing, apparently,  an  acute  malaria.  Constant  diarrhoea  followed  the 
attack,  resulting  in  great  exhaustion  and  death  from  broncho-pneumonia 
in  three  months.  Though  Baccelli  was  inclined  to  believe  that  the 
change  was  directly  due  to  the  action  of  some  toxic  substance  connected 
with  the  malarial  infection,  the  case  cannot  be  said  to  be  wholly 
convincing. 

Malarial  Hepatitis  ;  Malaria  and  Cirrhotic  Processes. — 
As  has  been  stated  in  the  section  on  Pathological  Anatomy,  many  ob- 
servers insist  upon  the  occurrence  of  a  true  atrophic  cirrhosis  of  the 
liver  as  a  sequel  to  malarial  fever.  There  are  many  reasons  which 
would  lead  us  to  believe  that  this  may,  in  some  instances,  occur,  but 
clinically,  in  this  climate  at  least,  such  cases  are  rarely  met  with.  In 
few  instances  does  one  meet  with  a  true  atropine  cirrhosis  of  the  liver 
in  which  other  important  etiological  factors  have  not  also  been  present. 
Xo.such  case  has  come  under  observation  in  the  Johns  Hopkins  Hos- 
pital in  the  seven  years  since  its  opening.  On  the  other  hand,  chronic 
hepatitis,  resulting  usually  in  an  increase  in  the  size  of  the  liver,  is  com- 
monly observed  in  malarial  cachexia  and  following  repeated  malarial 
infections.  Distinct  clinical  symptoms  due  to  the  hepatic  changes  do 
not  apparently  exist. 

Malarial  Paraly^ses. —  Cerebral  Paralyses. — Various  paralyses 
have  been  described  in  association  with  malaria.  The  diiFerent  forms 
which  may  occur  in  acute  pernicious  malaria  have  already  been  referred 
to.  They  are  usually  transitory,  disappearing  under  treatment,  and  are 
due  probably  to  circulatory  disturbances  induced  mechanically  by  the 
parasites :  they  are  almost  always  cortical  in  nature.  The  nervous 
symptoms  in  acute  malaria  are  more  commonly  irritative  than  paralytic. 

Occasionally  s^nnptoms  suggesting  involvement  of  the  spinal  cord 

^  Loc.  cit.  -  Loc.  cit. 

=•  Qaz.  Med.  di  Roma,  189B,  xix.  12L 


132  MALABTA. 

may  occur.  Several  Italian  observers  have  reported  cases  where  the 
symptoms  strongly  suggested  disseminated  sclerosis.  In  all  these  in- 
stances the  parasites  were  found  in  the  circulating  blood,  and  recovery 
followed  treatment  by  quinine.  In  one  of  Torti's^  cases  there  was^ 
however,  no  fever,  notwithstanding  the  presence  of  active  parasites  in 
the  blood.  In  such  instances  it  is  easy  to  conceive  that  without  exami- 
nation of  the  blood  a  diagnosis  Avould  be  quite  impossible.  DaCosta  ^ 
has  also  reported  a  case  of  paraplegia  with  intention  tremor,  severe 
headaches,  bitemporal  hemianopsia,  and  mental  symptoms,  where  the 
blood  showed  the  gestivo-autumnal  parasites.  Recovery  occurred  under 
quinine.  The  cases  of  "acute  ataxia"  reported  by  Kahler  and  Pick '^ 
were  probably  truly  malarial.  Bastianelli  and  Bignami  ^  have  reported 
a  case  show^ing  symptoms  of  the  so-called  "  electric  chorea  "  or  "  Dubinins 
disease.^'  This  was  associated  with  a  continued  fever,  the  nature  of 
which  was  not,  at  first,  determined.  Examination  of  the  blood  later 
showed  it  to  be  due  to  an  sestivo-autumnal  malarial  infection.  Recovery 
occurred  under  quinine.  They  believed  that  the  process  was  due  ta 
"  lesions  secondary  to  the  cerebral  localization  of  the  parasites." 

All  of  these  processes  coming  on  with  acute  malarial  fever  are  essen- 
tially favorable  in  their  course  if  treatment  be  begun  in  time.  Accord- 
ing to  Boinet  and  Salibert,  however,  permanent  paralyses,  both  cerebral 
and  spinal  in  nature,  may  follow  malarial  fever. 

Cases  of  peripheral  neuritis  following  malarial  fever  have  been, 
reported,  though  definite  proof  that  they  were  malarial  in  origin  has  not 
been  obtained.  From  what  we  know,  however,  of  the  pathogenesis  of 
the  disease,  we  may  readily  believe  that  malarial  fever  as  well  as  other 
acute  infectious  diseases,  may  be  followed  by  acute  degenerative  lesions 
in  the  peripheral  nerves. 

Some  observers  have  believed  that  there  was  some  predisposing  rela- 
tion between  malarial  fever  and  Raynaud's  disease  (symmetrical  gan- 
grene), though  this  is  by  no  means  proven.  Poncet  has  described  a 
retinitis  and  a  retino-ehoroiditis,  due  to  emboli  of  melaniferous  leuco- 
cytes in  the  capillaries. 

Mental  Diseases. — Various  mental  affections  may  follow  malarial 
fever,  just  as  may  be  the  case  with  any  acute  infection.  There  is 
nothing  especially  characteristic  in  these  cases.  Thus,  one  of  our 
instances  of  tertian  malaria  was  followed  by  an  attack  of  paranoia  last- 
ing for  several  months. 

True  Complications  and  Mixed  Infections. — Malaria,  like  any 
other  acute  disease,  is  subject  to  various  complications,  many  of  which 
are  a  result  of  mixed  infections  with  other  pathogenic  agents.  As  stated 
before,  many  of  the  symptoms  caused  by  mixed  infections  were  believed 
by  the  older  observers  to  be  due  directly  to  the  malarial  poison.  Of 
late,  however,  with  our  increased  facilities  for  study  and  appreciation 
of  these  conditions,  it  has  been  recognized  that  in  the  majority  of 
instances  the  complication  is  dependent  upon  a  true  mixed  infection. 

Pulmonary  Complications. — Pneumonia. — As  has  been  stated 

1  Bull.  d.  Soc.  Lane.  d.  Osp.  d.  Roma,  1891,  xi.  217. 

^  International  Clinics,  Philada.,  1891,  iii.  246. 

'^  Beitrdge  z.  Pathologie  u.  Pathologischen  Anatomie  des  Centralnervensystem,  Leipzig,  1879, 

*  Bull.  d.  R.  Aec.  Med.  di  Roma,  1893-94,  Anno  xx.  p.  221. 


SEQUELJE  AND  COMPLICATIONS.  133 

in  an  earlier  section,  many  observers  have  deseribeil  pernicious  levers 
M'hicli  (luring  the  paroxysm  showed  well  marked  pulmonary  symptoms, 
dys[)n(ca,  pain,  htcmoptysis.  These  symptoms,  dependent  probably  u])on 
the  special  localization  of  the  })arasites  in  the  pulmonary  ca])illaries,  are  to 
bo  sharply  distintiuished  from  true  pneumonia,  wiiich  may,  and  not  un- 
fre(piently  does,  complicate  a  malarial  attack.  ^Vgain,  in  certain  instances 
an  ordinary  acute  pneumonia  may  present  an  intermittent  fever  which 
simulates  quite  closely  the  chart  of  intermittent  malarial  fever.  These 
eases,  however,  may  be  readily  recognized  by  the  absence  of  the  ])arasite 
from  the  circulating  blo(  xl.  Such  cases  have  been  descril)ed  by  Wunderlich, 
Jaccoud,  Rcrtrand,  and  Andrew  Clark,  while  Ascoli '  gives  an  excellent 
ciiart.  True  acute  pneumonia  and  malarial  fever  may,  however,  coexist. 
In  these  instances  the  course  of  the  pneumonia  may  be  but  little  in- 
fluenced by  the  coexisting  malarial  fever,  while  in  other  instances  the 
exacerbations  and  remissions  of  temperature  may  be  quite  marked. 
Here  the  ])ulmonary  process  is  a  genuine  croupous  pneumonia,  due,  as 
has  been  shown  by  Marchiafava  and  Guarnieri,-  to  infection  with  the 
diplococcus  lanceolatus.  Its  course  is  quite  uninfluenced  by  the  admin- 
istration of  quinine,  and  its  connection  with  malarial  fever  is  purely 
accidental,  unless,  as  it  may  be  in  some  instances,  a  preceding  malaria 
has  prepared  the  ground  for  the  pneumococcus  infection  by  reducing  the 
vital  forces  of  the  individual.  Pneumonia  occurring  in  individuals  suf- 
fering with  chronic  malarial  cachexia  appears  to  pursue  an  unusually 
malignant  course,  owing,  doubtless,  to  the  reduced  condition  of  the 
patient.  Retarded  resolution  and  "  organization "  of  the  exudate  are 
not  uncommon  in  these  instances  (Ascoli).  Broncho-pneumonia  is  also 
€ceasioually  observed  in  association  with  malaria.  The  infection,  how- 
ever, is  purely  secondary,  in  no  way  directly  related  to  the  malarial 
process. 

Pleurisy. — Certain  observers  have  described  symptoms  in  acute 
pernicious  malaria  suggesting  pleural  involvement  where,  on  autopsy, 
nothing  was  to  be  found.  In  other  instances  pleurisy  and  malarial  fever 
may  coexist,  although  there  is  nothing  whatever  to  show  that  this  pleu- 
risy is  not  an  entirely  separate  process  from  the  malarial  infection. 
There  is  nothing  abnormal  in  the  clinical  or  pathological  course  of 
such  a  pleurisy ;  it  is  uninfluenced  by  the  administration  of  quinine. 
These  cases  are  not  to  be  confounded  with  the  pleural  transudations 
which  may  occur  in  cachectics.    Quinine  has  no  influence  upon  the  process. 

Typhoid  Fever. — The  relations  between  malarial  fever  and  typhoid 
fever  have  been  much  discussed,  and  are  today  probably  more  generally 
misunderstood  in  this  country  than  any  one  point  in  connection  with 
the  febrile  diseases.  Since  the  discovery  of  the  malarial  parasite,  with 
our  modern  means  of  diagnosis,  there  is  no  reason  for  the  existence  of 
any  such  confusion  at  the  present  day.  The  great  similarity'  between 
the  symptoms  in  certain  cases  of  astivo-autumnal  fever  with  typhoid 
fever  has  been  pointed  out  in  earlier  sections.  There  is,  however,  no 
excuse  whatever  for  the  physician  who  today  fails  to  recognize  the 
malarial  nature  of  such  a  fever  after  a  few  days'  observation.  The 
simple  examination  of  the  blood  will  invariably  settle  this  question, 
the  parasite  being  always  present. 

^  Loc.  eit.  ^  Bull.  d.  R.  Ace.  Med.  di  Roma,  xv.  1888-89,  355. 


134  MALARIA. 

Few  are  unfamiliar  with  the  term  so  commonly  employed,  "  typho- 
malarial  fever."  It  was  supposed  that  in  malarious  districts  there  ex- 
isted a  continued  fever  which  depended  upon  the  combined  action  of 
two  poisons,  that  of  malaria  and  that  of  typhoid  fever — true  "  pro- 
portio7iata/'  in  the  sense  of  the  old  Italian  observers.  This  fever  was 
supposed  to  be  markedly  resistant  to  quinine  and  to  betray  its  malarial 
nature  by  the  frequency  with  which  rigors  occurred.  We  know  today 
that  "  typho-malarial  fever  "  as  a  distinct  entity  does  not  exist.  Rigors 
occurring  in  the  course  of  typhoid  fever  are  by  no  means  uncommon^ 
but  are  of  themselves  wholly  insufficient  evidence  on  which  to  base  a 
diagnosis  of  malaria.  We  know,  on  the  other  hand,  that  there  exist^ 
in  this  country  at  least,  no  malarial  fevers  which  resist  for  more  than 
three  or  four  days  the  action  of  quinine.  True  complications  of  typhoid 
fever  and  malaria  may  occur,  but  they  are  rare,  only  one  doubtful  in- 
stance having  been  observed  in  seven  years  in  the  Johns  Hopkins  Hos- 
pital, where  both  typhoid  fever  and  malaria  are,  unfortunately,  very  com- 
mon. Typhoid  fever  may  be  acquired  by  a  patient  suifering  from  acute  or 
chronic  malaria.  A  fresh  malarial  infection  may  break  out  or  a  slumber- 
ing infection  may  come  to  life  again  during  the  course  of  typhoid  fever. 
But  this  condition  is  uncommon,  and  in  no  way  justifies  the  term  typho- 
malarial  fever.  There  is  little  doubt  that  the  enormous  majority  of  cases 
referred  to  today  as  "  typho-malarial "  fever  in  this  country  and  else- 
where are  cases  of  typhoid  fever,  pure  and  simple.  Too  much  stress 
cannot  be  laid  upon  this  point,  for  the  groundless  assumption  that  there 
exists  in  this  country  a  fever  due  to  the  combined  action  of  typhoid  and 
malarial  poison,  pursuing  a  fairly  characteristic  course  and  calling,  from 
its  malarial  nature,  for  the  continued  use  of  quinine,  has  exercised  in 
the  past,  and  is  exercising  today,  an  extremely  injurious  influence  upon 
the  medical  practice  of  this  country.  This  influence  cannot  fail  to  be 
appreciated  by  the  intelligent  observer  who  has  occasion  to  note  the 
quantities  of  quinine  which  are  systematically  administered  to  many 
cases  of  uncomplicated  typhoid  fever  in  various  districts  of  the  United 
States. 

In  the  instances  of  true  mixed  infection  of  typhoid  and  malarial 
fever  the  picture  may  be  most  varied.  If  a  fresh  malarial  attack  or  a 
relapse  break  out  during  the  course  of  typhoid  fever,  well  marked  in- 
dications of  the  paroxysms,  varying  according  to  the  type  of  parasite 
present,  may  be  observed,  as  shown  admirably  by  the  charts  recently 
published  by  Gilman  Thompson. '^  In  these  instances  the  blood  shows 
the  presence  of  the  parasites ;  these,  with  the  symptoms  dependent 
upon  them,  disappear  immediately  after  ordinary  doses  of  quinine.  If^ 
on  the  other  hand,  the  typhoid  fever  develop  in  the  course  of  latent 
or  chronic  malarial  infection,  the  symptoms  on  the  part  of  the  malarial 
parasite  may  be  almost  absent. 

Intestinal  Complications. — The  occurrence  of  diarrhoea,  partic- 
ularly in  children,  during  acute  paroxysms  is  well  known.  The  changes 
produced  by  the  malarial  parasite  in  the  intestine  in  certain  acute  per- 
nicious cases  have  already  been  considered ;  the  acute  choleriform  per- 
nicious paroxysm  is  truly  malarial  in  nature.  There  is  nothing,  how- 
ever, to  show  that  the   more  chronic  dysenteries  and  diarrhoeas  often 

1  IVans.  Ass.  Am.  Phys.,  1894,  110. 


9EQUELM  AND  COMPLICATIONS.  135 

associated  with  cachexia  arc  in  any  way  (Mrcctly  coiuicctcd  with  the 
action  of  the  malarial  poison,  exceptino-  in  so  far  as  this  may  have  pre- 
j)ared  the  oround.  It  is  not  impossible  to  conceive  that  severe  infec- 
tions mii>ht  follow  directly  npon  an  acute  choleriform  attack.  I*artic- 
ularlv  intercstino-  are  several  cases  noted  in  the  medical  clinic  of  the 
Johns  Ho[)kins  Hospital,  where  the  Aina'ba  coli  has  been  found  in  the 
dejecta  of  ])atients  sutfering'  simultaneously  with  acute  malaria  and 
dysentery.  In  all  of  these  instances  the  intestinal  process  might  well 
have  been  directly  ascribed  to  the  malarial  poison.  The  frequency  \\itli 
which  the  Amcx'ba  coli  is  associated  with  tropical  dysenteries  makes  it 
exceedingly  probable  that  many  of  these  post-malarial  intestinal  affec- 
tions in  tropical  climates  maybe  in  reality  due  to  a  mixed  infection  with 
the  two  protozoa,  as  in  oiu'  instances. 

Tuberculosis. — Numerous  observers,  and  particularly  Boudin,'  have 
asserted  that  tuberculosis  was  directly  antagonistic  to  malarial  fever  and 
the  converse.  Boudin  pointed  out  that  tuberculosis  was  rare  in  countries 
where  malaria  existed,  and  that  where  tuberculosis  was  common  malaria 
was  rare.  This  assumption  has  exerted  a  certain  influence  on  the  minds 
of  many.  Experience,  however,  has  shown  that  it  lacks  foundation. 
In  many  of  the  districts  where  malaria  is  common  it  is  true  that  tuber- 
culosis is  unusual,  owing  to  certain  climatic  influences.  In  the  northern 
regions,  where  tuberculosis  is  more  common,  malaria,  as  is  well  known, 
is  relatively  infrecpient.  In  other  regions  we  find  malarial  fever 
and  tuberculosis  side  by  side,  intimately  associated,  occurring,  by  no 
means  infrequently,  in  the  same  patient.  Marchiafava,"'  indeed,  is 
inclined  to  believe  from  his  observations  that  chronic  malaria  is  not  an 
unimportant  predisposing  cause  to  pulmonary  tuberculosis.  It  is,  how- 
ever, really  interesting  that  among  the  614  cases  analyzed  by  Hewetson 
and  the  author  in  not  a  single  instance  was  pulmonary  tuberculosis 
present. 

Other  Infections. — Infection  with  the  other  pathogenic  organisms 
is  not  so  very  rare  ;  thus  the  author  has  observed  furuncidosis,  parotifis, 
toiisillitis,  and  acute  rheumatism,  while  in  one  fatal  case,  admirably  studied 
by  Barker,  there  was  a  general  infection  with  the  Streptococcus  pyogenes. 
Antolisei  and  Laveran  have  observed  cases  of  variola  comjilicated  dur- 
ing convalescence  by  characteristic  malarial  fever,  while  Baccelli  has 
observed  the  same  in  cases  of  other  exanthemata. 

PosT-PARTUM  AND  PosT-oPERATiVE  Malaria. — One  hears  not  in- 
frequently of  post-partum  and  post-operative  malarial  fever,  and  it  is, 
alas  !  only  too  common  today  to  ascribe  elevations  of  temperature  during 
the  first  few  days  after  operation  and  during  the  puerperium  to  malarial 
fever.  This  condition  is  probably  rare.  There  are  few  such  instances  in 
literature  where  the  malarial  nature  of  post-partum  paroxysms  Avas  def- 
initely proven.  In  the  seven  years  since  the  opening  of  the  Johns  Hop- 
kins Hospital  not  a  single  case  of  post-operative  malaria  has  occurred. 
Undoubtedly,  the  reduced  condition  of  the  patient  during  these  periods 
might,  and  probably  does,  favor  a  recrudescence  of  the  latent  malarial 
infection.  It  is,  on  the  other  hand,  probable  that  the  majority  of 
instances  of  supposed  post-partum  and  post-operative  malaria  have  no 

'■  Tmite  des  Fievres  interraittentes,  Paris,  1842. 

''  Bull.  d.  Soc.  Lane.  d.  Osp.  d.  Boma,  1891,  Anno  xv.  180. 


136  3i:alabia. 

connection  whatever  with  true  malarial  fever,  but  represent  simply  a 
septic  infection.  This  has  been  the  case  in  every  instance  of  suspected 
post-operative  malaria  which  has  come  under  the  author's  observation. 
IxsoLATiox. — The  complication  of  an  active  or  chronic  malarial 
fever  with  insolation  is  probably  not  very  uncommon.  Bastianelli  and 
Bignami  '■  have  recently  demonstrated  in  an  interesting  manner  the  fre- 
quency with  which  such  cases  have,  in  Italy,  been  considered  as  essen- 
tially malarial  in  nature.  The  pernicious  malarial  fevers  are  particu- 
larly common  at  the  hottest  season  of  the  year,  while  the  individuals 
most  subjected  to  malarial  infection  are  also  often  those  who  work 
bareheaded  in  the  fields,  exposed  directly  to  the  sun's  rays.  These 
observers  called  attention  to  the  fact  that  a  number  of  instances  of  what 
has  been  considered  pernicious  comatose  malaria  have  been  reported  in 
which,  at  autopsy,  only  cerebral  hyperaemia,  pulmonary  hypostasis,  and 
slight  degenerative  changes  in  other  organs  were  observed.  In  some  of 
these  cases  no  malarial  parasites  were  to  be  found ;  in  others,  evidences 
of  a  recent  infection  ;  in  others,  perhaps  the  evidence  of  a  recent  infec- 
tion with  the  presence  of  a  small  number  of  active  parasites — far  too 
few,  however,  to  account  under  ordinary  circumstances  for  such  grave 
symptoms.  Cases  of  this  nature  have  led  some  observers  to  assume 
that  a  very  small  number  of  parasites  might  give  rise  to  severe  per- 
nicious symptoms,  owing  to  their  excessive  malignancy.  It  is  much 
more  probable,  as  Bastianelli  and  Bignami  state,  that  the  process  repre- 
sents a  complication  of  malarial  fever  with  insolation  which  might  occur 
in  an  individual  with  active  malarial  fever  or  in  one  who  has  recently 
recovered  from  an  attack.  Indeed,  it  is  not  impossible  that  a  preceding 
malarial  infection,  by  reducing  the  strength  of  the  individual,  may 
render  him  more  subject  to  such  attacks. 

Diagnosis. 

(1)  The  Regulaely  Inteemittext  Fevers. — The  diagnosis  of 
the  regularly  intermittent,  tertian,  and  quartan  fevers  is  generally  a  rela- 
tively simple  matter.  The  regular  paroxysms  with  their  three  stages  of 
chill,  fever,  and  sweating  are  so  characteristic  as  to  leave  little  doubt  in 
most  instances  concerning  the  nature  of  the  process.  The  antemia  and 
the  enlarged  spleen  which  are  present  in  the  vast  majority  of  instances 
are  also  important  from  the  point  of  view  of  difPerential  diagnosis.  Occa- 
sionally paroxysms  very  closely  similar  to  the  malarial  access  may 
occur  from  other  infectious  causes,  and  sometimes  the  regularit}^  with 
which  the  individual  paroxysms  may  succeed  one  another  may  lead 
to  errors  in  diagnosis.  The  paroxysms,  however,  in  malaria  diifer  in 
certain  respects  from  those  occurring  in  most  other  acute  infections. 
Thus,  the  average  duration  of  the  malarial  j^aroxysm,  if  we  estimate  the 
course  from  the  time  the  temperature  passes  99°  until  it  again  falls  below 
this  point,  is  from  ten  to  twelve  hours,  while  in  other  infections  the 
course  is  often  materially  shorter.  There  may,  of  course,  be  mild  mala- 
rial paroxysms  which  last  but  four  or  six  hours,  but  in  these  the  tem- 
perature is  correspondingly  moderate.  One  rarely  observes  in  malarial 
fever  temperatures  of  104°,  105°,  or  106°  in  a  paroxysm  lasting  as  short 

i  Bull.  d.  R.  Ace.  Med.  d.  Roma,  1893-94,  Anno  xx.  p.  lol. 


DIAGNOSIS.  137 

a  time  as  six  hours  or  even  less.  The  writer  has  seen  cases  of  septic  in- 
fection in  which,  for  a  considerable  lent^th  of  time,  chills  closely  simu- 
latinu'  those  of  malarial  fever  occurred,  while  the  amomia  and  enlart^ed 
spleen  were  also  ])rescnt.  The  chief  difierence  to  be  noted  was  the 
marked  diiference  in  the  length  of  the  paroxysms,  which  were  some- 
times as  short  as  four  or  live  hours,  the  temperature  reaching,  perhaps, 
within  this  time  a  point  as  high  as  106°.  The  same  may  be  true  of  the 
chills  which  are  not  so  infrequently  seen  during  the  course  of  typh(tid 
fever — chills  caused,  doubtless,  by  auto-intoxications  as  yet  not  under- 
stood. ^^'henever  the  temperature  rises  as  high  as  104°  and  the  ])ar- 
oxysm  lasts  no  longer  than  six  hours,  one  is  justified  in  the  suspicion 
that  the  fever  is  not  malarial  in  origin. 

At  times,  however,  other  infections  may  give  rise  to  paroxysms  most 
closely  simulating  those  of  malarial  fever.  Thus,  in  two  instances  the 
writer  has  observed  typical  quotidian  paroxysms  lasting  from  ten  to 
twelve  hours,  and  beginning  nearly  at  the  same  hour  on  two  successive 
days,  which  were  considered  to  be  malarial  in  nature,  but  which,  upon 
examination,  turned  out  to  be  due  to  acute  otitis  media  (in  one  instance 
due  to  the  diplococcus  lanceolatus). 

The  intermittent  fever  which  is  most  commonly  confused  with  mala- 
ria is  that  associated  with  jmbnonari/  tuberculosis.  It  is  probably  no 
exaggeration  to  say  that  the  majority  of  cases  of  pulmonary  tubercu- 
losis arising  in  the  malarial  districts  of  this  country  are,  at  some  time 
in  their  course,  mistaken  for  malarial  fever.  Intermittent  fever,  recur- 
ring often  at  fairly  regular  hours  on  succeeding  days,  is  the  rule  at  some 
stage,  earlier  or  later,  of  pulmonary  tuberculosis,  while  actual  chills 
may  occur.  It  is  natural  that  the  patient  should  ascribe  such  symp- 
toms to  malaria ;  there  is,  however,  no  excuse  today  for  such  error  on 
the  part  of  the  physician.  The  sallow  color,  the  anaemia,  the  enlarged 
spleen  will  serve  to  distinguish  the  malarial  process  from  the  tuberculo- 
sis, where,  though  the  face  be  pale,  the  lips  and  mucous  membranes  show 
usually  a  good  color,  while  splenic  enlargement  is  rare.  The  examina- 
tion of  the  lungs,  sputa,  and  blood  will  determine  the  diagnosis. 

The  chills  which  often  occur  in  the  course  of  gonorrhoea  or  those 
folloAving  catheterization  or  the  passing  of  sounds  may  be  confused  with 
malarial  fever.  The  urethra  should  always  be  examined  in  doubtful 
cases.  In  some  cases  of  grave  septicfemia  following  gonorrhoea  there 
may  be  little  or  no  evidence  of  an  actual  urethritis.  Here  the  exami- 
nation of  the  blood  will  immediately  settle  the  question.  In  the  one 
instance  ■  there  is  leucoc}i:osis  without  malarial  parasites ;  in  the  other, 
a  normal  or  reduced  number  of  leucocytes  with  the  presence  of  the  ma- 
larial organism.  In  all  these  cases  the  final  decision  must  be  arrived 
at  from  an  examination  of  the  blood.  It  is  through  this  alone  that  a 
positive  diagnosis  of  malarial  fever  can  be  made. 

Method  of  Examixatiox  of  the  Blood. — For  the  satisfactory 
examination  of  the  blood  an  oil-immersion  lens  is  absolutely  necessary. 
No  physician  today  can  consider  himself  equipped  for  practice  without 
a  good  microscope  and  an  oil-immersion  lens.  Though  much  valuable 
work  has  been  done  with  dry  lenses  and  lower  powers,  it  is  folly  to 
attempt  careful  work  without  better  means.  The  simplest  and  best 
method  of  studying  the  malarial  parasite  is  in  the  fresh  blood  at  the 


138  IIALABIA. 

bedside  or  in  the  consulting  room.  The  steps  toward  the  preparation 
of  the  specimen  are  quite  simj^le,  though  certain  precautions  must  be 
rigidly  adhered  to.  The  cover-glasses  and  the  slides  must  be  carefully 
Avashed  in  alcohol  or  alcohol  and  ether  in  order  to  remove  all  fatty  sub- 
stances ;  they  should  always  be  washed  immediately  before  use.  The 
blood  may  be  taken  from  any  part  of  the  patient's  body,  though  the 
lobe  of  the  ear  is  perhaps  preferable,  inasmuch  as  it  is  less  sensitive  and 
more  readily  approached  than  the  finger-tip,  while  a  smaller  puncture 
w^ill  draw  more  blood.  This  method  is  also  more  satisfactory  than  the 
puncture  of  the  finger,  in  that  the  patient  cannot  so  readily  observe  the 
proceeding — a  point  of  considerable  importance  in  nervous  patients  and 
in  children.  The  ear  is  first  thoroughly  cleaned ;  the  lobe  is  then 
punctured  with  a  small  knife  or  lancet.  For  the  most  careful  pro- 
cedures it  is  advisable  to  wash  the  ear  with  soap  and  water,  and  after- 
ward with  the  alcohol  and  ether.  But,  practically,  it  is  often  advisable 
to  make  as  few  preparations  as  possible,  and  unless  the  ear  or  finger  be 
extremely  dirty  one  may  proceed  at  once.  A  pin  or  needle  will,  of 
course,  answer  the  purpose,  but  it  is  well  to  remember  that  a  stab  made 
by  a  round  blunt-pointed  instrument  is  much  more  painful  than  that 
by  a  sharp  cutting  edge,  while  a  considerably  deeper  stab  is  required  to 
draw  a  given  quantity  of  blood.  If  a  very  sharp  spear-pointed  lancet 
be  used,  and  the  lobe  of  the  ear  taken  firmly  between  the  fingers  so  that 
the  skin  is  held  tense,  very  slight  pressure  with  the  tip  of  the  lance 
Avill  cause  an  incision  deep  enough  for  all  purposes.  This  process  is 
almost  without  pain  to  the  patient.  By  proceeding  carefully  blood  may 
often  be  obtained  in  this  manner  from  a  sleeping  infant  without  its 
awakening. 

After  the  first  several  drops  of  blood  have  been  wiped  away  the 
freshly  cleaned  cover-glass  is  taken  in  a  pair  of  forceps  and  allowed 
to  touch  the  tip  of  a  minute  drop  of  blood.  It  is  then  placed  imme- 
diately upon  a  perfectly  clean  slide.  It  is  well,  if  a  third  person  be 
present,  to  allow  the  slide  to  be  vigorously  rubbed  with  a  clean  linen 
cloth  just  before  the  application  of  the  cover-glass.  The  spreading  out 
of  a  drop  of  blood  will  be  thus  considerably  facilitated.  If  the  slide 
and  cover  be  perfectly  clean,  the  blood  will  immediately  spread  out 
between  them,  and,  unless  the  drop  of  blood  be  too  large,  the  corpus- 
cles may  be  seen  lying  side  by  side  entirely  unaltered  in  their  main  cha- 
racteristics. The  drop  of  blood  which  is  taken  should  be  very  small 
unless  the  patient  be  very  anaemic,  and  care  should  also  be  exercised 
that  the  tip  of  the  drop  only  touch  the  cover.  If  the  cover  be  placed 
rudely  against  the  drop  and  pressed  perhaps  also  against  the  ear,  the 
blood  may  so  far  spread  out  that  the  process  of  drying  may  have  begun 
at  the  edge  of  the  drop  before  the  glass  is  laid  upon  the  slide.  If  this 
be  the  case,  the  immediate  spreading  out  of  the  blood  between  the  slide 
and  the  cover  does  not  occur.  Xo  pressure  whatever  should  be  exerted 
upon  the  cover,  which  should  not  be  pushed  or  allowed  to  slide.  The 
specimens  will  remain  in  good  condition  for  a  considerable  length  of 
time,  an  hour  or  more — long  enough  to  be  thoroughly  examined.  I^ 
one  desire  to  observe  the  specimen  for  a  greater  length  of  time,  the  per- 
iphery of  the  glass  may  be  surrounded  by  paraffin  or  vaseline.  In 
this  manner  we  may  see  the  parasites  living  and  in  active  motion,  while 


DIAGNOSIS.  139 

the  most  exquisite  examples  of  phagocytosis  may  be  observed.  By 
enclosing  the  specimen  in  paraffin  or  vaseline  the  preparations  may,  iif' 
handled  carefully,  be  carried  from  the  residence  of  the  patient  to  the 
consulting  room  and  there  examined,  but  under  these  circumstances  one 
must  generally  rely  upon  dried  and  stained  specimens. 

The  preparation  of  specimens  for  staining  is  quite  simple,  re(piiring 
only  a  little  experience  and  practice.  Stained  specimens  are  of  especial 
assistance  in  the  detection  of  the  unpigmeuted  hyaline  bodies,  particu- 
larly the  pale  tertian  forms  and  those  of  the  a^stivo-autumnal  j)arasites. 
A  small  drop  of  blood  flowing  from  the  lobe  of  the  ear  or  the  finger-tip 
is  collected  upon  a  perfectly  clean  cover-glass,  which  is  immediately 
placed  upon  another  glass.  The  drop  of  blood,  if  the  two  covers  be 
perfectly  clean,  spreads  out  immediately  between  the  glasses.  The 
cover-glasses  are  then  drawn  apart.  If  neither  glass  be  lifted  or  tilted 
during  this  process,  they  will  slide  apart  readily  without  sticking.  If 
the  glasses  have  remained  together  so  long  that  they  have  begun  to 
adhere,  one  may  be  sure  that  the  specimen  will  be  no  longer  perfect. 
The  glasses,  thus  prepared,  are  allowed  to  dry  in  the  air,  which  they  do 
usually  in  the  course  of  a  few  seconds,  and  may  then  be  preserved  for 
an  almost  indefinite  length  of  time.  To  prepare  them  for  staining 
the  glasses  should  be  heated  upon  a  copper  bar  or  in  a  thermostat  at  a 
temperature  of  100°  to  120°  C.  for  two  hours,  according  to  the  method 
of  Ehrlich,  or  they  may  be  placed  in  absolute  alcohol  and  ether,  equal 
quantities,  for  two  hours  or  more  (Xikiforov's  method). 

The  malarial  parasite  is  readily  stained  by  most  of  the  basic  nuclear 
dyes.  The  simplest  method  is  perhaps  to  stain  with  a  concentrated 
aqueous  solution  of  methylene  blue  or  Loflei^s  methylene  blue : 

Concentrated  alcoholic  solution  of  methylene  blue,    30  c.c. 
Solution  of  caustic  potash  1  :  10,000  100  " 

In  either  instance,  the  specimens  should  be  stained  for  from  thirtv 
seconds  to  a  minute,  washed  in  w^ater,  dried  between  filter  papers,  and 
mounted  in  oil  or  balsam.  The  red  corpuscles  then  will  be  un- 
stained, wdiile  the  nuclei  of  the  leucocytes  and  parasites  will  be  stained 
a  clear  blue. 

A  contrast  stain  may  be  obtained  by  the  following  method  :  The 
cover-glass  specimen,  after  fixing  in  absolute  alcohol  and  ether  from 
four  to  twenty-four  hours,  is  placed  for  a  few^  seconds  (thirty  seconds  to 
five  minutes)  in  a  0.5  per  cent,  solution  of  eosin  in  60  per  cent,  alcohol, 
washed  in  water,  dried  between  filter  papers,  and  placed  for  from  thirty 
seconds  to  two  minutes  in  a  concentrated  aqueous  solution  of  methylene 
blue,  or  in  Loffler's  methylene  blue,  washed  in  water,  dried  between 
filter  j^apers,  and  mounted  in  Canada  balsam.  The  red  corpuscles  and 
the  eosinophilic  granules  are  stained  by  the  eosin,  while  the  nuclei  of 
the  leucocytes  and  the  parasites  take  a  blue  color. 

Admirable  results  may  be  obtained  by  a  modification  of  JRomanov- 
shy's  method.  Two  solutions  are  necessary — a  saturated  aqueous  solu- 
tion of  methylene  blue  and  a  1  per  cent,  watery  solution  of  eosin. 
The  older  the  methylene  blue  solution  the  better  the  results.  The 
staining  mixture  should  be  made  just  before  it  is  to  be  used.  To 
one  part  of  the  filtered  methylene  blue  solution  about  two  parts  of  the 


140  ■  MALARIA. 

eosin  solution  are  added.  This  is  carefully  stirred  with  a  glass  rod  and 
poured  into  a  watch-glass ;  it  should  not  be  filtered  after  the  mixture 
has  been  made.  The  cover-glasses,  fixed  according  to  the  methods 
above  described  or  by  hardening  in  alcohol  for  from  ten  minutes  up- 
ward, are  allowed  to  float  upon  the  top  of  this  fluid.  The  specimens 
are  covered  by  another  inverted  glass,  and  the  whole  by  an  inverted 
cylinder  which  is  moistened  on  the  inside.  In  from  half  an  hour  to 
three  hours — best  in  two  or  three  hours — good  siDccimens  are  obtained. 

For  quick  work  in  the  consulting  room  the  simple  stain  with  methy- 
lene blue  alone  is  perfectly  satisfactory,  though  the  observer  must  of 
course  have  sufficient  experience  to  be  able  to  distinguish  precipitates 
which  may  be  present  in  the  staining  solution  from  parasites.^ 

The  discovery  of  malarial  parasites  in  the  red  blood-corpuscles  is,  of 
course,  a  positive  sign  of  the  malarial  nature  of  the  process.  In  some 
instances  where  the  parasites  may  be  very  scanty  or  absent  the  presence 
or  absence  of  a  leucocytosis  is  an  important  diagnostic  sign.  As  will 
be  remembered,  the  leucocytes  in  malarial  fever  are  normal  or  dimin- 
ished in  number,  whereas  in  almost  all  processes  wdth  which  the  acute 
intermittent  malarial  fever  may  be  confounded  there  is  a  well  marked 
leucocytosis.  This  is  the  case  in  all  the  septic  infections  which  are  most, 
likely  to  be  confounded  with  tertian  and  quartan  fever ;  it  is  also  true 
of  tuberculosis,  at  least  when  accompanied  by  intermittent  fever.  The 
presence  of  a  marked  leucocytosis  is  strong  presumptive  evidence  against 
the  existence  of  malarial  fever.  In  some  instances  where  very  few 
parasites  are  present  the  finding  of  pigment-bearing  leucocytes  may  be 
an  important  aid  in  diagnosis.  Tertian  and  quartan  infections  where 
multiple  groups  of  parasites  are  present  may  occasionally  be  confounded 
with  typhoid  fever.  Well  marked  remissions  and,  almost  invariably, 
actual  intermissions,  usually  occur,  while  the  examination  of  the  blood 
will  readily  clear  up  the  diagnosis. 

The  differential  diagnosis  between  tertian  and  quartan  infections 
may  be  readily  made  in  the  fresh  specimen,  less  distinctly  in  the 
stained.  The  larger  and  more  actively  amoeboid,  pale  tertian  para- 
site with  fine  brownish,  actively  dancing  pigment  granules  may  be 
readily  distinguished  from  the  smaller,  less  active,  more  refractive  quar- 
tan parasite  with  its  coarser,  more  slowly  moving,  darker  granules.  In 
the  case  of  the  tertian  parasite  the  red  corpuscles  may  be  seen  to  become 
expanded  and  pale  with  the  growth  of  the  organism,  while  in  the  quar- 
tan parasite  the  corpuscle  is  shrunken  and  of  a  deeper,  more  brassy 
color.  If  the  blood  be  examined  just  before  or  during  the  paroxysm, 
the  more  irregularly  segmenting  tertian  organisms  with  their  numerous 
(twelve  to  thirty)  segments  may  be  clearly  distinguished  from  the  smaller 
regular  forms  in  quartan  fever  with  their  fewer  (six  to  twelve)  segments. 
The  presence,  in  either  instance,  of  one  or  more  groups  of  parasites  may 
usually  be  readily  determined.  Combined  infections  with  quartan  and 
tertian  parasites — which,  though  very  rare,  do  exist — may  also  be  readily 
made  out. 

In  the  stained  specimen   the  size  of  the  pigment  and  the  parasite 

^  The  experienced  observer  may  obtain  sufficiently  good  specimens  for  diagnosis  in 
many  instances  by  rapid  heating  of  the  cover-glass  over  the  flame  for  a  few  minutes  ;  the 
results,  however,  are  uncertain. 


DLK.'XOSIS.  141 

and  the  hcliavior  of  tlic  red  (•()r])uscl(',  pale  in  nnv  instance,  taking-  a 
doej)  c'osin  stain  in  the  other,  and  the  charaeteristies  of"  the  se<iinentin<:; 
forms,  shonld  enable  us  also  to  make  a  ditl'erenlial  diat;nosis. 

If  it  be  impossible  to  make  a  mieroseopieal  examinati<jn  of  the 
Idood,  the  therapeutic  test  is  usually  snflieient ;  thus,  in  the  refrularly 
intermittent  fevers  there  is  rarely  any  recurrence  of  the  fever  after 
fortv-eiii'ht  hours  from  tlu'  l)e<iinnin<>-  of  the  administration  of  <|uinine. 
In  the  majttrity  of  instances  of  tertian  infection  in  this  climate  all  traces 
of  fever  disaj)j)ear  within  twenty-four  hours. 

(2)  Thk  ^Estiyo-autumnal  Fevers. — While  the  diajinosis  in  the 
regularly  intermittent  tertian  and  quartan  fevers  is  a  relatively  sim])le 
matter,  the  same  is  not  true  of  the  more  irregular  sestivo-antumnal 
forms  of  malaria.  In  some  instances,  where  the  paroxysms  are  of 
shorter  duration  and  occur  at  regular  intervals,  usually  (juotidian, 
the  diagnosis  may  be  as  self-evident  as  in  the  regularly  intermittent 
fevers.  The  longer  paroxysms,  occurring  at  intervals  of  approxi- 
mately forty-eight  hours  one  from  another,  with  their  less  rapid  rise, 
but  with  a  complete  intermission  between  them,  are  also  generally 
easily  recognized  when  vre  take  into  consideration  the  aniemia,  the  en- 
larged spleen,  and  the  herpes  labialis  which  are  so  commonly  present. 
When,  however,  from  any  of  the  varioiLs  causes  above  mentioned  the 
separate  paroxysms  become  more  or  less  complicated  or  merged  one  with 
another,  so  that  at  first  but  slight  transient  intermissions,  then  perhaps 
only  irregular  remissions,  and  finally  a  continued  high  fever,  result,  the 
diagnosis  becomes  often  more  difficult.  Such  a  case  often  presents  itself 
in  the  form  termed  by  Baccelli  ^'  snhco)itunia  fi/phoidea."  The  general 
clinical  appearances  are  so  similar  to  those  of  typhoid  fever  that  a  dis- 
tinction without  examination  of  the  blood  may  be  quite  impossible.  In 
a  certain  number  of  instances  vestiges  of  the  paroxvsms  still  may  be  made 
out,  a  well  marked  acme  in  the  fever  being  reached  at  approximately  the 
same  hour  at  quotidian  or  tertian  intervals,  though  in  other  instances  all 
traces  of  the  individual  paroxysms  may  have  disappeared.  Sometimes 
the  history  of  several  sharply  intermittent  paroxysms  in  the  beginning 
of  the  illness  may  lead  us  to  a  correct  diagnosis.  Again,  the  prodromal 
symptoms  are  much  less  frequent  and  severe,  as  a  rule,  in  malaria  than 
in  t}"phoid.  Her])es  is  common  in  sestivo-autumnal  malaria,  unusual  in 
typhoid  fever.  Delirium  may  appear  quite  early  in  a  malarial  attack  ;  it  is 
rare  during  the  first  few  days  of  a  typhoid.  Bronchitis  is  more  common 
in  typhoid  than  in  continued  malarial  fever.  Marked  abdominal  syni])- 
toms,  though  they  may  occur,  are  unusual  in  malaria  ;  the  rule  in  typhoid 
fever.  Certain  ervthemata,  and  especially,  urticaria,  may  be  present  in 
malarial  fever,  while  the  characteristic  typhoid  roseola  does  not  occur. 
In  both  instances  the  spleen  is  usually  enlarged.  An  important  diag- 
nostic sign  is  the  anaemia  which  is  almost  invariably  present  if  the  ma- 
larial fever  has  lasted  more  than  a  few  davs,  while  in  t^qjhoid  fever 
anaemia  during  the  first  two  weeks  is  rare.  Another  important  sign  is 
the  slight  icteric  hue  which  is  usually  ]:)resent  in  malaria  ;  rare  in  typhoid. 
Ehrlich's  diazo  reaction  is  unusual  in  the  urine  in  malarial  fever  ;  it  was 
found  in  but  6  per  cent,  of  the  cases  classified  by  Hewetson  and  the 
author,  while  it  is  almost  invariably  present  in  typhoid. 

Here,  however,  as  in  all  other  forms  of  malaria,  the  final  decision 


142  MALABTA. 

is  to  be  reached  only  by  examination  of  the  blood,  where  the  small, 
amoeboid,  and  ring-shaped,  hyaline  sestivo-autumnal  parasites  are  to  be 
found.  If  the  process  has  lasted  a  week  or  more,  the  pigmented  ovoid 
and  crescentic  bodies  are  also  usually  present.  In  rare  instances  quite 
severe  febrile  symptoms  may  be  present,  while  the  peripheral  circulation 
may  at  times  show  but  a  small  number  of  parasites.  Here  the  discovery 
of  pigment-bearing  leucocytes  may  often  be  of  assistance.  The  dimin- 
ished number  of  leucocytes  which  one  finds  under  these  circumstances 
does  not  help  us  in  the  differential  diagnosis  from  typhoid  fever,  where 
also  the  leucocytes  are  almost  invariably  subnormal  in  number.  If  the 
case  occur  in  a  neighborhood  where  it  is  impossible  to  obtain  the  aid  of 
the  microscope,  the  diagnosis  may  be  definitely  made  by  the  therapeutic 
test.  No  malarial  fever  now  known  resists  good  doses  of  quinine  for 
more  than  three  or  four  days.  It  is  generally  safe  to  say  that  if  the 
process  be  malarial  the  temperature  will  be  practically  normal  by  the 
fourth  day.  If  quinine  fails  to  influence  the  fever,  we  may  rest  assured 
that  the  process  is  either  non-malarial  or  a  mixed  infection. 

The  confusion  with  typhus  fever  might  occur  in  some  instances,  but 
here,  again,  the  examination  of  the  blood  will  settle  the  question. 

As  in  the  case  of  the  regularly  intermittent  fevers,  the  process  may 
be  confounded  with  tuberculosis  or  other  various  septic  infections.  The 
one  safe  method  of  differential  diagnosis  is  the  examination  of  the  blood. 

PERisricious  Malaria. — The  diagnosis  in  some  pernicious  paroxysms 
may  be  at  times  confusing. 

Comatose  Pernicious  Fever. — This  type  of  fever  must  be  distinguished 
from  sunstroke,  ursemia,  cerebral  hemorrhage.  The  differentiation  of 
such  an  attack  from  sunstroke  is  by  no  means  simple.  As  Bastianelli 
and  Bignami  have  pointed  out,  individuals  Avho  are  subjected  to  mala- 
rial infection  are  often  those  working  in  the  fields  and  most  exposed  to 
the  rays  of  the  sun  at  the  hottest  season  of  the  year,  while  the  clinical 
symptoms  of  the  two  processes  may  be  closely  similar.  It  is  interesting 
to  note  that  the  case  of  comatose  pernicious  fever  referred  to  above  as 
occurring  in  a  tertian  infection  was  at  first  mistaken  for  sunstroke.  The 
slight  jaundice,  the  anaemia,  the  enlarged  spleen  would  serve  to  sug- 
gest the  malarial  nature  of  the  process,  while  the  examination  of  the 
blood  gives  a  positive  clue  to  the  diagnosis.  In  the  tetanic,  meningeal, 
eclamptic,  and  hemiplegic  types  the  same  symptoms  may  lead  to  a  cor- 
rect diagnosis. 

The  Algid  Type. — In  this  type  of  paroxysm,  where  the  temperature 
may  be  normal  or  subnormal,  and  where  often  (from  the  actual  conden- 
sation of  the  blood)  the  ansemia  may  not  be  as  apparent,  the  diagnosis 
may  be  considerably  in  doubt.  Here,  however,  icterus  and  enlarged 
spleen  are  suggestive,  while  examination  of  the  blood  will  give  posi- 
tive diagnosis.  It  is  in  cases  of  this  nature  that  the  physician  who 
makes  systematic  blood  examinations  in  all  doubtful  cases  will  be 
enabled  at  times  to  gain  information  which  will  save  the  life  of  his 
patient. 

The  Hemorrhagic  Type. — The  diagnosis  in  some  of  the  instances  of 
this  nature  must  be  made  between  malarial  and  yellow  fever.  The  early 
appearance  of  albumin  and  casts  in  yellow  fever  is  suggestive,  while  the 
spleen  is  often  but  little  enlarged  in  this  affection. 


Tho  examination  of  the  blood  may  in  some  cases  be  the  sole  reliable 
niethotl  of  Jitlerentiation, 

Muhii'Ktl  J[(riit<)(/f()hiiiiiri(i. — The  diauiiosis  here  lies  usuallv  l)et\veen 
yellow  fever,  the  ordinary  paroxysmal  Inemoo^lobiniiria,  and  aente 
nephritis  from  some  other  toxic  orit^in.  And  here,  again,  tlie  chief 
reliance  must  be  placed  upon  the  examination  of  the  blood. 

Poiif-jMtrfum  and  Post-operative  Malaria. — A  dia<rnosis  of  these  con- 
ditions can  only  be  made  upon  examination  of  the  blood.  The  malarial 
paroxysms  ditfer  from  the  paroxysm  due  to  se])tic  infection  chietly  by 
their  greater  regularity  and  by  their  average  longer  duration.  The 
blood,  apart  from  the  presence  of  the  specific  parasites  and  pigment, 
shows  in  the  one  instance  diminution  in  the  number  of  leucocytes,  and 
in  the  other  well  marked  leucocytosis. 

Chronic  JLiIarial  Cachexia. — The  diagnosis  of  chronic  malarial 
cachexia  is  usually  relatively  easy.  It  is  chiefly  to  be  confounded  with 
grave  primary  or  secondary  ansemia  or  with  leukaemia  and  pseudo- 
leukjemia.  The  malarial  process  may  usually  be  distinguished  from 
splenic  ansemia  by  the  presence  of  pigment  and  parasites  in  the  blood. 
In  some  instances,  however,  where  these  are  not  to  be  found,  the  en- 
larged spleen,  the  grave  ansemia,  the  hemorrhagic  tendency,  the  drop- 
sical etfusions  present  in  both  conditions  may  render  the  diagnosis 
almost  impossible  without  appealing  to  the  history  of  the  patient.  The 
progress  of  such  cases  under  proper  treatment  is  usually,  however, 
decisive.  The  malarial  cachexia  responds  generally,  slowly  but  progress- 
ively, to  treatment.  Thus,  the  author  has  seen  a  spleen  which  reached 
beyond  the  uml^ilicus  and  almost  to  the  pubes  diminish  under  treatment 
until  it  was  only  just  palpable,  while  the  blood  returned  from  1,()00,000 
red  corpuscles  to  the  cubic  centimetre  to  the  normal  condition,  the 
patient  remaining  in  perfectly  good  health  in  a  non-malarious  district. 
The  diagnosis  from  leukaemia  is  readily  made  by  examination  of  the 
blood. 

Posf-ina/aria!  A  nam  in. — An  absolute  differential  diagnosis  between 
post-malarial  ana?mia  and  some  other  secondary  antemite  is  impossible. 
The  tendency,  however,  in  the  post-malarial  anaemia  to  a  diminution  in 
the  number  of  leucocytes  is  always  marked,  while  a  relative  increase  in 
the  large  mononuclear  elements  is  very  suggestive.  As  has  been  said 
before,  there  is  nothing  characteristic  in  the  nephritis  which  follows 
malarial  fever. 

Other  Complications  and  Mixed  Infections. — In  some  of  the 
mixed  infectious  to  which  reference  has  been  made  above  a  certain 
diagnosis  can  only  be  made  by  the  discovery  of  the  parasites  and  the 
persistence  of  the  complicating  process  after  the  disappearance  of  the 
organisms  under  quinine.  Thus,  the  diagnosis  of  t_i/phoid  fever  may  be 
made  if  the  characteristic  symptoms  continue  after  the  clearing  up  of 
the  complicating  malarial  process. 

In  the  case  of  jmeumonia  the  diagnosis  depends  more  upon  the 
physical  examination,  knowing  as  we  do  that  the  malarial  parasite  is 
of  itself  incapable  of  producing  actual  pneumonic  consolidation.  The 
same  is  true  of  pleurisy. 

The  occurrence  of  diarrhoea  or  dysentery  during  the  active  malarial 
process  may  or  may  not  be  directly  due  to  the  malarial  poison.     The 


144  3IALARIA. 

presence  of  the  Amoeba  coli  in  the  stools  is  evidence  of  a  complicating- 
process,  while  in  other  instances  of  diarrhoea  in  acute  malaria  the  result 
of  the  specific  treatment  must  be  awaited  before  one  can  form  a  definite 
diagnosis. 

Parotitis,  tonsillitis,  acute  rheumatism,  the  exanthemata,  occurring  in 
connection  with  malarial  fever,  may  be  recognized  by  their  usual 
symptoms. 

Prognosis. 

The  Regulw'ly  Intermittent  Fevers.  —  The  prognosis  in  tertian  and 
quartan  fevers  as  for  ultimate  recovery  is  almost  invariably  good.  The 
writer  knows  of  but  one  instance  in  which  actual  pernicious  symptoms 
were  present  in  tertian  or  quartan  infection.  Without  systematic  and 
careful  treatment  relapses  and  grave  cachexia  may,  however,  follow — 
a  cachexia  which  may  well  lay  the  patient  open  to  the  gravest  second- 
ary complicating  processes.  It  is  not  improbable  that  in  certain  of 
these  instances  a  fatal  chronic  nephritis  may  follow  repeated  malarial 
infections. 

JEstivo-autumnal  Fever. — In  ordinary  cases  of  sestivo-autumnal  fever 
which  come  early  under  treatment  the  prognosis  is  perfectly  good.  Treat- 
ment must,  however,  be  more  active  and  longer  carried  out  than  in  the 
regularly  intermittent  fevers.  Imperfectly  treated  cases  are  more  likely 
to  be  followed  by  cachexia  and  grave  post-malarial  anaemia. 

Pernicious  Fevers. — Wherever  pernicious  symptoms  have  developed 
the  prognosis  is  extremely  grave,  and,  unless  active  treatment  be  insti- 
tuted, usually  wholly  unfavorable.  In  a  patient  first  coming  under  obser- 
vation in  a  pernicious  paroxysm  an  entirely  favorable  prognosis  can  never 
be  given  for  at  least  forty-eight  hours  after  the  beginning  of  treatment. 
It  is  always  possible  that  a  single  pernicious  paroxysm  may  be  succeeded, 
despite  treatment,  by  another  upon  the  following  day.  If  active  treat- 
ment has  been  begun  during  a  pernicious  paroxysm  and  no  succeeding 
paroxysm  has  occurred  within  forty-eight  hours,  the  prognosis  is  usually 
favorable. 

Malarial  Hcemoglobinuria. — The  prognosis  here  is  always  extremely 
grave  ;  indeed,  the  dangers  of  a  fatal  outcome  are  not  past  until  several 
days  after  the  complete  disappearance  of  fever  and  of  symptoms  on  the 
part  of  the  urine. 

Chronic  3Ialarial  Cachexia. — In  the  milder  grades  of  chronic  malarial 
cachexia  the  prognosis  is  good  if  the  patient  can  be  compelled  to  adopt 
a  properly  hygienic  life.  In  the  more  severe  grades  recovery  is  ex- 
tremely slow,  and  at  times  almost  impossible,  unless  the  patient  be 
transferred  into  a  more  healthy  region. 

Post-malarial  Ancemia. — The  aneemise  following  malaria  are  often 
extremely  grave.  In  those  instances  where  the  nucleated  red  cor- 
puscles are  scanty  or  absent  and  the  leucocytes  are  diminished  in  num- 
ber, and  in  those  cases  where  the  blood  shows  the  characteristics  of  true 
pernicious  anaemia,  the  prognosis  is  extremely  grave. 

The  prognosis  in  the  various  complications  of  malaria  is  influenced 
only  by  the  possible  unfavorable  effect  of  the  coexisting  malarial  in- 
fection. Secondary  infections  occurring  in  individuals  suffering  from 
malarial  cachexia  appear  to  pursue  an  unusually  unfavorable   course. 


TREATMENT.  145 


Treatment. 


General  Meast^res. — CV-rtain  f»;('iu'ral  liycrionic  measures  arc  advis- 
able, and  sometimes  very  im])«)rtaiit,  in  the  treatment  of"  malarial  fever. 

Jicsf  ill  Bid. — It  is  always  j)riident,  if"  ])ossii)le,  to  ki'ej)  a  ])ati('nt  with 
malarial  fever  in  bed  for  twenty-fonr  or  forty-eight  honrs  ;  in  the  more 
severe  sestivo-autumnal  fevers  it  is  absolutely  necessary.  The  sim|)lcr 
regularly  intermittent  fevers  often  show  a  temporary  and  sometimes 
permanent  s])ontaneous  recovery  following  r<?st  in  bed,  without  further 
treatment.  In  hospital  practice  it  is  our  rule  to  keej)  a  patient  with 
malariii  in  bed  until  the  entire  disappearance  of  fever,  whether  it  be 
intermittent  or  subcontinuous.  It  is  not  impossible  that  the  more  satis- 
factory results  of  hospital  treatment  may,  in  part,  depend  upon  the  fact 
that  the  patients  are  so  much  more  readily  kept  at  rest. 

Change  of  Surrov lid ings. — If  the  patient's  dwelling  be  in  a  malarious 
district,  it  is  always  important,  if  })ossible,  that  the  individual  be  removed 
into  more  healthy  surroundings.  Thus,  recovery  from  chronic  cachexia 
is  greatly  favored  by  the  removal  into  higher,  more  healthy  regions.  In 
some  instances  of  advanced  cachexia  the  removal  may  be  absolutely 
necessary.  In  the  ordinary  acute  malarial  fevers  it  is,  however,  gen- 
erally perfectly  possible  to  treat  the  case  in  the  malarial  district  itself. 
The  patient  should  be  kept,  while  under  treatment,  in  one  of  the  upper 
stories  of  the  house  ;  he  should  be  warned  against  remaining  out  of 
doors  at  night  during  convalescence,  and  prevented,  as  far  as  possible, 
from  subsequent  exposure  to  infection. 

Diet. — In  the  simple  intermittent  fevers  the  patient  may  be  given  an 
ordinary  nourishing  general  diet.  During  the  paroxysms,  which  last  but 
ten  or  twelve  hours  in  all,  the  patient  need  not  be  forced  to  eat ;  it  is, 
however,  generally  "svell  that  liquids,  milk,  broths,  soups,  should  be  taken 
in  small  quantities.  Stimulants  may  be  administered  symptomatically. 
In  the  more  severe  subcontinuous  fevers,  where  there  is  usually  com- 
plete anorexia,  the  patient  may  be  given  liquids  of  all  sorts,  soups,  milk, 
broths,  at  short  intervals  ;  while,  if  he  be  hungry  and  there  be  no  gastro- 
intestinal symptoms,  there  is  no  contraindication  to  soft  solids  and  eggs. 
In  cases  ^¥here  there  are  marked  gastro-intestinal  symptoms  great  care 
must,  of  course,  be  exercised  with  the  diet.  Easily  digested  liquids, 
such  as  boiled  milk,  albumin-water,  and  broths  should  alone  be  given. 

Exposure  to  the  Air. — There  are  districts  where  experience  has  led 
the  inhabitants  to  believe,  probably  justly,  that  exposure  to  the  night 
air  is  injudicious.  It  may  be  unwise  in  such  regions  for  the  ])atient  to 
be  allowed  to  sleep  with  his  window  open.  If,  however,  the  patient  be  in 
a  healthy  district  and  be  accustomed  to  living  and  sleeping  with  open 
windows,  there  is  no  reason  why  a  change  should  be  made  during  the 
existence  of  the  fever.  There  is  no  fever  which  we  know  today  which 
is  unfavorably  influenced  by  fresh  air  and  open  windows,  provided  the 
individual  be  accustomed  to  such  air  beforehand. 

Quixixe. — Malarial  fever  is  one  of  the  few  diseases  against  which 
we  possess  a  remedy  which  truly  deserves  to  be  called  specific.  This 
remedy,  in  the  form  of  cinchona  bark,  was  introduced  into  Europe  in 
1640  by  the  countess  del  Chinchon  (wife  of  del  Chinchon,  the  Spanish 
governor  of  Peru),  who  had  recovered  from  a  severe  attack  of  iutermit- 

VOL.    I.— 10 


146  MALARIA. 

tent  fever  after  taking  a  powder  administered  by  a  corregidor  of  Loxa. 
As  far  as  is  known,  this  snbstauce  was  first  used  by  the  Indians  in  this 
region  as  a  remedy  against  malarial  fever.  The  powder,  which  was 
known  at  first  as  "  the  powder  of  the  countess,"  and  afterward  as 
"  the  Jesuits'  powder "  for  the  reason  that  it  was  introduced  into  gen- 
eral use  by  the  Jesuits  in  Rome  in  1649,  was  prepared  from  the  bark 
of  a  Peruvian  tree.  This  was  for  years  known  as  Peruvian  bark, 
though  its  officinal  name.  Cinchona,  is  derived  from  that  of  its  intro- 
ducer to  the  Eastern  hemisphere.  It  was  at  first  administered  in  the 
form  of  the  pulverized  bark,  the  cinchona  powder,  which  contains,  in 
addition  to  various  alkaloidal  substances,  a  considerable  quantity  of 
tannin.  Today,  however,  the  pulverized  bark  is  no  longer  in  general 
use,  its  place  having  been  taken  by  various  salts  of  its  active  principle, 
quinine. 

Action  of  Quinine  on  the  Malarial  Parasite. — For  centuries  after  the 
introduction  of  quinine  and  after  its  specific  action  in  malarial  fever  had 
been  noted  the  exact  mode  of  action  remained  unknown.  As  long  ago 
as  1867,  Binz^  correctly  concluded  that  the  efficacy  of  quinine  in 
paludism  depended  upon  its  action  as  a  protoplasmic  poison  upon  some 
lower  organism  which  he  assumed  to  be  the  cause  of  the  process.  The 
extremely  toxic  action  of  quinine  upon  the  infusoria  was  at  that  time 
clearly  demonstrated.  Since  the  development  of  our  knowledge  con- 
cerning the  malarial  parasite  it  has  been  possible  to  study,  to  a  certain 
extent,  the  direct  action  of  quinine  upon  the  hsematozoa.  Laveran 
noted  the  immediate  disappearance  of  the  parasites  following  the  ad- 
ministration of  quinine,  and  in  1881  asserted  that  ''  it  is  because  it 
destroys  the  parasite  that  quinine  causes  the  disappearance  of  the  man- 
ifestations of  paludism."  He  showed  that  by  allowing  a  1  :  10,000  solu- 
tion of  quinine  to  run  under  the  cover-glass  the  movements  of  the  para- 
site were  immediately  arrested,  as  they  are  upon  subjecting  the  organism 
to  any  other  protoplasmic  poison. 

Golgi  ^  has  studied  the  action  of  quinine  on  the  tertian  and  quartan 
parasites.  He  noted  that  after  the  administration  of  quinine  the  quar- 
tan organism,  in  its  endoglobular  stage,  shows  a  coarser  granulation  with 
a  metallic  reflex,  while  the  protoplasm  shows  a  certain  cloudiness.  At 
times  one  may  see  abortive  segmenting  forms  which  are  smaller  than 
the  normal,  with  a  lack  of  regularity  and  fewer  segments.  The  pig- 
ment also  may  not  collect  as  sharply  in  a  clump  in  the  middle  of 
the  parasite.  In  the  tertian  parasite  the  changes  are  more  marked, 
owing  to  the  greater  normal  activity  of  the  organism.  The  body  is 
round  and  immovable,  and  shows  a  sharper  outline  than  usual,  while 
the  pigment  has  a  peculiar  metallic  reflex  and  tends  to  collect  in 
clumps.  Full  grown  tertian  forms  may  present  a  large  transparent 
swollen  condition  with  very  active  movements  of  the  pigment  granules. 
Sometimes  the  pigment  may  collect  toward  the  periphery,  leaving  an 
hyaline  space  in  the  middle.  Mannaberg^  asserts  that  three  hours  after 
the  administration  of  0.5  of  quinine  the  amoeboid  forms  of  the  tertian 
parasite  show  a  marked  diminution  in  their  activity.  In  several  hours 
more  the  number  has  greatly  diminished,  while  many  of  those  present 

1  Centralblatt  f.  d.  med.  Wiss.,  1867,  p.  308. 

2  Deutsch.  med.  WocL,  1892,  661,  695,  707,  729.  ^  Loc.  cit. 


TREATMENT.  147 

ari'  tratiincntcd,  resiiltin<:;  in  the  presence  ot"  several  sej)arat('  spherules 
in  the  red  corpuscle.  Full  tii'own  forms  show  a  cessation  ot"  the  niove- 
nieiits  of  the  pi<;-nient,  the  body  havin<r  a  somewhat  retractive  homoge- 
neous appearance.  Lar<;e  hydropic  forms  with  active  pi<;ment  may  also 
be  seen.  These  two  latter  forms  may  occur  normally  during  the  par- 
oxysm, as  Golo;i  and  Mannabcrg  also  assert ;  they  are  probably  degen- 
erate forms.  The  writer  has  also  observed  in  the  case  of  the  tertian 
])arasite  the  somewhat  greater  refractiveness  of  the  organism,  the  col- 
lection of  the  j)igment  into  clumps,  and  the  cessation  of  active  move- 
ments, as  well  as  the  presence  (jf  a  greater  number  of  fragmenting  forms 

Romanovsky '  and  Mannaberg-  have  made  interesting  studies  with 
.stained  specimens.  Both  observers  note  the  loss  of  affinity  for  coloring 
matters  in  the  chromatin  substance  of  the  nucleus.  They  also  note  that 
in  the  segmenting  forms,  after  quinine  has  been  given,  the  greater 
number  of  the  segments  show  no  nucleoli.  These  changes  in  the 
nucleus  they  believe  to  be  evidence  of  a  necrotic  process.  The  segments 
without  nucleus  Mannaberg  terms  "  still-born."  Baccelli  ^  noted  that  in 
«estivo-autumnal  fever  after  the  intravenous  injection  of  quinine  there 
was  an  increase  in  the  activity  of  the  small  amceboid  forms,  which,  often 
inside  of  twenty-four  hours,  disappeared  without  showing  any  outward 
.signs  of  degeneration.  Marchiafava  and  Bignami/  studying  the  sestivo- 
autumnal  fevers,  note  that  the  administration  of  quinine  is  followed  by 
an  increase  in  niuuber  of  shrunken,  brassy  colored  corpuscles.  They 
believe  that  the  included  parasites  are  incapable  of  further  develop- 
ment. 

Most  observers  who  have  been  able  to  test  the  action  of  quinine  upon 
the  malarial  parasite  will  agree  with  Golgi  that  in  tertian  and  quartan 
fever  quinine  acts  most  markedly  on  the  free  young  segments,  less  upon 
the  more  advanced  forms  where  the  red  corpuscle  is  in  greater  part  de- 
stroyed, and  least  upon  the  young  endoglobular  forms.  If  quinine  be 
given  several  hours  before  the  paroxysm,  it  will  not  prevent  segmenta- 
tion, but  it  will  destroy  the  new  group  of  parasites,  the  fresh  segments. 
Segmentation  takes  place,  toxic  sul^stances  are  produced  and  enter  into 
the  blood  serum,  and  the  chill  follows,  being  at  most  a  little  modified  or 
retarded.  The  further  development  of  the  new  group  of  organisms  is, 
however,  prevented,  and  on  the  following  day  no  parasites  whatever 
may  be  observed.  Marchiafava  and  Bignami  '^  arrive  at  the  same  conclu- 
sion in  the  case  of  the  sestivo-autumnal  parasite.  They  state  ''  that  the 
maximum  and  most  rapid  action  of  the  remedy  is  exercised  on  that 
phase  of  the  extraglobular  life  of  the  parasite  which  follows  the  com- 
pleted segmentation."  They  note,  as  does  Golgi  in  the  case  of  the  ter- 
tian and  quartan  organisms,  that  the  segmentation  cannot  be  prevented 
if  quinine  be  given  when  the  parasite  has  reached  the  preparatory  stages. 
*'  Quinine,"  they  say,  "  acts  on  the  amceV)a  of  malaria  during  those 
phases  of  its  life  in  which  it  absorbs  nourishment  and  develops  ;  when 
the  nutritive  activity  comes  to  an  end,  the  transformation  of  haemoglobin 
into  black  pigment  having  been  accomplished,  and  the  phase  of  repro- 
duction begins,  then  quinine  becomes  inefficacious  against  this  process." 

1  Cent,  fur  Backt.,  1892,  xi.  Nos.  6  and  7,  219  ;  and  Si.  Pet.  med.  Woch.,  1891,  Xos.  34 
and  35.  ^  Loc.  at.,  and  Cent,  fur  klin.  Mecl,  1891,  No.  27. 

3  Deutsch.  med.  Woch.,  1892,  No.  32,  721.  *  Loc.  cit.  »  Loc.  cit. 


148  MALABIA. 

To  best  combat  the  further  development  of  a  group  of  malarial  parasites 
quinine  should  be  in  solution  in  the  blood  at  the  time  of  the  setting-  free 
of  the  fresh  parasites — i.  e.  during  and  several  hours  before  the  parox- 
ysm. In  ordinary  tertian  or  quartan  fevers,  Avith  moderate  regular  daily 
doses  of  quinine,  the  parasites  will  usually  wholly  disappear  from  the 
peripheral  circulation  inside  of  three  days.  In  sestivo-autumnal  fever 
the  time  may  be  a  little  longer.  All  observers  agree  that  the  crescentie 
bodies  are  affected  slowly  if  at  all  by  quinine ;  they  remain  in  the  blood 
long  after  all  other  forms  of  the  parasite  have  disappeared. 

Effects  of  Quinine  upon  the  Human  Being. — In  small  doses,  such  as 
are  ordinarily  required  therapeutically,  quinine  causes  no  subjective 
symptoms.  In  somewhat  larger  doses,  however,  it  produces  at  times  a 
ringing  in  the  ears,  roaring  or  sometimes  tinkling  noises,  and,  finally,, 
more  or  less  deafness.  Larger  doses  are  followed  by  a  dimming  of  the 
vision,  even  to  complete  blindness.  Einger  has  noted  that  this  may 
sometimes  begin  in  one  eye,  and,  indeed,  exist  for  considerable  time 
upon  one  side  alone.  The  pupil  is  usually  dilated.  In  larger  doses  a 
severe  frontal  headache,  with  giddiness  and  staggering  gait,  delirium,, 
and  great  muscular  weakness,  may  follow,  and,  finally,  in  still  larger 
doses,  convulsions  and  death.  At  times  large  doses  of  quinine  are  fol- 
lowed by  certain  cutaneous  disturbances.  Einger  describes  an  intense 
general  erythema  similar  to  a  scarlet  fever  rash  and  followed  also  by 
desquamation.     Urticaria  also  at  times  occurs. 

Manner  in  tckich  Quinine  should  be  Given. — Like  another  commonly 
used  and  extremely  valuable  drug,  digitalis,  qainine,  which  is  our  main 
stay  in  malarial  processes,  is  very  frequently  abused.  Laveran  well 
says  :  "  In  a  general  w^ay  it  may  be  said  that  in  malarial  districts  far  too 
much  sulphate  of  quinine  is  given  to  patients  who  have  no  need  of  it, 
while  a  sufficient  quantity  is  not  given  to  patients  suifering  from 
paludism."  The  very  degree  of  its  efficacy,  as  in  the  case  of  mercury 
and  iodide  of  potassium  in  syphilis,  is  probably  accountable  for  the  lax 
manner  in  which  it  is  frequently  given.  When  one  or  two  doses  are 
followed  by  a  complete  disappearance  of  symptoms,  the  immediate  relief 
is  so  great  that  the  patient  fails  to  recognize  the  importance  of  continued 
treatment,  and,  by  abandoning  the  regular  regime,  lays  himself  open  to. 
repeated  relapses. 

It  is  of  considerable  importance  to  determine  in  an  individual  case 
how  and  in  what  form  quinine  should  be  given.  The  following  tables,. 
taken  from  Laveran,  show  the  percentage  of  quinine  which  the  different 
salts  contain,  as  well  as  their  relative  solubility  : 

Salts  of  Quinine  classified  according  to  the  Percentage  of  the  Alkaloid 

vhich  they  contain. 

Quinine. 

100  parts  of  the  basic   muriate  of  quinine   contain 81.71  per  cent. 

"         "  neutral     "  "  "        81.61  " 

"         "         basiclactate  "  "        78.26         " 

"         "  "      bvdrobromate     "  "        76.60         " 

"         "  "     sulphate  "  "        74.31         " 

"         "  "     sulphovinate      "  "        72.16         " 

"         "         neutral  lactate  "  "        62.30         " 

"         "  "      bvdrobromate    "  "        60.67  " 

"         "  "      sulphate  "  "       59.12         " 

"         "  "      sulphovinate      "  "       56.25         "• 


TREAT  Mi: ST.  149 

tSalh  of  Quinine  classified  according  to  their  Solubility  in  Water  {Regnauld 

and  VUlejcan). 

Water. 

J  part  1)1'  llic  iK'Utral  liydrocliloratf  i)f  ([iiinine  is  soluble  in 0.96 

'•       "  "       sulplioviuate         "  "  "  0.70 

"       "  "       lactate  "  "  "  2. 

"       "        basic      sulphovinate         "  "  "  3.30 

"       "        neutral  hvdrobnunate       "  "  "  6.33 

"       "  "       sulpliat*.'  "  "  "  9.00 

"       "        basic      lactate  "  "  "  10.29 

"       "  "       hvilrochlorate       "  "  "  21.40 

"       "  "       hvdrobromate       "  "  "  45.02 

"       "  "       sulphate  "  "  "  581.00 

The  ordinarv  method  of  administering  quinine  is  by  the  mouth  ;  the 
i^ommon  form  in  which  it  is  given  in  this  and  most  countries  is  as  the 
^dphatc.  The  sulphate  of  quinine  is  very  slightly  soluble  in  water,  but 
quite  readily  .soluble  in  dilute  acids.  The  best  manner  to  administer 
this  form  of  quinine  is  in  water  containing  a  sufficient  quantity  of  dilute 
hydrochloric  or  sulphuric  acid  to  hold  the  salt  in  solution.^  The  ex- 
tremely bitter  taste  is  sometimes  an  objection  in  sensitive  patients  :  this, 
in  the  case  of  the  cj[uinine  powder,  may  be  partly  obviated  by  mixing 
Avith  an  equal  quantity  of  powdered  ginger.  The  drug  may  also  be 
administered  in  the  form  of  pills  or  in  capsules.  Quinine  pills  are  con- 
venient, but  are  open  to  the  common  objection  that  in  many  instances 
the  commercial  pill  is  an  highly  insoluble  object.  Thus,  it  is  not  at  all 
infrequent  in  dispensary  practice  for  the  physician  to  be  consulted 
by  patients  with  simple  intermittent  fever  who  have  taken  quinine  pills  ^ 
without  effect,  while  the  solution  or  the  powder  has  an  immediate  result. 
For  more  rapid  action  the  quinine  may  be  administered  hypodermically 
oi',  according  to  the  method  of  Baccelli,  intravenously.  For  these  pur- 
poses more  soluble  salts  than  the  sulphate  must  be  used.  Thus,  for 
subcutaneous  use  the  neutral  hydrochlorate  of  quinine  is  an  excellent 
salt.     De  Beurmann  and  Yillejean  ^  use  the  following  formula  : 

R.  Bihydrochlorate  of  cpiinine,  5. 

Distilled  water,  q.s.  ad  10. 

1  c.c.  (TTLxv)  of  this  solution  contains  0.5  (gr.  vijss)  quinine. 

If  the  hydrochlorate  of  quinine  is  not  to  be  obtained,  one  may  make 
use  of  the  ordinary  sulphate,  as  follows  : 

^:.  Sulphate  of  quinine,  1. 

Tartaric  acid,  0.5 

Distilled  water,  10. 

The  officinal  bisulphate  of  quini)ie  is  soluble  in  about  9  or  10  parts 
of  water,  and  may  be  used  hypodermically  if  a  more  soluble  salt  cannot 
be  obtained. 

'  The  druggist  customarily  adds  about  1  drop  of  the  dilute  acid  to  1  grain  (0.65)  of  the 
salt. 

-  My  colleague,  Dr.  L.  F.  Barker,  has  actually  observed  the  discharge  of  well  preserved 
quinine  pills  from  faecal  fistulse  in  three  instances. 

^  Quoted  from  Laveran,  Du  Paludisme,  etc. 


150  MALARIA. 

Baccelli  ^  uses,  as  an  intravenous  injection,  the  following  mixture^ 
which  he  has  found  to  act  with  the  greatest  rapidity  and  the  most 
marked  eifect : 

I^.  Quiuinse  hydrochloratis,  1.0 

Sodii  chloridi,  0.075 

Aquse  destillatse,  10.0 

The  solution  is  perfectly  clear  and  should  be  injected  lukewarm.  The 
procedure  is  described  by  Baccelli  as  follows  :  "  After  the  veins  of  the 
forearm  have  been  made  turgescent  by  means  of  a  circular  tourniquet 
above  the  elbow,  we  introduce  a  Pravaz  needle  in  a  direction  from  below 
upAvard  into  the  lumen  of  the  vein.  We  select  a  small  one  in  order  to 
avoid  hemorrhage  afterward.  Generally,  we  are  accustomed  to  select 
one  situated  upon  the  flexor  side  of  the  forearm.  The  syringe  holds  5 
c.c,  and  is  filled  according  to  the  dose  which  is  to  be  given,  and  con- 
nected with  the  needle  before  its  introduction."  The  most  rigid  anti- 
sepsis must  be  observed.  The  stab  wound  is  closed  with  collodion  after 
the  needle  has  been  withdrawn. 

The  bimuriate  of  quinine  and  urea,  which  contains  nearly  80  per  cent, 
of  quinine  and  is  soluble  in  less  than  its  own  bulk  of  water,  is  another 
convenient  form  in  which  to  administer  the  drug. 

The  hypodermic  use  of  quinine  is  attended  by  considerable  pain  and 
real  danger  of  a  subsequent  abscess  or  necrosis.  If  the  solution  and  the 
instruments  be  carefully  sterilized,  there  is  little  danger  of  abscess,  but 
at  times  a  considerable  area  of  necrosis  may  result.  It  is  always  import- 
ant to  introduce  the  needle  well  into  the  subcutaneous  tissue  ;  if  this 
be  neglected  and  the  solution  be  introduced  into  the  deeper  part  of  the 
cutis,  necrosis  usually  follows.  Quinine  may  be  given  by  rectum ;  this 
is,  however,  a  last  resort,  and  is  practically  never  necessary  excepting,  at 
times,  in  children. 

2'he  Time  at  which  Quinine  should  be  Given. — If  one  but  remember 
the  studies  of  Laveran,  Golgi,  Mannaberg,  and  others  concerning  the 
eifect  of  quinine  upon  the  parasite,  and  then  consider  the  close  rela- 
tion between  the  development  of  the  parasite  and  the  symptoms  of  the 
malarial  infection,  one  may  readily  perceive  the  time  at  which,  theo- 
retically, the  drug  should  be  best  administered.  Inasmuch  as  it  has  been 
shown  that  quinine  acts  most  effectually  upon  the  young  extracorpus- 
cular  parasite,  it  would  seem  fair  to  conclude  that  the  period  just  before 
or  during  the  paroxysm  should  be  that  at  which  quinine  might  be  ad- 
ministered with  most  eifect,  and,  as  has  been  clearly  shown,  this  is  the 
case.  A  dose  of  quinine  shortly  before  a  paroxysm  in  the  regularly 
intermittent  fevers  will  not  affect  that  paroxysm,  but  will  prevent  a 
recurrence  of  the  succeeding  one  dependent  upon  that  group  of  organ- 
isms. Thus,  a  single  moderate  dose  of  quinine  given  just  before  or 
during  a  paroxysm  in  single  tertian  or  quartan  infection  will  cause 
generally  a  total  disappearance  of  the  symptoms,  while  in  the  case  of 
a  double  tertian  infection  it  may  often  be  seen  to  change  the  type  of  the 
fever  from  quotidian  to  tertian.  Thus,  in  such  an  instance  the  par- 
oxysm expected  upon  the  following  day  will  occur,  but  that  expected 

^  Studien  vher  Malaria,  Berlin,  1895. 


TREATMEST.  151 

in  forty-cii^lit  hmirs  will  not  :ij)|)(':ir,  the  oivator  part  of  tlic  <ironj)  of 
parasitos  Iiavinu-  been  destroyed.  The  same  has  been  shown  to  be  true 
in  sestivo-antuinnal  fever,  thoui;h  the  parasites  are  nnieh  more  resistant 
to  the  action  of  quinine  than  those  of  tlie  regularly  intermittent  fevers. 
Admhiidfation  of  Quinine,  in  the  Begidarly  Intermittent  Fevers. — Here 
it  is  generally  best  to  place  the  patient  upon  regular  eontinued  treatment 
with  (piinine.  If  it  be  ])ossible  to  keej)  tlie  patient  in  bed,  vei'v  small 
doses  will  often  be  sultieient.  Thus,  ().0(j5  (gr.  j)  three  times  a  day  will, 
in  many  instances,  be  followed  by  a  disappearanee  of  the  symptoms.  In 
practice  we  may  give,  according  to  the  severity  of  the  case,  from  0.13  to 
0.325  (gr.  ij-gr.  v)  three  times  a  day.  If  in  tertian  fever  the  patient  be 
seen  on  the  day  between  the  paroxysms,  0.325  (gr.  v),  three  times  a  day 
will  generally,  if  the  patient  be  confined  to  bed,  ])revent  even  any  suc- 
ceeding paroxysm.  One  may  predict,  almost  with  certainty,  the  entire 
disappearance  of  the  fever  after  this.  If  the  patient  be  seen  first  just 
before  an  expected  paroxysm  or  during  the  attack,  it  may  be  well  to 
give  a  single  large  dose,  0.325-0.65  (gr.  v-gr.  x),  and  follow  this  by 
smaller  doses,  0.13  (gr.  ij),  three  times  a  day.  If  the  paroxysms  have 
been  severe,  it  is  sometimes  wise  to  give  large  closes  of  the  drug  (0.325- 
0.(35  (gr.  v-gr.  x) )  during  the  first  days  of  treatment  at  the  hour  when 
without  treatment  the  paroxysm  might  have  been  expected.  The  para- 
sites in  tertian  and  quartan  infections  disappear  from  the  blood  generally 
within  three  days,  but  treatment  with  small  doses,  0.4  (gr.  vj),  in  twenty- 
four  hours  should  be  continued  for  at  least  three  weeks. 

^Estico-autionnal  Fevers. — In  the  treatment  of  sestivo-autumnal  fever 
larger  quantities  of  quinine  must,  as  a  rule,  be  given.  In  ordinary  cases 
where  no  pernicious  symptoms  have  developed  one  may  start  treat- 
ment with  0.325  (gr.  v)  every  four  hours.  In  most  cases  under  such 
treatment  fever  will  entirely  disappear  inside  of  three  days.  If  symp- 
toms of  cinchonism  develop,  the  dose  may  be  reduced.  If  the  patient 
come  under  observation  during  a  paroxysm,  or  if  the  history  be  obtained 
of  a  severe  paroxysm  having  recently  occurred,  it  may  be  Avell  to  begin 
with  larger  single  doses.  Thus,  during  or  just  before  a  paroxysm  0.65 
(gr.  x)  may  be  administered,  followed  by  0.325  (gr.  v)  every  four  hours. 
If  severe  nervous  manifestations  accompany  the  paroxysm  and  the  de- 
velopment of  pernicious  symptoms  be  feared,  it  may  be  well  to  adminis- 
ter the  quinine  hypodermically  or  intravenously.  It  is  rarely  necessary 
to  give  doses  larger  than  1.0  (gr.  xv).  It  may  rarely  be  necessary  to 
give  several  doses  of  this  size  at  intervals  of  several  hours  during  a  long- 
continued  paroxysm  ;  usually  two  or  three  doses  at  intervals  of  four 
hours  are  sufficient,  while  afterward  it  will  be  possible  to  give  smaller 
quantities  (0.325)  every  four  hours.  Such  doses  will  usually  prevent 
the  recurrence  of  a  paroxysm  due  to  this  group  of  parasites.  It  is, 
however,  possible  that  a  second  large  group  of  parasites,  which  all 
treatment  has  failed  to  influence,  may  on  the  following  day  produce  a 
fatal  paroxysm.  The  same  course  should  be  pursued  during  the  suc- 
ceeding paroxysm.  It  has  long  been  a  well  recognized  fact  in  malari- 
ous districts  that  if  the  patient  survive  the  second  paroxysm  after  the 
beginning  of  treatment,  ultimate  recovery  is  usually  assured.  In  true 
pernicious  paroxysms  the  experience  of  Baccelli  would  seem  to  show 
that  intravenous  injections   of  quinine  are   by  far  the  most  efficacious. 


152  MALARIA. 

Baccelli  has  used  successfully  the  solution  of  quinine  described  on 
page  150.  It  is  apparently  unnecessary  to  use  doses  larger  than  1.0 
(gr.  xv). 

Malarial  Hcemoglobinuria. — The  same  general  rules  which  apply 
to  the  treatment  of  the  other  pernicious  fevers  hold  good  in  the  case 
of  malarial  hsemoglobinuria.  It  should,  however,  be  noted  that  cer- 
tain observers  believe  that  large  doses  of  quinine  exert  a  distinctly 
injurious  influence  upon  the  blood,  aggravating  often  the  destruction 
of  the  red  corpuscles.  Thus,  Plehn  ^  in  a  recent  article  goes  so  far  as 
to  advise  an  expectant  treatment  in  these  cases,  asserting  that  recovery 
is  more  likely  to  result  under  careful  nursing  and  general  treatment 
than  under  the  administration  of  quinine.  This  view  is  not  held  by 
the  majority  of  observers. 

CiNCHONiSM. —  Contraindications  to  Quinine. — There  is  a  great  dif- 
ference in  the  susceptibility  of  different  individuals  to  quinine.  Rela- 
tively small  doses  produce  cinchonism  in  some  individuals,  while  others 
are  extremely  tolerant  of  the  drug.  In  the  majority  of  instances,  how- 
ever, in  which  complaint  is  made  it  is  based  upon  the  fact  that  the  drug 
has  been  administered  in  injudiciously  large  doses.  The  writer  has 
never  observed  but  one  case  in  which  it  was  impossible  to  administer 
quinine  in  sufficient  doses  to  combat  ordinary  malarial  manifestations 
without  serious  symptoms.  In  this  instance,  occurring  in  a  colleague, 
the  symptoms  produced  by  quinine  or  other  cinchona  derivatives  are 
interesting  enough  to  mention  here.  After  taking  0.13  (gr.  ij)  of  the  sul- 
phate of  quinine,  in  half  an  hour  the  patient  had  a  feeling  of  oppression 
in  the  epigastrium,  followed  by  nausea,  vomiting,  and  then  soon  by  "  a 
hot  prickling  sensation  over  the  entire  skin."  On  one  occasion,  without 
extreme  itching,  there  was  an  intense  scarlatinoid  erythema,  lasting  for 
hours  and  followed  by  desquamation ;  on  another  occasion,  after  0.195 
(gr.  iij)  of  salicylate  of  cinchonidia,  a  most  intense  general  urticaria. 
Cases  of  this  nature  are  extremely  rare,  and  there  are  few  in- 
stances probably  in  which  individual  susceptibility  is  any  true  contra- 
indication to  the  administration  of  quinine  in  malarial  fever.  The 
prejudice  against  the  drug  is  very  strong  in  the  mind  of  some  in- 
dividuals, and  it  is  not  infrequently  wise  for  the  physician  to  intro- 
duce quinine  in  a  form  unfamiliar  to  the  patient. 

Other  Cinchona  Derivatives. — Various  other  cinchona  deriva- 
tives have  been  used  as  substitutes  for  quinine  in  the  treatment  of 
malarial  fever.  Thus,  einchonin,  cinchonidin,  quinidin,  and  quinoidin 
have  been  recommended.  The  efficacy  of  these  drugs  is,  however,  so 
far  below  that  of  the  various  salts  of  quinine  that  their  employment  is 
inadvisable. 

Methylene  Blue. — Next  to  quinine,  the  most  valuable  remedy 
in  malarial  fever  is,  probably,  methylene  blue.  This  substance  was  first 
employed  in  1891  by  Gutmann  and  Ehrlich,^  who  were  led  to  its  use  by 
the  observation  of  Celli  and  Guarnieri  that  the  malarial  parasites  were 
stained  while  yet  living  by  this  substance.  They  found  that  in  small 
doses  quite  a  marked  eifect  was  obtained  in  several  cases  of  intermittent 
fever.  Since  this  time  the  drug  has  been  used  by  a  number  of  different 
observers,  most  of  whom  agree  in  the  conclusion  that  methylene  blue 

^  Loc.  cit.  ^  Berliner  klin.  Woch.,  189L 


TREATMENT.  153 

])()ss('sses  a  well  marked  antimalarial  action,  the  ])arasitos  often  (lisa])- 
j)earing  from  the  hlood  and  the  patient  reeoverino-  after  its  administi-a- 
tion.  As  an  antimalarial  aucnt  it  is,  however,  as  the  observations  of  the 
author'  have  shown,  far  behjw  quinine  in  ettieieney,  while  the  parasite 
acquires,  apparently,  a  certain  tolerance  to  the  dru^  after  its  continued 
use.  In  certain  mild  cases  of  the  regularly  intermittent  fevers  it  maybe 
^iven  in  doses  of  0.13  every  four  hours  in  capsnk',  with  j)(»ssibly  a  cura- 
tive eflect.  Larger  doses  have  been  given  without  ill  elfect — doses  as 
high  as  3.0  (gr.  xlv)  in  twenty-four  hours.  The  only  unpleasant  symptom 
following  its  use  is,  apparently,  strangury,  which  may  be  prevented  by 
the  administration  of  small  quantities  of  ])owdered  nutmeg  at  the  same 
time.  After  ingestion  of  methylene  blue  the  urine  has  a  dee})  blue  color  ; 
the  fcPces  become  blue  on  exposure  to  the  air.  AVhile  in  certain  instances 
methylene  blue  may  have  a  curative  elfect,  it  is  so  far  inferior  to  quinine 
that  its  value  is  certainly  extremely  limited. 

Fhexocoll. — Within  the  last  few  years  several  Italian  observers 
have  reported  moderate  successes  from  the  treatment  of  malarial  fever 
with  the  hydrochlorate  or  acetate  of  phenocoll,  a  derivative  of  phenace- 
tin.  It  may  be  given  in  doses  of  1.0  (gr.  xv).  It  has  been  prescribed 
in  the  treatment  of  malaria  in  children. 

Other  Remedies. — A  large  number  of  other  di'ugs  have  been  at 
one  time  and  another  employed  in  the  treatment  of  paludism.  Thus 
iodine,  strychnine,  sulphur,  arsenic,  alum,  preparations  of  eucalyptus 
and  helianthus  have  been  recommended.  AVith  the  exception  of  arsenic, 
which,  as  will  be  said,  is  often  of  use  in  anaemia  and  chronic  cachexia, 
the  value  of  these  substances  is  slight. 

Further  Treatment. — Besides  the  treatment  with  the  specific 
drug,  certain  accessory  and  symptomatic  measures  are  often  important. 
The  value  of  purgation  has  long  been  insisted  upon,  and  the  old  custom 
of  beginning  the  treatment  of  malarial  fever  by  administering  a  mercu- 
rial purge  is  probably  in  some  instances  of  value.  In  cases  where  there 
are  grave  intestinal  symptoms  it  should  be  avoided.  Profuse  vomiting 
or  purging  during  a  paroxysm  should  be  controlled,  as  far  as  possible, 
by  morphia  administered  hypodermically.  Excitement  and  active  de- 
lirium during  the  fever  may  also  at  times  require  the  use  of  morphia. 
In  the  collapse  in  pernicious  fevers  most  active  stimulation  must  at 
times  be  resorted  to  ;  alcohol,  strychnia,  and  ether  may  be  freely  admin- 
istered hypodermically.  In  the  algid  forms  external  heat  should  be 
applied,  as  well  as  enemata  of  warm  water.  In  continued  high  fever, 
particularly  if  there  be  delirium,  cold  sponging  or  the  actual  cold  bath 
may  be  of  value. 

During  convalescence  the  most  serious  symptom  with  which  we 
have  to  deal  is  the  ancemia.  In  these  cases  iron  and  arsenic  are  oiu' 
mainstays.  In  most  instances  iron  akjne,  either  in  the  form  of  Bland's 
pills  or  as  the  tincture  of  the  chloride,  in  full  doses,  will  be  followed 
by  good  results.  In  severe  cases  arsenic  may  be  resorted  to ;  it  is 
best  given  in  Fowler's  solution  (liquor  potassii  arsenitis).  It  is  well  to 
begin  with  small  doses  (gtt.  iii,  f.  i.  d.),  and  to  increase  the  dose  steadily, 
one  drop  every  other  day,  until  the  physiological  effect  is  observable — 
slight  suffusion  and  injection  of  the  conjunctivae,  gastro-intestinal  symp- 

^  Johns  Hopkins  Sfosp.  Bulletin,  1892,  No.  22,  49. 


164  MALARIA. 

toms.  The  dose  should  then,  after  a  few  days'  pause,  be  reduced  and 
maintained  at  the  highest  possible  limit.  Some  very  grave  ausemiaa 
which  closely  simulate  true  pernicious  anaemia  and  react  but  little  ta 
iron  may  show  marked  improvement  after  vigorous  treatment  with 
arsenic.  It  should  be  borne  in  mind  that  in  rare  cases  arsenical 
neuritis  may  follow.  In  some  instances  it  is  well  to  continue  the  use 
of  strychnia  in  some  form  as  a  bitter  tonic  during  convalescence. 

Treatment  of  Chronic  Malarial  Cachexia. — The  treatment 
of  chronic  cachexia  is  often  a  very  difficult  matter.  Active  treatment  by 
quinine  will  readily  remove  the  parasite  from  the  circulation  and  put  an 
end  to  acute  symptoms,  but  the  extreme  debility  and  the  grave  anaemia 
are  often  very  obstinate.  Owing  to  the  great  susceptibility  of  such 
patients  to  fresh  infections  or  to  a  reappearance  of  an  old  infection 
after  the  cessation  of  treatment  by  quinine,  it  is  sometimes  almost  neces- 
sary to  remove  the  sufferer  to  a  non-malarious  district.  The  anaemia, 
which  is  usually  the  gravest  symptom,  should  be  treated  according  to 
the  suggestions  given  above.  It  is  in  these  cases  that  persistent  and 
vigorous  treatment  by  arsenic  is  especially  valuable.  The  patient  should 
be  kept  from  all  undue  exertion ;  if  the  anaemia  be  very  grave,  rest  in 
bed  is  important.  The  diet  should  be  most  nourishing,  and  the  patient 
should  be  allowed  to  sit  in  the  sun  and  fresh  air  in  the  middle  of  the 
day  if  the  climate  be  not  too  hot.  Bitter  tonics  are  often  valuable,  par- 
ticularly strychnia.  Most  cases  of  this  nature  will  recover,  even  in  a 
malarious  district,  if  treatment  be  properly  carried  out.  The  majority 
of  cases  of  malarial  cachexia  owe  their  origin  to  the  carelessness  of  the 
patient,  who  does  not  carry  out  proper  treatment  with  quinine  and  fails 
to  observe  the  ordinary  prophylactic  measures. 

Prophylaxis.  —  General  public  prophylactic  measures,  such  as 
proper  drainage,  cultivation  of  the  soil,  and  so  forth,  cannot  be  con- 
sidered here.  The  individual,  however,  may  adopt  certain  measures 
which  may  protect  him  in  the  most  malarious  districts.  If  it  be  neces- 
sary to  visit,  temporarily,  notoriously  malarious  districts,  let  him,  so  far 
as  possible,  choose  the  season  at  which  the  fevers  are  least  prevalent. 
The  dwelling  should  be  sought  upon  ground  as  high  and  dry  as  possible. 
Exposure  at  night  in  damp  or  marshy  districts  should  be  avoided  ;  the 
sleeping  apartment  should  be  an  upper  story  of  the  house.  Despite  the 
experimental  evidence  against  the  idea  that  infection  occurs  through 
the  gastro-intestinal  tract,  it  is  prudent  to  boil  all  drinking  water  com- 
ing from  malarious  districts.  Medicinally,  quinine  in  small  doses  will 
often  prevent  infection.  If  the  district  be  extremely  malarious,  the 
various  simple  wines  containing  cinchona  are  insufficient  protection, 
and  it  is  prudent  to  take  several  grains  of  quinine  daily.  Monti  ^  has 
recently  reported  good  results  from  the  administration  of  tile  sulphate 
of  quinine  in  doses  of  0.40  (gr.  vj)  every  other  day.  Sezary^  believed 
that  a  smaller  quantity,  0.15  (a  little  over  gr.  ij),  daily  was  sufficient  to 
protect  the  individual  under  most  circumstances. 

^  Loc.  cit.  ^  Medecine  moderne,  1892. 


DENGUE. 

By  HAMILTON  A.  WEST,  M.  D. 


Definition. — Dengue,  Break-bone  Fever,  Knockel  Koorts,  Rheu- 
matic Scarlatina,  Eruptive  Kheumatic  Fever,  are  the  princii)al  names 
applied  to  an  acute,  benignant,  specific  fever  of  short  duration,  preva- 
lent usually  in  extensive  epidemics  in  tropical  and  subtropical  regions. 
It  consists  of  two  paroxysms  of  fever  separated  by  an  interval  either 
of  complete  apyrexia  or  a  decided  remission  of  temperature,  and  attended 
by  severe  muscular  and  articular  pains,  and,  in  a  considerable  proportion 
of  cases,  also  by  an  eruption  of  variable  character. 

History. — Dengue  first  attracted  attention  by  the  extensive  preva- 
lence of  an  epidemic  in  the  West  India  Islands  in  1827 ;  previously,  in 
1779,  an  account  of  its  occurrence  in  Java  was  given  by  David  Brvlon, 
and  in  the  subsequent  year  Benjamin  Rush  described  an  epidemic  preva- 
lent in  Philadelphia.  The  West  India  epidemic  began  in  September, 
1827,  in  the  island  of  Saint  Thomas,  rapidly  extending  southward  over 
the  Caribbean  Islands  to  Colombia,  and  northward  to  various  cities  in 
the  United  States,  notably  Pensacola,  Charleston,  Mobile,  Xew  Orleans, 
and  Savannah,  a  few  cases  occurring  as  far  north  as  Boston,  Philadel- 
phia, and  New  York.  The  next  extensive  epidemic  took  place  from 
1848-50  in  various  large  cities  in  South  Carolina,  Georgia,  Alabama, 
Louisiana,  and  Texas.  Reliable  observers  state  that  as  many  as  eight- 
tenths  of  the  population  of  such  cities  as  Augusta  and  Charleston  would 
have  the  disease  during  a  period  of  six  weeks,  showing  such  rapid  and  gen- 
eral dispersion  as  hardly  to  be  equalled  in  this  regard  by  any  other  malady. 

After  about  two  decades  dengue  appeared  in  Arabia  in  1871,  extend- 
ing southward  by  the  routes  of  travel  to  Zanzibar  and  other  towns  on 
the  East  African  coast ;  thence  to  Java,  reaching  and  spreading  over 
India  in  1872,  invading  several  English  stations  in  China  and  Burmali, 
and  extending  to  the  Gulf  States  in  1873.  This  epidemic  was  not  only 
widespread,  but  intense,  in  some  places  hardly  a  person  escaping.  In 
Madras  it  is  said  that  every  house  was  invaded.  In  1880  another  epi- 
demic occurred,  beginning  in  Cairci  and  spreading  over  the  whole  of 
Egypt,  and  extending  afterward  to  many  towns  in  Xorth  and  South 
Carolina,  Georgia,  Florida,  Mississippi,  Louisiana,  and  Texas. 

In  1883  an  epidemic  of  dengue  appeared  in  Syria,  first  observed  at 
Latakia  on  the  northern  coast.  It  spread  by  importation,  but  never 
reached  beyond  two  thousand  feet  above  the  level  of  the  sea,  the  high 
and  dry  mountain  air  seeming  to  be  unfavorable  to  its  propagation. 
Its  prevalence  in  Beyrout  was  almost  universal.  This  epidemic  pre- 
vailed in  Egypt  also,  and  was  marked  by  the  same  characteristics  of 
pandemicity.    In  1885  there  was  a  severe  epidemic  in  the  State  of  Texas, 

155 


156  DENGUE. 

visiting  many  of  the  larger  towns,  not  confined  to  those  upon  the  Gulf 
Coast,  as  Galveston  and  Houston,  but  extending  far  into  the  interior,  to 
San  Antonio,  Austin,  Dallas,  as  well  as  to  many  smaller  places,  reach- 
ing an  altitude  of  nine  hundred  feet  above  the  sea  level,  and  attacking 
a  large  proportion  of  the  population  in  the  infected  localities.  So  far, 
with  exception  of  the  southern  provinces  of  Spain,  Europe  has  escaped. 
Dengue  occasionally  occurs  sporadically  in  the  places  most  subject  to  it, 
as  in  India,  JSTorthern  Egypt,  and  various  localities  in  the  Gulf  States.  In 
Galveston  sporadic  cases  or  mild  epidemics  are  not  infrequent. 

Etiology. —  Climate. — It  will  be  observed  from  the  above  imperfect 
historical  sketch  that  the  disease  is  restricted  to  quite  definite  territorial 
limits,  its  latitudinal  range  extending  from  about  32°  N.  to  22°  S.,  and, 
though  in  rare  instances  it  may  have  occurred  as  far  north  as  Boston, 
New  York,  and  Philadelphia,  such  events  are  exceptional. 

Season. — The  influence  of  heat  as  a  predisposing  factor  is  shown  not 
only  by  the  above  facts,  but  by  the  occurrence  of  the  disease  in  colder 
climates  during  the  summer  and  autumn  seasons,  and  its  prompt  disap- 
pearance upon  the  advent  of  winter.  In  strictly  tropical  climates,  as  in 
the  West  India  Islands,  it  may  prevail  every  month  during  the  year, 
and  does  not  seem  to  be  affected  by  weather  changes.  In  semi-tropical 
regions  its  extension  into  the  winter  months  is  apparently  favored  by  an 
unusual  prolongation  of  summer  heat.  In  December,  1894,  sporadic 
cases  occurred  in  Galveston,  as  the  month  was  unusually  warm,  reaching 
within  two  degrees  of  the  highest  mean  temj^erature  for  twenty  years. 
The  question  arises  as  to  what  influence  high  temperatures  may  have  in 
the  development  of  dengue.  That  no  extraordinary  range  of  tempera- 
ture occurred  during  the  years  of  most  extensive  epidemics  in  Texas  is 
shown  by  the  following  :  In  August,  1873,  the  average  temperature  for 
the  month  was  normal;  September,  1°  above;  October,  2°  below;  No- 
vember, 2°  below;  December,  1°  below.  In  1885,  August,  1°  above; 
September,  1°  below;  October,  2|°  below;  November,  1°  above;  De- 
cember, normal. 

A  humid  atmosphere  appears  generally  to  be  favorable  to  the  propa- 
gation of  dengue  fever,  as  will  be  noted  by  this  condition  prevailing  in 
the  localities  where  it  has  occurred  with  the  greatest  frequency.  Such 
local  influences  are,  however,  not  essential,  as  has  been  repeatedly  shown 
by  the  occurrence  of  epidemics  at  altitudes  of  from  six  hundred  to  nine 
hundred  feet  above  the  sea  level  and  in  climates  ordinarily  dry  and 
salubrious. 

Influence  of  Mace,  Sex,  and  Social  Condition. — The  susceptibility  to 
this  disease  appears  to  be  almost  universal.  During  the  time  of  its 
epidemic  prevalence  it  attacks  with  peculiar  impartiality  all  ages  and  all 
classes  of  the  population.  There  is  hardly  any  infection,  if  we  except 
epidemic  influenza,  which  is  so  indiscriminate,  so  general,  and  so  rapid 
in  its  march  and  progress. 

Specific  Causes. — Although  the  clinical  history  of  dengue,  and  its 
apparent  spread  by  air  currents,  individual  contact,  and  fomites, 
point  to  a  specific  pathogenic  micro-organism  as  its  essential  cause, 
no  eifort,  so  far  as  the  writer  knows,  was  made  looking  to  the  dis- 
covery of  such  causative  agent  until  1885.  At  this  time,  during  the 
prevalence  of  an  epidemic  in  Austin,  Texas,  Dr.  J.  W.  McLaughlin 


hTWLOaV.  157 

mado  a  series  of  observations  by  which  he  was  finally  eonvinced  that  he 
had  isolated  the  inieroeoeeus  of  denoiie.  The  resnlts  oi'  these  investi<ia- 
tions  were  reported  to  the  American  Medical  Association  at  its  nieetiM>i- 
in  IHHi),  were  afterward  briefly  referred  to  at  the  International  Medical 
Congress  in  1887,  and  phot()ii;ra])hs  of  ])ure  eultures  were  exhibited  at 
the  l*an-Anieriean  ^Medical  Congress  in  1893.  Dr.  Mcl^aiighlin  states  : 
"  1.  Tliat  he  examined  mieroscopieally  the  blood  of  twenty  persons 
sutferiiii!;  from  dengue  in  its  various  stages,  taking  it  directly  from  the 
veins,  and  found  in  all  a  peculiar  staphyloeoceus.  2.  Using  necessary 
precautions  to  exclude  alien  germs  and  obtain  chemical  cleaidiness,  he 
introduced  upon  the  point  of  a  sterilized  platinum  w'ire  a  small  fraction 
of  a  drop  of  dengue  blood  into  test-tubes  containing  sterilized  culture 
jelly,  and  grew  upon  it  the  same  micro-organisms  which  the  blood  con- 
tained. 3.  Using  requisite  precautions  against  the  introduction  of  any 
foreign  element,  he  aspirated  into  a  series  of  Liebig's  potash  bulbs  the 
blood  directly  from  the  arm  of  a  dengue  patient.  The  bulbs  were  then 
hermetically  sealed,  and  those  micro-organisms  which  the  blood  con- 
tained allowed  to  grow  upon  the  contents  of  the  bulbs  as  a  nutritive 
medium.  The  temperature  was  constantly  maintained  at  100°  F.  At 
the  expiration  of  six  months  the  contents  of  the  first  bulb  Avas  examined 
under  high  powder,  with  the  result  of  finding  the  same  micro-organism  as 
was  present  in  the  blood  drawn  directly  from  the  arm  of  the  fever 
patient  and  that  had  been  grown  pure  on  the  culture  media."  Dr. 
McLaughlin  thus  summarizes  the  results  obtained  from  the  preceding 
methods  of  examination  :  "  I  found  a  species  of  micrococcus,  of  un- 
usually small  size,  in  the  blood  of  all  persons  having  dengue  whom  I 
examined,  which  has  unique  biological  characteristics  that  distinguish 
this  from  all  other  species  of  pathogenic  micrococci,  and  make  it  highly 
probable,  at  least,  that  this  microbe  is  causative  of  dengue.  The  unique 
biological  habit  of  this  micro-organism  is  displayed  by  it  in  the  group 
forms  that  occur  when  it  is  grown  in  artificial  culture  media.  These 
are  as  follows  :  When  a  culture  preparation  of  this  micrococcus  is  suit- 
ably stained  and  examined  wdth  a  high  power  (say  a  yV^^^  homogeneous 
immersion  lens),  the  picture  that  is  presented  to  the  eye  will  be  made  up 
of  (1)  circular  groupings  of  cocci  around  a  larger  coccus  (arthrospore) 
that  is  located  in  the  centre  of  the  group  ;  (2)  surrounding  and  imbed- 
ding the  cocci  wdll  be  seen  a  gelatinous  substance — microprotein — of 
definite  form  and  shape  ;  (3)  these  squares  of  microprotein  in  which 
the  cocci  are  imbedded  join  similar  squares,  side  to  side,  and  thus  form 
clear  and  distinct  filaments.  The  separate  segments  of  the  filament,  and 
the  micrococci  grouped  around  a  larger,  centrally  located  coccus  in  each 
segment,  can  all  be  distinctly  seen  in  stained  preparations  when  exam- 
ined with  high-power  objectives. 

"  Not  all  the  filaments  that  can  usually  be  seen  in  the  same  micro- 
scopic picture  are  perfect  in  form  like  these  described.  Others  will  be 
seen  that  are  undergoing  a  process  of  disintegration,  the  end  of  which  is 
to  liberate  the  cocci  they  contain,  and  filaments  in  all  stages  of  disinte- 
gration, from  the  beginning  of  the  process  to  its  ending  and  the  complete 
liberation  of  the  cocci,  will  be  observed.  At  the  beginning  of  disinte- 
gration the  filaments  appear  swollen,  lose  their  distinct  outline  and  the 
markings  that  differentiate  their  parts.     Then  the  filaments  fall  away. 


158  DENGUE. 

enlarge,  and  assume  an  imperfectly  circular  form,  and  finally  coalesce 
and  spread  out,  so  that  the  picture  they  present  (in  stained  preparations) 
is  that  of  an  irregular  mosaic.  The  circular  grouping  of  the  cocci  is 
still  retained,  while  the  microprotein  which  formed  the  principal  mass 
of  the  segments  retains  sufficient  of  its  outlines  of  these,  at  their  points 
of  coalescence,  to  jjroduce  the  mosaic.  Finally,  as  disintegration  con- 
tinues, all  order  in  the  grouping  of  the  cocci  disappears,  and  these 
bodies  are  seen  scattered  irregularly  over  the  microscopic  field.  But  it 
will  now  be  observed  for  the  first  time  that  each  coccus  is  surrounded 
by  a  capsule — a  covering  of  microprotein  which  it  brought  with  it 
from  that  of  which  the  segments  were  composed.  All  the  free  micro- 
cocci that  were  seen,  whether  obtained  directly  from  the  blood  or  from 
artificial  cultures,  were  encapsulated.  Xo  filaments  were  found  in  the 
blood  that  was  obtained  direct  from  the  veins,  and  I  cannot  be  sure  they 
were  in  the  blood  cultures  made  of  this  micrococcus.  I  found  many 
bodies  having  the  outlines  of  filaments,  but  as  I  found  no  diiferentiating 
stain  that  the  coccus  would  hold  when  it  was  washed  out  of  the  blood 
cells  by  the  decolorizing  washes,  I  cannot  be  sure  that  the  bodies  seen 
in  the  blood  cultures  were  the  filament-group  form  of  this  coccus  ob- 
tained from  other  artificial  cultures. 

"  Blood  as  a  culture  medium  for  this  micrococcus  was  obtained  by 
aspirating  it  directly  from  a  vein  of  a  dengue  patient  into  sterilized  tubes 
and  bulbs.  These  were  then  j^laced  in  a  culture  oven  at  100°  F.  and 
examined  microscopically  at  different  periods.  All  contained  large 
numbers  of  the  micro-organisms." 

As  dengue  is  a  mild  disease,  it  will  be  comparatively  easy  to  confirm 
these  observations  of  McLaughlin  by  inoculations  upon  the  human  sub- 
ject. The  question  will  doubtless  be  determined  upon  the  advent  of 
another  epidemic. 

COMMUNICABILITY. — The  query  as  to  the  communicability  of  this 
disease  has  been  so  far  unsettled.  Its  rapid  and  widespread  diffusion 
seems  to  preclude  its  exclusive  extension  by  contact  of  individuals.  On 
the  contrary,  positive  facts  in  evidence  of  its  conveyance  along  routes  of 
travel  and  from  one  person  to  another  point  to  its  being  communicable. 
The  evidence  goes  to  show  that  the  micro-organism  which  produces  the 
disease  may  escape  from  the  body  of  a  person  sick  with  dengue  and 
infect  another  individual.  Dr.  Dickson  states  that  immunity  is  conferred 
by  previous  attacks.  He  observed  in  Charleston  that  in  1850  only  those 
escaped  the  disease  who  had  suffered  from  it  in  1828.  Upon  this  point, 
however,  there  is  no  unanimity  of  oj)inion.  Poggio  expresses  astonish- 
ment that  one  attack  should  protect  so  little  from  another.  Thomas 
considers  that  once  having  had  the  disease  a  person  is  more  liable  to 
suffer  from  it  than  before,  at  least  during  an  epidemic.  The  same  author 
cites  instances  of  patients  who  had  dengue  in  Savannah  in  1880  whom 
he  had  treated  for  the  same  disease  previously. 

The  truth  appears  to  be  that  immunity  from  previous  attacks  is 
much  less  often  conferred  than  in  most  other  infectious  diseases. 

Pathological  Anatomy. — Dengue  being,  in  the  vast  majority  of 
cases,  a  non-fatal  disease,  no  structural  changes  have  been  noted  as 
characteristic.  In  the  epidemic  in  Galveston  of  1885  my  colleague, 
Dr.  Paine,  observed  a  localization  of  inflammation  upon  the  serous 


SYMPTOMS  AND  CLINICAL  HISTORY.  159 

membranes,  especially  the  ])l('ura  and  peritoneum,  hut  these  arc  to  be 
rey;ar(led  as  complications  rather  than  as  usual  anatomical   chaufjcs. 

Symptoms  and  Cijxical  Histouy. — 'I'he  |)crio(l  of  incubation  varies 
from  two  to  live  days.  The  onset  is  usually  sudden.  The  initial  symp- 
toms are  rigjors  or  chilly  sensations,  headache  more  or  less  intense,  pains 
in  the  muscles  of  the  limbs  and  l)ack  or  apparently  deeper  seated  in  the 
bones  and  joints.  Coincidently  there  is  a  rise  of  temperature,  which 
varies  from  101°  to  106°  F.  Anorexia  is  usually  coni])lete  ;  nausea  and 
vomitino-  are  common  ;  the  tongue  is  moist  and  acquires  a  yellowish 
coat.  The  pulse  and  respiration  are  quickened  in  proportion  to  the 
extent  of  the  fever,  the  former  ranging  from  95  to  120  per  minute.  In 
children  convulsions  may  occur  at  the  outset,  and  with  a  high  tempera- 
ture they  are  frequently  delirious.  The  face  is  turgid,  the  eyes  red  and 
watery.  The  urine  is  rather  scanty  and  high  colored,  but  is  rarely  albu- 
minous. Lassitude,  weakness,  and  restlessness  are  usually  present  and 
proportionate  to  the  severity  of  the  attack.  The  joints  are  not  only  pain- 
ful and  stitfened,  but  in  many  instances  sM'ollen.  These  symptoms,  after 
persisting  several  days,  are  followed  in  a  considerable  number  of  eases 
by  an  eruption  which  varies  very  much  in  appearance.  Dickson  describes 
the  exanthem  as  appearing  usually  on  the  fifth  or  sixth  day,  and  consist- 
ing of  minute  papulae,  somewliat  elevated,  of  a  florid  red  color,  distributed 
in  irregular  patches.  It  is  noticed  first  in  the  face,  then  on  the  trunk 
iind  thighs,  gradually  spreading  to  the  extremities.  AYhen  fully  devel- 
oped it  is  attended  with  some  itching  and  burning,  and  generally  dis- 
appears in  two  or  three  days  with  some  desquamation.  The  eruption 
sometimes  resembles  urticaria  or  measles  ;  ordinarily  it  is  scarlatinous 
in  form,  but  is  less  diffused  than  that  of  either  rubeola  or  scarlet  fever. 

The  exanthem,  according  to  the  writer's  experience,  is  absent  in 
many  cases.  In  all  probabilit}'  it  varies  in  frequency  in  different  epi- 
demics. During  the  progress  of  these  symptoms  the  fever  continues, 
the  temperature  rising  on  the  second  or  third  day  to  102°,  103°,  or 
even  105°  F.  It  then  declines  and  returns  to  normal  on  the  fifth  day. 
According  to  the  observations  of  D'Aquiu  of  Xew  Orleans,  "the  tem- 
perature curves  of  dengue  showed  a  continuous  and  steady  rise  until  the 
highest  point  was  reached  on  the  first,  second,  or  third  day  of  the  attack. 
Then  comes  a  short  stadium  of  a  few  hours,  and  then  a  remission,  even 
to  be  followed  by  another  rise  of  temperature,  which,  however,  never 
reaches  the  maximum  point  of  the  first."  The  eruption  generally  ap- 
pears with  the  second  access  of  fever,  and  simultaneously  there  is  inflam- 
matory enlargement  of  the  suboccipital,  cervical,  axillary,  and  inguinal 
l}Tnphatic  glands. 

A  disposition  to  hemorrhages  from  the  mucous  membranes  has  been 
noted  in  a  considerable  proportion  of  cases.  Bleeding  may  take  place 
from  the  nose,  giuns,  stomach,  intestines,  and  uterus.  Menorrhagia, 
metrorrhagia,  abortions,  and  miscarriages  are  likely  to  occur. 

Convalescence  is  usually  slow,  and  is  characterized  by  an  amount  of 
prostration  and  weakness  apparently  out  of  proportion  to  the  severity 
and  gravity  of  the  disease.  The  stomach  is  left  in  a  weak  and  irritable 
condition  ;  there  are  anorexia,  nausea,  and  vomiting.  Xot  infrequently 
one  or  two  weeks  elapse  before  a  restoration  to  the  normal  vigor  of  mind 
and  body  is  established.    A  better  idea  of  the  symptomatology  of  the  dis- 


160  DENGUE. 

ease  will  be  obtained  by  a  brief  analysis  of  the  more  important  clinical 
events. 

Tlie  Muscular  and  Arthritic  Pains. — Every  author  who  has  ever 
described  dengue  has  called  attention  to  the  severity  of  these  symp- 
toms ;  especially  is  this  the  case  if  he  himself  has  been  the  victim. 
The  various  names  which  have  been  given  to  the  disease  are  significant 
as  to  the  prominence  of  the  rheumatoid  manifestations.  It  is  hardly 
necessary  to  remark  that  such  events  should  be  diiferentiated  from  true 
rheumatism.  We  have  in  dengue  an  exaggeration  of  what  is  observed 
in  many  other  of  the  infectious  diseases  ;  that  is,  a  predilection  upon  the 
part  of  the  specific  pathogenic  agent  to  affect  the  muscular  structures. 
There  are  many  of  the  milder  cases  where  the  pain  is  located  in  the 
muscles,  chiefly  of  the  neck  and  limbs,  the  joints  not  being  especially 
involved. 

Course  of  the  Fever. — The  statement  that  there  are  two  paroxysms 
of  fever  separated  by  an  interval  of  complete  apyrexia  requires  modi- 
fication. It  was  founded,  doubtless,  upon  the  accounts  of  the  earlier 
writers  before  careful  thermometric  observations  had  been  made,  the 
period  of  decided  remission  being  taken  for  complete  intermission. 
Thus  Eugene  Foster  states  that  out  of  500  cases  seen  by  him  in  the 
epidemic  at  Augusta,  Georgia,  in  1880,  there  was  but  one  paroxysm, 
lasting  from  four  to  seven  days.  Confirming  the  statement  of  ^  Dr. 
D'Aquin,  already  quoted,  that  there  was  a  continuous  and  steady  rise 
of  temperature  until  the  highest  point  was  reached,  most  frequently  on 
the  second  day,  then  a  short  stadium  of  a  few  hours,  then  a  remission, 
soon  to  be  followed  by  another  access  of  fever,  which,  however,  never, 
reached  the  first  maximum  of  heat.  Dr.  John  Wortabet  ^  in  his  descrip- 
tion of  the  epidemic  of  1883  in  Syria  says  that  the  fever  was  continuous 
from  three  to  five  days,  ranging  from  99.5°  to  104.5°  F.,  being  higher 
in  the  forenoon  than  in  the  afternoon,  and  that  the  paroxysm  occurring 
on  the  sixth  day  was  very  rarely  observed  in  the  Syrian  epidemic.  The 
observations  of  D'Aquin  have  since  been  confirmed  by  Vauvray,  Avho 
studied  the  disease  in  Egypt,  also  by  Dr.  Brun,  who  observed  the  epi- 
demic which  prevailed  in  1888-89  in  Beyrout,  Syria.  There  are,  doubt- 
less, however,  some  cases,  as  described  by  Martialis  of  India,  Thomas 
of  Savannah,  and  Holliday,  where  there  is  a  distinct  interruption  of  the 
fever,  followed  by  a  milder  secondary  thermic  paroxysm. 

The  Eruption. — During  the  first  febrile  paroxysm  the  initial  rash  is 
observed.  In  India  this  rash  has  been  noted  by  Martialis  and  Charles 
as  present  in  from  one-half  to  two-thirds  of  the  cases.  It  is  usually 
transitory,  lasting  only  during  the  first  febrile  period,  and  varies  in 
appearance  from  a  slight  blush  to  a  well  marked  erythema.  The  ter- 
minal rash  is  more  constantly  present  than  the  primary  one.  It  has  no 
uniform  appearance,  and  may  be  erythematous,  miliarial,  urticarial,  or 
herpetic,  and  is  indicative,  should  there  be  no  relapses,  of  the  decline 
of  the  disease.  Upon  its  first  manifestation  there  is  often  a  slight  rise 
of  temperature  ;  sometimes  there  are  successive  crops,  and  desquamation 
is  coincident  with  convalescence.  The  frequency  with  which  any  erup- 
tion at  all  occurs  varies  in  different  epidemics.  Unquestionably  there 
are  many  cases  where  it  is  entirely  absent. 

^  Transactions  Ninth  International  Medical  Congress,  vol.  iv.  p.  467. 


'SYMPTOMS  AND   CLINICAL  HISTORY.  161 

GJandalar  KiiUvnjcinrnt.^. — Siiicf  the  lime  of  Dickson  nearly  all  writers 
on  den<rae  have  described,  in  connection  with  the  ern])tion  and  appearing 
about  the  same  time,  inflammation  of  the  lym|)haties  of  the  neek,  axilla, 
lifoins,  and  elsewhere.  In  a  brief  repoi't  made  by  the  writer  uj)on  the 
epidemic  of  bSSo  in  (Jjdveston  reference  was  made  to  tiie  fact  that  no 
such  olandular  involvement  was  found  in  the  cases  then  observed,  but 
the  testimony  of  medical  friends  both  here  and  in  other  portions  of  Texas 
is  convincin(>;  of  the  faet  that  this  epidemic  did  not  differ  from  those 
which  preceded  it  as  regards  the  occurrence  of  this  syni|)tom  ;  and, 
while  it  may  not  have  been  noticed  in  the  praetice  of  several  physicians, 
the  observation  of  a  large  number  of  cases  would  show  a  certain  propor- 
tion in  Avhich  it  was  found. 

Hemorrhages. — A  disposition  to  bleed  from  various  mucous  mem- 
branes has  been  observed  by  a  number  of  practitioners.  My  colleague, 
Dr.  Paine,^  in  speaking  of  the  Texas  epidemic  in  1885,  refers  to  "  serious 
hemorrhages  from  the  colon,  stomach,  vagina,  and  uterus,"  and  states 
"  that  the  two  latter  organs  seemed  to  bear  the  brunt  of  this  congestive 
action,  as  manifested  by  the  frequent  sanguineous  exudations  from  these 
parts.  It  often  happened  that  women  menstruated  out  of  their  regular 
term,  sometimes  profusely,  and  suffered  from  menorrhagia  when  seized 
at  a  normal  epoch.  Old  women  long  past  the  menopause  w^ere  known 
to  lose  blood  from  their  genitalia.  Miscarriages  at  every  stage  of  preg- 
nancy occurred."  Foster  ^  mentions  hemorrhages  from  the  nose,  gums, 
lungs,  uterus,  and  bowels,  one  instance  of  the  latter  finally  proving  fatal. 
He  also  mentions  two  cases  of  black  vomit  similar  to  that  seen  in  yellow 
fever.  As  to  hsematemesis  and  intestinal  fluxes,  while  there  is  no  reason 
that  bleeding  should  not  occur  from  the  stomach  and  bowels  in  a  disease 
showing  such  decided  hemorrhagic  tendencies,  the  diagnosis  of  dengue 
should  receive  careful  consideration  under  such  circumstances.  Refer- 
ence to  this  point  will  be  made  subsequently. 

Relapses. — The  frequency  of  relapses  is  generally  admitted  as  being 
one  of  the  distinctive  features  of  the  clinical  career  of  dengue.  Baret 
and  Mahe  estimate  the  frequency  of  relapses  at  Reunion  in  1869  as  15 
per  cent.  By  a  relapse  should  be  understood  a  recurrence  of  an  attack 
after  complete  recovery.  Relapses  should  not  be  confounded  wath  exacer- 
bations, which  have  been  mentioned  as  occurring  frequently  after  the 
remission. 

Varieties. — A  consideration  of  the  symptomatology  of  dengue  would 
be  incomplete  without  a  description  of  the  varied  £orms  which  the  disease 
assumes  in  the  same  and  in  different  epidemics.  It  is  on  account  of  such 
differences  that  one  writer  will  give  prominence  to  one  set  of  symptoms, 
and  another,  describing  it  as  he  observes  it,  will  emphasize  certain  other 
phases.  So  far  as  a  variety  of  forms  is  concerned,  dengue  does  not  depart 
in  this  respect  from  the  rule  observed  by  other  infectious  diseases.  It 
is  sufficiently  descriptive  to  divide  dengue  into  two  classes  :  First,  that 
mild  form  which  runs  a  shorter  course,  two  to  three  days,  and  in  which 
such  manifestations  as  high  fever,  arthritis,  hemorrhages,  glandular  en- 
largements, etc.  are  absent ;  and  second,  the  more  intense  form,  which 
will  in  the  main  conform  to  the  description  herein  given.     As  to  the 

^  Transactions  Ninth  International  Medical  Congress,  vol.  iv.  pp.  470,  471. 
'^  Reference  Handbook  of  the  Medical  Sciences,  vol.  ii.  p.  .397. 
Vol.  I.— 11 


162  DENGUE. 

denguis  maligna  mentioned  by  Charles  of  Calcutta,  I  think  it  will  be 
conceded  that  the  term  "malignant"  as  applied  to  dengue  is  a  mis- 
nomer, since  the  disease  is  a  remarkable  one  in  respect  to  its  mildness. 
The  writer  distinctly  remembers  his  first  impressions  of  dengue  obtained 
from  professional  friends  in  the  epidemic  of  1873,  that  "  it  was  a  good 
epidemic — good  for  the  doctor,  making  many  people  so  sick  that  these 
were  compelled  to  send  for  him,  and  at  the  same  time  causing  no  one  to 
die."  So  universal  is  the  benignancy  of  this  fever  that  when  mortality 
occurs  there  is  strong  ground  to  suspect  the  accuracy  of  the  diagnosis. 
But  this  portion  of  the  subject  will  receive  further  notice. 

Complications  and  Sequels. — Considering  the  amount  of  suffer- 
ing and  discomfort  incident  to  dengue  fever,  the  comparative  absence  of 
serious  complications  and  sequelae  is  somewhat  unique,  aside  from  those 
symptoms  which  have  been  mentioned,  such  as  occasional  convulsions 
in  children,  a  disposition  to  abortion,  uterine  and  other  hemorrhages, 
rarely  a  pleurisy  or  peritonitis.  The  explanation  of  the  fact  lies  in  the 
non-affinity  of  the  infection  for  such  vital  organs  as  the  brain,  lungs, 
heart,  or  kidneys. 

Convalescence  is  frequently  characterized  by  anorexia,  an  irritable 
stomach,  and  an  extent  of  muscular  weakness  and  nervous  depression 
apparently  out  of  proportion  to  the  duration  and  gravity  of  the  disease. 

Diagnosis. — The  ensemble  of  symptoms  as  above  outlined  ordi- 
narily renders  the  recognition  of  dengue  an  easy  matter  :  especially  is  this 
the  case  during  the  progress  of  an  epidemic ;  but  sporadic  cases  or  epi- 
demics occurring  coincidently  with  yellow  fever,  influenza,  typhoid  and 
malarial  fevers  are  not  so  easily  differentiated.  Any  one  having  practi- 
cal experience  during  the  combined  prevalence  of  these  fevers  can 
readily  understand  that  they  may  be  frequently  confounded  even  by 
expert  diagnosticians. 

Differential  Diagnosis  between  Dengue  and  Yelloio  Fever. — The  idea 
that  these  two  diseases  are  identical,  or  at  least  that  dengue  was  a  modi- 
fied yellow  fever,  was  never  tenable,  but  was  nevertheless  held  by  a 
number  of  reputable  physicians  who  had  studied  the  maladies  at  the 
bedside.  The  facts  giving  currency  to  this  view  are  briefly  as  follows  : 
Dengue  often  prevails  concurrently  with,  precedes,  or  follows  an  epi- 
demic of  yellow  fever.  The  t^vo  diseases  have  similar  (though  not 
identical)  geographical  distribution,  follow  like  isothermal  lines,  and  are 
affected  by  similar  climatic  and  seasonal  influences.  The  clinical  events 
of  mild  cases  of  yellow  fever  may  so  closely  resemble  those  of  dengue 
as  to  justify  Porcher  ^  in  this  statement :  "  It  is  a  significant  fact  that 
we  have  never  been  able  to  distinguish  accurately  between  the  two — to 
say  of  every  case  and  at  every  stage  of  these  two  diseases,  '  This  is 
yellow  fever,  this  only  break-bone ;'  yet  the  well  marked  examples  of 
undeniable  yellow  fever  were  as  different  in  every  material  aspect  from 
lighter  forms  of  break-bone  coexisting  with  it  as  black  is  from  Avhite." 
The  following  table,  arranged  from  the  presentation  of  the  facts  by 
Foster,  will  serve  to  accentuate  the  distinction  between  the  two  diseases, 
and  at  the  same  time,  show  the  points  wherein  they  resemble  each 
other  :  in  spite  of  their  similiarity,  the  fact  that  dengue  and  yellow  fever 
are  entirely  different  diseases  cannot  be  too  strongly  emphasized  : 

^  Transactions  American  Public  Health  Association,  art.  xxxviii. 


DIAGNOSIS.  163 

Yellow  Fever.  Dengue. 

Arrested  by  severe  frost.  Arrested  also  by  frost. 

One  febrile  paroxysm  characterized  by  a  Usually  one  paroxysm,  but  sometimes  two  ; 
steady  rise  and  lasting  about  three  days.         a  steady    rise   of   temperature   until  the 

acme  is  reached  ;  a  short  stadium,  fol- 
lowed by  a  remission,  then  a  second  rise. 
Duration,  live  to  eight  days. 

IStomac'li  irritable,  vomiting  frequent.  Vomiting  not  so  frequent. 

Tongue,  white  centre,  red  edges,  pointed.         Tongue  white,  yellowish,  rarely  red  edges. 

Pulse  slows  while  tenqjerature  rises.  Pidse   increases   in   rapidity   with   rise   of 

temperature. 

Eruption  rarely  or  never  present.  Eruption  present  in  the  majority  of  cases. 

Jaundice  usually  present.  Jaundice  extremely  rare. 

Urine  albuminous  and  often  suppressed.  Urine  free  from   albumin   and  never  sup- 

I^ressed. 

No  involvement  of  lymphatic  glands.  Lymphatic  glands  involved  in  some  cases. 

Hemorrhagic  tendency  frequent,  alarming,  Tendency  to  hemorrhage  comparatively 
and  terminal.  rare,  and,  as  a  rule,  insignificant. 

Often  fatal.  Proverbially  non-fatal. 

Not  protective  against  dengue.  Not  protective  against  yellow  fever. 

Usually  confers  immunity  against  subse-  Not  generally  protective  against  a  second 
(pient  attacks.  attack. 

To  illustrate  the  practical  nature  of  this  subject  and  of  the  close 
resemblance  between  dengue  and  yellow  fever,  it  is  Avorth  mentioning 
that  upon  the  report  of  an  outbreak  of  dengue  at  Key  West  in  August, 
1893-94,  it  was  thought  by  Dr.  Swearingen,  the  Health  Officer  of  Texas, 
to  be  sufficient  reason  to  temporarily  quarantine  against  that  port ;  which 
action  led  to  some  controversy  with  the  health  officials  of  Florida. 
Dr.  Swearingen  ^  based  his  procedure  upon  the  grounds  that  "  dengue, 
Avhile  not  generally  regarded  as  a  quarantinable  disease,  has  been  so 
often  associated  Avith  yellow  fever,  by  making  its  appearance  sometimes 
just  prior  to  that  disease,  and  closely  resembling  it  in  certain  mani- 
festations, and  by  its  appearance  in  Key  West  concurrently  with  yellow 
fever  in  Havana,  with  which  city  Key  West  is  in  near  proximity  and 
close  relations,  that  in  the  interests  of  public  health  in  Texas  it  was 
thought  best  to  take  no  risks  until  sufficient  time  had  elapsed  to  demon- 
strate the  safety  of  resuming  intercourse."  In  all  cases  like  this  the 
public  should  have  the  benefit  of  the  doubt,  and  the  action  of  Dr. 
Swearingen  was  perfectly  satisfactory,  justifiable,  and  wise. 

Differential  Diagnosis  between  Dengue  and  Influenza. — It  would  be 
interesting  to  draw  a  similar  line  of  comparison  between  dengue  and 
epidemic  influenza.  The  points  of  resemblance  are — the  rapid  and 
widespread  diffi^ision,  affecting  all  classes,  all  ages,  and  all  conditions 
with  indiscriminate  violence  ;  the  frequency  of  relapses  and  liability  to 
repeated  attacks ;  the  want  of  harmony  between  the  apparent  severity 
and  small  mortality  of  uncomplicated  cases ;  the  sudden  onset,  the 
character  and  intensity  of  the  pains,  and  the  disproportionate  mental 
and  physical  depression  during  the  period  of  convalescence.  The  points 
of  distinction  are — the  differences  in  geographical  distribution,  climatic 
and  seasonal  influences ;  the  absence  of  eruption  in  influenza  except 
herpes ;  the  absence  of  remission  or  intermission  of  the  fever  in  influ- 
enza ;  the  usual  involvement  of  the  air-passages  in  the  latter  and  its 
non-occurrence  in  dengue ;  the  greater  frequency  and  severity  of  com- 

^  Texas  Sanitarian,  Austin,  Dec.  24,  1894,  p.  65. 


164  DENGUE. 

plications  and  sequelae  in  influenza.     It  is  easy  to  see,  however,  that  the 
two  diseases  might  readily  be  confounded. 

Typhoid  Fever  and  Dengue. — At  first  thought  one  would  hardly 
suppose  that  dengue  and  typhoid  fever  would  ever  be  confused,  the  two 
disorders  being  so  dissimilar ;  yet  that  such  confusion  may  occur  when 
both  are  epidemic  will  readily  appear.  At  the  close  of  the  epidemic  of 
dengue  in  1885  in  Galveston  numerous  cases  were  reported  by  several 
physicians,  denominated  as  typho-dengue.  The  clinical  events  narrated 
were  fever  of  long  duration  (three  to  six  weeks),  intestinal  hemorrhages, 
suppurative  inflammation  of  the  parotid  glands,  and  in  quite  a  number 
a  fatal  ending.  The  writer  contended  in  a  discussion  of  these  cases 
before  the  Galveston  County  Medical  Society  that  the  term  typho-dengue 
was  a  misnomer  ;  that  the  disease  described  was  genuine  typhoid  fever ; 
and  that  it  was  proven  to  be  such  chiefly  by  its  duration,  the  gravity  of 
the  symptoms,  and  its  mortality.  The  confusion  arose  from  the  previous 
rarity  of  enteric  fever,  and  the  occurrence  of  a  mild  epidemic  at  the 
close  of  a  more  extensive  one  of  dengue. 

Malaria  and  Dengue. — Dengue  may  also  be  confounded  with  malarial 
fever  :  especially  is  this  so  in  regard  to  sporadic  cases  of  the  former  or 
at  the  commencement  of  an  epidemic  of  dengue  when  the  latter  is  jDre- 
vailing.  The  differences  in  the  febrile  movement,  the  absence  of  erup- 
tions in  malaria,  the  rapid  supervention  of  anaemia,  and  the  presence  in 
the  blood  of  the  hsematozoon,  suflice  to  establish  the  distinction,  though 
the  writer  could  relate  cases  where  it  was  by  no  means  easy  to  make  a 
differential  diagnosis. 

Prognosis. — The  prognosis  is  almost  invariably  favorable.  Atten- 
tion has  been  called  to  the  fact  that  every  author  who  has  written  upon 
the  subject,  perhaps  without  exception,  has  described  dengue  as  a  mild 
disease  and  without  mortality  except  as  the  result  of  an  intercurrent  or 
rather  accidental  complication,  such  as  convulsions  in  weakly  children 
and  septicaemia  from  a  badly  treated  abortion.  So  when  we  hear  of 
deaths  from  dengue  as  a  result  of  intestinal  hemorrhages  or  from  black 
vomit,  or  any  other  causes,  we  should  view  the  diagnosis  with  suspicion. 
The  fact  alone  that  the  so-called  dengue  is  attended  by  mortality  is 
sufiicient  cause  to  call  in  question  the  diagnosis. 

Treatment. — It  is  useless  to  discuss  the  old  antiphlogistic  plan  of 
treatment — general  bleeding,  active  emeto-cathartics,  etc. — as  it  has  very 
properly  been  discarded.  The  attempts  to  prevent  attacks  during  an 
epidemic  by  the  use  of  quinine  have  been  proven  to  be  entirely  ineffect- 
ual. Quarantine  measures,  except  when  there  is  a  suspicion  of  yellow 
fever,  are  not  likely  to  be  enforced  at  present,  but  the  time  may  come 
when  even  this  disease,  though  universally  acknowledged  to  be  non-fatal^ 
will  be  controlled  in  its  march  to  a  great  extent  by  governmental  author- 
ity. We  do  not  as  yet  know  to  what  extent  this  can  be  accomplished, 
but,  judging  by  its  method  of  dispersion,  there  is  reason  to  believe  in 
the  probability  of  such  restriction. 

Medicinal  Treatment. — The  disease  being  self-limited,  the  indications 
are  to  relieve  the  symptoms.  If  the  stomach  is  full  at  the  time  of  attack, 
a  mild  emetic  would  not  be  out  of  place.  Apomorphia,  one  tenth  of  a 
grain  hypodermically,  will  act  with  certainty  and  rapidity,  or  the  older 
emetics,  ipecacuanha,  mustard,  salt,  and  warm  water,  which  are  handy. 


TREATMENT.  16o 

may  l)o  u.sed.  The  bowels  ordinarily  re([uire  attention,  thougii  excesrsive 
purgation  is  not  desirable.  Moderate  doses  of  ealorael,  five  to  six  grains 
in  a  single  dose,  or  the  same  (juantity  divided  into  several  smaller  doses, 
has  the  etieet,  when  the  bowels  are  moved,  to  relieve  the  nausea  and 
headaehe  by  its  revulsive  and  evaeuant  action,  as  well  as  to  favorably 
affect  the  alimentary  canal  for  assimilation  and  absorption.  Many  prac- 
titioners prefer  to  prescribe  a  more  rapidly  acting  purgative,  as  some  of 
the  salines,  emulsions  of  castor  oil,  etc.  To  relieve  the  intense  headache 
a  hot  mustard  foot-bath  at  the  outset  is  of  decided  service.  The  differ- 
ent coal-tar  antipyretics  are  indicated  for  the  relief  of  the  rheumatoid 
pains,  as  well  as  to  reduce  excessive  fever,  and  can  be  employed  accord- 
ing to  individual  preferences.  AVhile  quinine  cannot  be  depended  upon 
as  a  prophylactic,  it  aids  in  controlling  the  pyrexia  and  pains,  besides 
having  a  tonic  effect.  The  salicylates  are  also  useful  analgesics.  A  very 
good  combination  at  the  outset  would  be  the  following  for  adults  : 

R.  Calomel,  6  grains  ; 

Phenacetin,  ^  drachm ; 

Quinine  bisulphate,  15  grains. 

Mix  and  divide  into  ix  capsules. 
Sig.  Take  three  capsules  every  three  hours. 

After  the  above,  phenacetin  with  quinine,  ten  grains  of  the  former 
to  five  grains  of  the  latter,  may  be  continued  every  four  to  six  hours 
according  to  the  temperature  and  severity  of  the  pains.  When  the  pain 
is  unusually  acute  opiates  may  be  required.  Morphia  and  atropia  given 
hypodermically  afford  the  quickest  relief.  Salicylic  acid  or  salicylate 
of  sodium  is  objectionable  on  account  of  the  disagreeable  head  symptoms 
and  nausea  frequently  produced  by  either  medicament.  Salophen,  how- 
ever, is  free  from  these  objections,  and  is  a  useful  addition  to  the  phen- 
acetin and  quinine ;  it  may  be  given  in  doses  of  ten  or  fifteen  grains 
according  to  the  effects  produced. 

Active  hydrotherapy — that  is,  the  use  of  cold  baths — is  ordinarily 
not  required.  AYarm  baths,  however,  having  the  water  at  a  comfortable 
temperature — say  from  90°  to  95°  F. — allay  nervous  excitement  and  gen- 
erally add  to  the  well-being  of  the  patient.  Cold  applications  to  the 
head  and  sponging  the  body  with  tepid  evaporating  lotions,  as  of  alcohol 
and  water,  assist  in  accomplishing  the  same  results.  Irritability  of  the 
stomach  generally  subsides  when  the  bowels  have  been  freely  moved. 
If  this  symptom  is  obstinate,  iced  champagne,  Yichy  and  Apollinaris 
waters,  subnitrate  of  bismuth,  dilute  hydrocyanic  acid,  with  sinapisms 
to  the  epigastrium,  are  remedies  and  measures  which  are  indicated. 
Turpentine  stupes  and  anodyne  embrocations  assist  in  relieving  the 
rachialgia.  The  diet  ordinarily  should  consist  of  milk,  meat  broths,  and 
gruels.  Lemonade  and  orangeade  are  gratefid  to  the  taste.  To  relieve 
the  depression  of  convalescence  the  moderate  and  careful  use  of  alco- 
holic stimulants,  with  such  reconstructives  as  the  phosj)hates  of  iron, 
quinine,  and  strychnine,  essence  of  calisaya,  Ducros'  elixir,  etc.,  are 
often  required  and  subserve  a  useful  purpose. 


ENTERIC  OR  TYPHOID  FEVER. 

By  J.  C.  WILSON,  M.  D. 


Definition. — An  acute,  infectious  disease,  characterized  clinically 
by  a  febrile  movement  varying  in  duration  from  twenty-one  to  twenty- 
eight  days,  by  gastro-intestinal  catarrh,  marked  prostration,  rapid  wast- 
ing, marked  nervous  symptoms,  and  a  scanty  eruption  of  isolated,  slightly 
elevated,  rose-colored  spots,  which  disappear  upon  pressure  and  are  de- 
veloped in  successive  crops ;  anatomically  by  constant  lesions  of  the 
lymph-follicles  of  the  intestines,  enlargement  of  the  mesenteric  glands 
and  of  the  spleen,  and  parenchymatous  degeneration  of  the  viscera. 
Eberth's  bacillus  is  present  in  the  lesions. 

Synonyms. — To  enteric  fever  many  names  have  been  applied.  It 
is  called  by  the  Germans  "  typhus  abdominalis  "  to  differentiate  it  from 
true  typhus — "typhus  exanthematicus."  Louis,  in  1829,  gave  to  the 
disease  the  name  of  "  typhoid  fever  "  (fievre  typhoide),  a  designation  that 
has  since  passed  into  almost  universal  use.  To  the  name  "  typhoid," 
however,  there  are  the  same  objections  that  apply  to  the  "  typhus  abdom- 
inalis "  of  the  Germans,  as  both  terms  would  imply  a  relation  to  typhus 
fever  which  exists  neither  clinically  nor  anatomically.  Although  no 
longer  in  use,  the  term  "  slow  nervous  fever  "  of  Huxham's  day  is  finely 
descriptive.  Other  names  still  occasionally  loosely  used  are  "gastric 
fever,"  "  intestinal  fever,"  "  ileo-typhus,"  and  "  infantile  remittent 
fever."  The  last  was  at  one  time  employed  to  designate  the  fever  as 
it  occurs  in  early  childhood.  The  disease  at  this  period  of  life  is 
characterized  by  marked  remissions  in  its  temperature  range,  and  Avas 
for  a  long  time  regarded  as  a  distinct  affection  not  in  any  way  related 
to  enteric  fever,  from  which  infants  and  young  children  were  supposed 
to  enjoy  a  high  degree  of  immunity.  Later  investigations,  however, 
proved  the  erroneous  character  of  these  views  and  established  the 
identity  of  the  so-called  infantile  remittent  fever  with  enteric  fever. 

"  Enteric  fever  "  seems  the  most  appropriate  name  for  the  affection. 
It  indicates  at  once  the  site  of  the  constant  and  most  important  of  the 
gross  lesions,  and  by  the  use  of  the  term  "  fever "  coupled  with  the 
adjective,  the  infectious  character  of  the  process.  For  these  reasons, 
and  because  it  is  not  open  to  the  objections  that  may  be  urged  against 
"  typhus  abdominalis  "  and  "  typhoid,"  it  is  now  extensively  employed 
among  English-speaking  physicians,  and  especially  in  army  and  navy 
medical  circles  and  in  government  reports. 

Etiology. — Enteric  fever  is  due  to  the  implantation  in  a  susceptible 
organism  of  a  specific  infecting  principle — the  bacillus  of  Eberth. 

Predisposing  Influences.  —  These  constitute,  first,  all  conditions 
which  favor  the  development  and  accumulation  of  the  infecting  prin- 


168  ENTERIC  OR   TYPHOID  FEVER. 

ciple,  and,  second,  those  conditions  Avliich  increase  the  susceptibility  of 
the  individual  to  the  cause  of  this  particular  fever  and  the  liability  of  his 
exposure  to  it. 

The  geographical  distribution  of  enteric  fever  is  wide.  This  disease 
prevails  in  all  countries  and  in  every  climate.  It  is,  however,  especially 
prevalent  in  temperate  climates.  It  is  the  great  fever  of  the  present 
historical  epoch,  just  as  the  plague  was  in  Europe  the  great  fever  of 
the  Middle  Ages  and  typhus  the  great  fever  of  the  seventeenth  and 
eighteenth  centuries.  Enteric  fever  is  endemic  in  the  British  Islands, 
in  Continental  Europe,  and  in  ]S"orth  America.  Hirsch  has  reached  the 
conclusion  that  the  general  prevalence  of  this  disease  in  Europe  and 
America  dates  no  farther  back  than  the  second  and  third  decades  of  the 
present  centuiy ;  that  is,  from  the  period  which  typhus  {der  Petechial 
Tfphus)  ceased  to  prevail  generally  and  in  many  localities  disappeared 
altogether.  In  America  enteric  fever  prevails  from  Hudson  Bay  to  the 
Gulf  of  Mexico.  In  newly  settled  districts,  where  the  land  is  being 
gradually  brought  under  cultivation,  the  malarial  fevers  are  common ; 
after  a  time,  as  populations  increase,  the  malarial  diseases  and  enteric 
fever  prevail  side  by  side ;  finally,  when  the  land  has  been  generally 
taken  up,  drained,  and  tilled,  and  villages  and  cities  abound,  true  agues 
and  remittents  largely  disappear,  while  enteric  fever  becomes  the  usual 
endemic  fever,  common  in  proportion  to  the  neglect  of  the  sanitary 
measures  by  which  alone  it  can  be  kept  in  check. 

Climate,  not  directly,  but  as  determining  the  mode  of  life  in  commu- 
nities, has  much  influence  upon  the  extent  of  the  prevalence  of  enteric 
fever. 

The  season  of  the  year  is  a  predisposing  influence  of  great  importance. 
About  50  per  cent,  of  the  cases  occur  during  the  months  of  August, 
September,  and  October.  The  number  of  cases  decreases  during  Novem- 
ber and  December,  is  lowest  from  February  to  May,  again  increasing  in 
June.  This  fever  is  so  much  more  common  in  the  latter  part  of  the 
year  that  it  is  known  in  some  districts  of  the  United  States  as  "  autum- 
nal "  or  "  fall  fever." 

The  loeather,  as  regards  dryness  and  moisture,  exerts  a  decided  in- 
fluence upon  the  prevalence  of  enteric  fever.  Its  prevalence  is  greater 
during  hot  and  dry  seasons  ;  less  during  cool  and  wet  summers.  Out- 
breaks of  enteric  fever  in  localities  supplied  by  surface  water  or  shallow 
wells  have  frequently  followed  abundant  rains. 

Age  is  of  great  importance  among  the  predisposing  causes.  Enteric 
fever  is  especially  a  disease  of  adolescence  and  early  adult  life.  The 
period  of  greatest  susceptibility  is  between  the  ages  of  fifteen  and  thirt}', 
the  liabilitv'  diminishing  progressively  both  above  and  below  these  limits. 
In  1864,  Murchison  demonstrated  at  the  Pathological  Society  of  London 
the  intestines  of  an  infant  six  months  old  who  had  been  attacked  at  the 
same  time  with  her  mother.  Cases  in  the  first  year  of  life  are,  however, 
exceedingly  rare,  but  from  the  termination  of  this  period  the  liabilit}' 
gradually  increases  through  infancy  and  childhood.  The  explanation 
of  the  fact  that  the  proportion  of  the  cases  occurring  in  infancy  is 
smaller  than  that  of  childhood  and  adolescence  is  found  in  the  greater 
exposure  to  the  cause  of  the  disease  in  the  later  periods.  Enteric  fever 
is  not  common  in  advanced  life.     I  have,  however,  seen  cases  in  the 


THE  EXCITING   CAUSE. 


169 


Fig. 


iifty-oii]jhth  and  sixty-ninth  year.  This  ininiunity  is  to  be  accounted 
for  hv  the  fact  that  a  \wy^q  projjortion  of  iiulividuals  surviving  to  the 
hiter  i)eriods  of  life  have  previously  suffered  from  the  disease. 

Si'x  exerts  no  |)re(lisi)osiuij:  influence.  The  disparity  shown  by  sta- 
tistics is  due  to  the  fact  that  a  ureater  number  of  males  than  females 
sufferino-  from  acute  disease  are  admitted  to  hospitals.  Certain  statis- 
tical series  would  ap])ear  to  show  that  the  disease  is  more  frequent  in 
boys  than  in  girls.  These  statistics  fail  to  embody  the  fact  that  beyond 
the  age  of  infancy  girls  are  much  less  exposed  to  the  infection  than 
boys.  The  latter,  in  their  outdoor  sports — bathing,  swimming,  and  the 
like — incur  especial  risk  in  drinking  water  directly  defiled  by  sewage. 

The  mode  of  life  is  without  influence.  Enteric  fever  is  as  apt  to 
occur  in  the  houses  of  the  affluent  as  in  the  most  crowded  and  destitute 
localities.  The  prevalence  of  enteric  fever  in  the  great  centres  of  pop- 
ulation diminishes  in  proportion  as  protection  of  the  water  supply  ad- 
vances and  sewer  systems  are  improved.  In  rural  districts  where  sani- 
tarv  regulations  are  ig-nored  the  dis- 
ease  appears  to  be  upon  the  increase. 
I  have  knowledge  of  several  suburban 
localities  in  which  enteric  fever,  for 
many  years  prevalent,  has  wholly  dis- 
appeared within  a  short  time  after  the 
introduction  of  artesian  water  and  the 
abandonment  of  shallow  wells. 

The  Exciting-  Cause. — The  micro- 
organism described  by  Eberth,  Koch, 
Gaff  ky,  and  others,  and  known  as  the 
bcK-illus  typhosus  or  baciUus  typhi  ab- 
dominalis,  is  at  the  present  time  gen- 
erally accepted  as  the  cause  of  enteric 
fever.  This  organism  is  constantly 
present  in  the  specific  lesions  of  the 
disease.  The  bacilli  are  about  one 
third  the  diameter  of  a  red  blood- 
corpuscle  in  length  and  about  three 
times  as  long  as  broad — 2.5  by  0.8  //. 
They  are  blunt  and  rounded  at  the  ends  (Fig.  8),  in  one  of  which, 
sometimes  in  both,  especially  in  cultures,  there  are  areas  of  dense  pro- 
toplasm that  have  been  regarded  as  spores.  They  are  motile.  They 
can  be  readily  grown  in  pure  cultures  on  nutritive  media  of  differ- 
ent kinds,  and  can  be  now  differentiated  from  certain  other  bacteria  with 
which  they  were  formerly  confounded,  especially  the  bacterium  coli 
commune.  This  bacillus  completely  fulfils  two  of  the  requirements  of 
the  law  formulated  by  Koch  in  regard  to  the  evidence  that  a  disease  is 
caused  by  a  given  micro-organism  :  it  is  present  in  every  case  of  the 
disease  and  in  such  distribution  as  will  explain  the  specific  lesions,  and 
it  can  be  isolated  in  pure  culture.  The  third  requirement  of  the  chain 
of  evidence,  that  the  disease  must  be  reproduced  by  inoculation  of  the 
isolated  organism,  remains  unfulfilled.  The  results  of  inoculation  ex- 
periments have  in  most  instances  been  due  to  the  toxic  rather  than  the 
infective  properties  of  the  inoculated  substance.     It  has  therefore  been 


Typhoid  bacilli  in  Peyer's  patch  before 
ulceration  (Charcot). 


170  ENTERIC  OB   TYPHOID  FEVER. 

concluded  that  the  lower  animals  are  not  susceptible  to  enteric  fever. 
The  fact  that  hyperplastic  and  ulcerative  lesions  of  the  lymph  struc- 
tures of  the  intestines  have  followed  such  inoculations  is  not  conclusive, 
since  it  has  been  shown  that  similar  lesions  may  be  caused  by  the  bac- 
terium coli  commune  and  other  micro-organisms. 

Abbott  in  a  number  of  experiments  upon  rabbits  obtained  a  single 
positive  result.  In  this  case  there  was  an  ulcer  in  the  ileum  identical 
with  those  found  in  the  intestines  in  the  human  subject,  and  typhoid 
bacilli  were  demonstrated  in  characteristic  clumps  in  sections  of  the 
spleen  and  were  obtained  from  that  organ  by  culture  methods. 

The  difficulties  regarding  the  subject  are  not  insurmountable.  Recent 
researches  have  shown  that  definite  toxic  and  immunizing  substances 
are  produced  by  this  bacillus.  These  results  tend  to  support  the  view 
already  almost  universally  accepted,  that  the  organism  in  question  is  the 
specific  cause  of  enteric  fever. 

The  bacilli  have  been  found  in  the  blood,  especially  in  that  drawn 
from  the  spleen  and  the  rose-colored  spots.  They  tend,  however,  to- 
colonize  in  clumps  in  the  lymph-tissues  of  the  intestines,  in  the  mesen- 
teric glands,  in  the  spleen,  in  the  marrow  of  the  bones,  and  in  the  liver. 
They  have  been  found  in  the  bile,  in  the  urine,  more  abundantly  when 
it  is  albuminous,  and  in  the  sweat.  They  have  been  isolated  from  en- 
docardial vegetations  and  from  serous  and  purulent  exudates  in  different 
parts  of  the  body.  They  cannot  be  discovered  in  the  stools  until  the 
tenth,  sometimes  not  until  as  late  as  the  sixteenth,  day.  In  fatal  cases 
cultures  of  the  intestinal  contents  have  frequently  given  negative  re- 
sults. 

The  most  active  existence  of  this  organism  is  parasitic.  It  is,  how- 
ever, a  facultative  saprophyte,  and  is  capable  of  a  prolonged  existence 
under  favorable  circumstances  both  within  the  body  of  the  patient  who 
has  suffered  from  enteric  fever  and  outside  of  the  human  organism. 
Outside  the  body  it  retains  its  vitality  for  a  variable  period  of  time. 
The  extreme  duration  of  this  period  is  not  known.  In  ordinary  water 
it  is  measured  by  weeks.  Hochstetter  found  typhoid  bacilli  capable  of 
growth  after  they  had  been  for  twelve  days  in  a  siphon  of  seltzer  water. 
They  survive  longer  in  closed  cisterns  and  reservoirs  than  when  exposed 
to  light,  and  Janowsky  has  shown  that  cultures  cease  to  develop  after 
some  hours  of  exposure  to  sunlight.  That  they  retain  their  vitality  in 
running  water  has  been  shown  by  the  history  of  many  epidemics. 
Prudden  found  them  capable  of  culture  after  having  been  frozen  in  ice 
for  several  months  and  after  repeated  freezing  and  thawing.  Prudden 
and  Ernst  found  them  in  the  water-filters  of  houses  in  which  cases  of 
enteric  fever  had  developed.  Whether  or  not  they  increase  in  ordinary 
water  remains  unsettled.  It  is  generally  believed  that  some  increase 
does  take  place.  They  grow  luxuriantly  in  milk  without  causing  coagu- 
lation or  changing  its  appearance  in  any  respect.  They  retain  their 
vitality  for  months  in  fecal  matter,  and  many  local  outbreaks  have  been 
traced  to  the  disturbance  of  privy-vaults  into  which  the  stools  of  enteric- 
fever  patients  have  been  previously  emptied.  UfPelmann  has  shown 
that  typhoid  bacilli  have  a  remarkable  vitality  and  tenacity  in  dried 
fecal  matter.  They  not  only  continue  to  live,  but  also  grow  and  multi- 
ply, upon  the  surface  of  the  soil,  and  where  the  ground  is  frequently 


THE  EXCITING  CAUSE.  171 

moistened  they  penetrate  to  a  consideral)lc  depth,  retaining  their  vitality. 
There  is,  however,  no  proof  that  typhoid  bacilli  are  capable  of  an  in- 
definite existence  outside  the  body,  much  less  of  an  iudcHnitelv  \)yu- 
lonoed  indej)endent  and  viu'orous  non-j)anisitic  o-rowth.  On  the  con- 
trary, there  is  reason  to  bi'lieve  that  sunlight,  dis[)ersion,  the  action  of 
putri'factive  bacteria  (Karlinski),  and  unsuitable  or  insutlicient  pabulum 
would  ultimately  lead  to  their  extinction  were  it  not  for  constant  renewal 
by  the  infection  of  fresh  cases. 

The  iicrms  find  access  to  the  body  by  way  of  various  ingesta.  If,  as 
exceptionally  aj)pears  to  have  been  the  case,  they  are  inhaled  witii  par- 
ticles of  dust  Hoatino-  in  the  air,  it  is  probable  that  they  become  en- 
tangled in  the  secretions  of  the  mouth  or  pharynx  and  are  swallowed. 
The  common  vehicle  is  drinking  water  which  has  been  defiled  by  se\vage. 
The  endemic  prevalence  of  the  disease  in  cities  and  many  local  epi- 
demics are  to  be  attributed  to  this  cause.  Even  water  that  has  been 
recently  boiled  may  take  up  germs  from  a  contaminated  filter  or  from 
contaminated  ice. 

Many  local  epidemics  have  originated  in  the  pollution  of  the  water 
supply  by  a  single  patient.  Among  these  none  is  more  important  than 
the  well  known  epidemic  at  Plymouth,  Pa.,  in  1865.  A  portion  of  the 
water  supply  of  the  town  was  derived  from  a  reservoir  filled  from  a 
mountain  stream  some  distance  above.  A  case  of  enteric  fever  occupied 
a  house  upon  the  banks  of  this  stream  during  January,  February,  and 
March.  The  copious  dejections  of  this  patient  w^ere  thrown  upon  the 
ground,  which  was  at  that  time  frozen  and  covered  with  snow.  Toward 
the  end  of  March  a  thaw,  accompanied  by  a  rainfall,  took  place.  About 
the  10th  of  April  an  epidemic  of  enteric  fever  developed  in  the  town, 
chiefly  among  the  inhabitants  whose  water  supply  came  from  the  reser- 
voir.    In  a  population  of  8000  people  1200  cases  occurred. 

The  following  personal  observation  illustrates  a  very  common  mode 
of  the  propagation  of  enteric  fever :  A  physician  developed  the  disease 
under  the  following  circumstances  :  His  house  stood  upon  a  small  lot  in 
a  village  at  the  time  and  for  a  long  time  previously  free  from  enteric 
fever.  Early  in  September  the  patient's  brother  came  to  his  house  ill 
with  enteric  fever.  The  dejections  from  this  case,  treated  w'ith  a  small 
amount  of  a  so-called  commercial  disinfectant,  were  thrown  into  the  privy, 
an  ordinary  open  vault  such  as  is  common  in  country  places.  The  well 
from  which  the  drinking  water  for  the  household  was  obtained  was 
about  twenty-five  paces  distant.  Toward  the  close  of  September  the 
physician  fell  ill  with  enteric  fever,  and  within  a  few  days  three  other 
cases  occurred  in  his  household. 

Infection  is  less  common  by  the  way  of  milk,  in  which  the  germs 
grow  luxuriantly  without  altering  its  physical  characteristics.  A  num- 
ber of  epidemics  have  been  traced  to  this  cause.  The  infection  in 
these  cases  cannot  be  traced  to  disease  in  the  cow,  but  to  an  admix- 
ture of  defiled  water  Avith  the  milk,  either  intentionally  or  as  the  result 
of  its  use  in  cleansing  milk-cans.  The  transmission  of  the  infecting 
principle  by  milk  was  definitely  established  by  the  investigations  of 
Ballard  during  a  local  epidemic  at  Islington  in  1871.  The  outbreak 
■was  shown  to  be  due  to  the  employment  of  water  defiled  by  direct  com- 
munication with  drains  for  the  purpose  of  washing  the  milk-cans. 


172  ENTERIC  OR   TYPHOID  FEVER. 

Circumscribed  epidemics  have  occurred  in  which  the  most  careful 
efforts  to  trace  the  source  of  the  disease  have  been  without  positive 
result.  In  an  outbreak  a  few  years  ago  in  a  military  academy  in  the 
neighborhood  of  Philadelphia  this  was  the  case.  Among  132  students 
14  cases  developed  in  rapid  succession.  The  infection  was  virulent,  5 
of  the  14  cases  terminating  fatally.  One  of  the  patients  came  under 
mv  observation,  and  subsequently  recovered  in  the  German  Hospital 
of  Philadelphia.  Painstaking  investigations  conducted  by  competent 
observers  failed  to  reveal  the  source  of  infection.  A  theory  that  the 
first  case  was  due  to  infected  milk  obtained  at  a  shop  in  a  neighboring 
city  could  not  be  established. 

The  possibility  that  typhoid  bacilli  may  be  present  on  the  surface  of 
raw  vegetables  or  other  articles  of  food  that  have  been  washed  with 
water  containing  them  is  not  to  be  overlooked.  Articles  of  food  may  be 
contaminated  by  the  soiled  fingers  of  the  patient  himself  or  of  his 
attendants. 

The  bacilli  may  be  transported  from  the  fecal  discharges  of  a  patient 
to  articles  of  food  by  means  of  house-flies.  Oysters  "  plumped "  or 
freshened  for  market  by  exposure  for  a  short  time  in  the  fresh  water 
of  streams  defiled  by  the  sewage  of  towns  or  cities  may  become  infected. 
Conn  has  reported  an  epidemic  at  Middletown  which  he  attributes  to  the 
eating  of  uncooked  oysters  infected  in  this  way.  Foote  found  in  river 
ovsters  a  larger  number  of  micro-organisms  than  in  those  from  the  sea. 
He  shov/ed  that  the  bacillus  typhosus  preserves  its  vitality  in  the 
brackish  water  in  which  oysters  are  laid  down,  and  for  a  longer  time 
in  the  oyster  itself. 

It  was  at  one  time  thought  that  the  infecting  principle  of  enteric 
fever  was  not  immediately  capable  of  giving  rise  to  the  disease,  but 
that  its  pathogenic  properties  were  acquired  in  the  course  of  a  short  time 
in  consequence  of  changes  after  leaving  the  body.  In  accordance  with 
this  view  enteric  fever  was  regarded  as  a  contagious  miasmatic  disease. 
The  theory  of  Pettenkofer  that  the  poison  is  not  eliminated  in  a  con- 
dition capable  of  immediately  giving  rise  to  the  disease,  but  that  it 
acquires  its  pathogenic  properties  in  consequence  of  changes  in  the  soil, 
and  that  these  changes  are  favored  by  the  action  of  the  ground  Avater,  is 
of  a  similar  nature.     These  theories  are  no  longer  tenable. 

The  doctrine  of  Murchison  and  his  followers  that  the  specific  cause 
of  this  disease  may  be  generated  de  novo  in  decomposing  sewage  in 
which  the  discharges  of  enteric  fever  patients  are  not  present  is  like- 
wise untenable.  It  is  true  that  filth,  defective  sewers,  cesspools,  and 
soils  contaminated  with  fecal  matter  favor  the  accumulation  of  typhoid 
germs,  and  in  some  cases  supply  media  for  their  growth,  but  these  con- 
ditions cannot,  in  the  absence  of  the  specific  infecting  principle,  give 
rise  to  enteric  fever.  There  is  no  proof  whatever  that  this  disease  in 
the  absence  of  the  germ  referred  to  can  be  generated  by  the  products 
of  decay  or  decomposition,  by  sewer  exhalations,  by  tainted  food,  or  by 
the  action  of  other  bacteria. 

By  far  the  largest  proportion  of  the  bacilli  are  without  doubt  destroyed 
within  the  body.  The  remainder  find  their  way  out  in  the  stools,  to  a 
slight  extent  in  the  urine,  very  rarely  in  the  vomited  or  expectorated 
matters  or  the  perspiration.     They  are  not  eliminated  by  the  expired 


ANATOMICAL  CHANGES  IN  THE  INTESTINES.  \1'?> 

air.  Enteric  fever  cannot  therefore  be  regarded  as  contagious  in  the 
ordinary  nieaninij:  of  tlie  term.  It  is  coniniunicable  by  the  iiifcctiiitr 
principle  contained  in  these  matters,  but  chielly  in  the  fecal  discharges. 
This  infecting  prinei[)le  is  invariably  derived  cither  diivctly  (•!•  indirectly 
from  a  previous  case. 

Sporadic  cases  of  enteric  fever  occasionally  occur  under  circumstances 
that  baliie  explanation.  This  has  sometimes  been  the  case  among  small 
bodies  of  troops  in  practically  uninhabited  districts,  as  in  border  cam- 
paigns. The  suggestion  that  the  infection  under  these  circumstances 
has  taken  place  by  means  of  typhoid  bacilli  in  condensed  milk  or  other 
articles  of  food,  and  that  the  innnunity  of  those  who  escape  is  to  Ije 
ascribed  to  previous  attacks  of  enteric  fever,  is  plausible.  The  alter- 
nate suggestion  that  the  infecting  principle  of  enteric  fever  is  a  germ 
widely  diffused  in  nature,  and  that  it  acquires  pathogenic  properties 
when  developed  in  contact  with  decomposing  fecal  or  other  organic 
matter,  has  not  met  with  general  acceptance. 

Pathological  Anatomy. — ;The  typhoid  bacilli,  gaining  access  to 
the  organism  by  way  of  the  gastro-intestinal  tract,  enter  the  lymph 
structures  of  the  intestines  and  there  develop,  elaborating  toxic  prin- 
ciples to  which  the  constitutional  phenomena  are  due.  Brieger,  Friinkel, 
and  others  have  isolated  from  bouillon  cultures  of  the  bacilli  a  toxalbu- 
min  to  which  the  term  typho-toxin  has  been  applied.  The  fact  that 
typhoid  bacilli  are  not  found  in  the  fecal  discharges  in  the  early  course 
of  the  disease,  but  first  appear  about  the  time  of  the  necrosis  of  the  lymph 
elements,  justifies  the  assumption  that  the  bacilli  do  not  develop,  as  do 
those  of  cholera,  within  the  lumen  of  the  gut. 

The  constant  and  characteristic  gross  anatomical  changes  of  enteric 
fever  are  to  be  studied  in  the  solitary  and  agminate  glands  of  the  intes- 
tines, especially  at  the  lower  end  of  the  ileum,  in  the  associated  lymph- 
atic structures  of  the  mesentery,  and  in  the  spleen. 

Anatomical  Changes  in  the  Intestines. — The  anatomical  changes 
in  the  intestines  may  be  divided  into  four  stages. 

1.  The  Stage  of  Infiltration  or  Hyperplasia. — In  this  stage  swelling  of 
the  solitary  and  agminate  glands  takes  place,  and  is  due  to  hyperplasia 
of  their  elements,  the  surrounding  mucous  membrane  being  intensely 
hypersemic.  The  agminate  glands  are  distinctly  elevated  above  the 
surrounding  surface,  and  after  the  early  hypersemia  and  congestion  have 
disappeared  become  grayish  white  or  opaque  in  appearance,  with  a 
slightly  rough,  irregularly  mammillated  surface.  The  solitary  follicles 
are  not  invariably  affected,  but  when  affected  they  constitute  shot-like 
projections  from  an  eighth  to  a  quarter  of  an  inch  in  diameter.  The 
hyperplasia  of  the  lymph  elements  extends  deeply  into  the  submucous 
tissue,  but  at  the  borders  it  is  limited,  so  that  both  the  solitary  and 
agminate  lymph  follicles  are  distinctly  differentiated  from  the  surround- 
ing mucous  membrane  by  abrupt  margins.  The  whitish  or  opaque 
appearance  of  the  glands  is  due  to  the  compression  of  the  bloodvessels  : 
nor  is  the  infiltration  limited  to  the  glands,  but  may  proceed  deeper, 
involving  the  submucous,  the  muscular,  and  even  the  serous  layers  of 
the  intestine. 

The  infiltration  attains  its  maximum  development  some  time  between 
the  end  of  the  first  week  and  the  tenth  day  of  the  disease.     At  this 


174  ENTERIC  OB  TYPHOID  FEVER. 

stage  of  the  process  the  anatomical  change  may  cease  and  resolution 
take  place ;  if,  however,  as  is  commonly  the  case,  the  bloodvessels  have 
become  so  choked  that  repair  is  impossible,  necrosis  of  the  lymph  struc- 
tures results. 

In  children  hyperplasia  of  the  lymj)h  follicles  is  not  uncommon  in 
intestinal  diseases.  It  occurs  also  in  scarlet  fever,  measles,  and  diph- 
theria. While,  therefore,  hyperplasia  of  the  lymph  follicles  is  not 
peculiar  to  enteric  fever,  a  marked  enlargement  of  these  structures  is 
rarely  seen  in  adults  in  any  other  febrile  affection. 

2.  The  Stage  of  Necrosis. — The  hyperplasia  of  the  lymph  follicles  ad- 
vances. Resolution  is  no  longer  possible.  Mechanical  interference  with 
the  blood  supply  from  the  pressure  of  the  infiltrated  tissues,  the  growth 
of  the  bacilli,  and  the  direct  action  of  the  concentrated  toxic  principles 
evolved  at  the  seat  of  their  activity  are  factors  in  bringing  about  rapid 
and  more  or  less  extensive  necrosis  in  the  affected  glands.  The  swollen 
patches  and  discrete  follicles  undergo  sloughing,  which,  on  the  one  hand, 
may  be  superficial,  involving  only  the  epithelial  and  subepithelial  struc- 
tures, and,  on  the  other,  may  extend  to  and  involve  the  peritoneal  coat 
of  the  intestine.  Between  these  extremes  necrosis  of  varying  depth 
occurs,  the  muscularis  commonly,  but  by  no  means  invariably,  limiting 
the  process.  The  infiltration  and  necrosis  are  jsrogressively  more  marked 
toward  the  lower  end  of  the  small  intestine,  and  in  severe  cases  the 
mucosa  of  the  ileum  for  some  inches  above  the  ilio-csecal  valve  is 
extensively  gangrenous.  The  attached  sloughs  are  of  a  grayish- white 
color,  or  they  may  be  stained  yellowish  brown  or  green  by  the  intes- 
tinal contents,  especially  the  bile ;  sometimes,  being  infiltrated  with 
blood,  they  are  dark  in  color.  The  separation  of  the  sloughs  takes 
place  during  the  latter  half  of  the  second  and  the  course  of  the 
third  week. 

3.  The  Stage  of  Ulceration. — The  sloughs  are  gradually  detached, 
separation  taking  place  first  at  the  borders.  Ulcers  of  varying  depth 
and  of  a  size  and  form  corresponding  to  the  necrotic  tissue  are  thus 
formed.  If  an  entire  patch  be  involved,  the  resulting  ulcer  is  elliptical, 
of  considerable  size,  and  situated  opposite  the  mesentery,  its  long  axis  cor- 
responding to  the  long  axis  of  the  bowel.  It  is  more  common  to  find 
irregularly  circular  or  ovoid  forms  which  occupy  a  portion  only  of  the 
Peyer's  patch,  or  two  or  more  irregularly  bordered  forms  of  ulceration 
separated  by  bands  of  mucosa.  Very  extensive  ulceration  is  sometimes 
encountered  just  above  the  ileo-ceecal  valve.  The  edges  of  the  ulcers  are 
usually  abrupt,  the  surrounding  tissues  being  thickened  and  often  over- 
hanging. Their  bases  may  be  formed  by  the  submucosa ;  more  com- 
monly they  are  formed  by  the  muscularis,  sometimes  by  the  serosa,  and 
in  those  instances  in  which  the  necrosis  involves  the  peritoneum  the 
wall  of  the  gut  may  slough  out  through  its  entire  thickness.  Ulcers 
resulting  from  necrosis  of  the  solitary  follicles  are  usually  small  and 
round.  "When  death  has  occurred  late  in  the  course  of  the  attack 
irregular,  serpiginous  ulceration  is  in  some  instances  observed. 

4.  The  Stage  of  Cicatrization. — The  swelling  in  the  edges  of  the  ulcers 
gradually  diminishes,  the  base  becomes  covered  with  a  delicate  layer 
of  granulation  tissue,  and  the  mucosa  extends  over  the  healing  surface, 
which  is  ultimately  invested  with  epithelium.     The  gland  structure  is 


AXAT'OMICAL   changes  IX  THE  INTESTINES.  175 

to  some  extent  re-fonned.  Tlic  resulting  scar  is  slightly  depressed, 
usually  pio-niented,  smooth  and  less  vascular  than  the  surrounding 
mucosa.  It  has  no  tendency  to  contract  or  pucker  or  to  narrow  the 
lumen  of  the  gut.  AVhen  cicatrization  progresses  in  tiiis  favorable 
manner  the  time  occupied  l)y  the  process  of  healing  is  j)rol)al)ly  aljout  a 
fortnight.  Lesions  are  sometimes  seen  in  which  cicatrization  is  going 
on  in  one  place  while  in  another  active  ulceration  is  in  progress.  When 
death  occurs  during  a  relapse  patches  of  active  ulceration  coexist  with 
the  nearly  healed  ulcers  of  the  primary  attack. 

The  solitarv  glands  of  the  caecum  and  colon  are  involved  in  a  con- 
siderable proportion  of  the  cases.  The  appendix  may  also  be  the  seat 
of  ulceration.  Perforation  of  the  csecum  is  a  rare  event.  The  lesions 
of  the  lymph  structures  of  the  intestine  do  not  in  all  instances  go  on  to 
necrosis.  It  is  probable  that  resolution  without  extensive  necrosis  takes 
place  in  the  abortive  cases  and  in  many  of  the  cases  in  childhood.  This 
process  results  from  fatty  and  granular  changes  in  the  cells  which  under- 
go destruction  and  are  absorbed. 

There  is  associated  with  these  lesions  catarrhal  inflammation  of  the 
large  and  small  bowel,  to  which  must  be  ascribed  many  of  the  intes- 
tinal symptoms,  and  in  particular  the  diarrhoea. 

A  limited  number  of  cases  have  been  reported  in  which  the  symp- 
toms of  enteric  fever  have  occurred,  but  upon  section  the  intestinal 
lesions  have  not  been  found,  although  the  mesenteric  glands,  spleen,  and 
kidnevs  have  been  enlarged  and  congested.  The  presence  of  the  bacilli 
of  Eberth  in  the  affected  organs  is  necessary  to  the  diagnosis  of  enteric 
fever. 

Hemorrhage  from  the  bowels  occurs  in  about  5  per  cent,  of  the  cases. 
It  occurs  at  the  time  of  the  separation  of  the  sloughs.  The  frequent 
occurrence  of  large,  even  fatal,  hemorrhages  points  to  the  implication 
of  arterial  twigs  of  some  size  in  the  necrotic  process.  Adherent  clots 
may  be  found  at  the  source  of  the  bleeding.  Oozing  of  blood  may 
occur  from  the  swollen  borders  of  the  ulcer. 

Intestinal  perforation  occurs  with  about  equal  frequency.  The  open- 
ing may  be  round  or  "  punched  out "  or  slit-like  and  linear.  In  the 
former  case  it  results  from  the  separation  of  a  slough  that  has  involved 
the  wall  of  the  gut  throughout  its  entire  thickness,  including  the  peri- 
toneum ;  in  the  latter  from  tearing  of  the  base  of  an  ulcer  extending 
to  the  peritoneum  in  consequence  of  active  peristaltic  movement.  Per- 
foration occurs  more  commonly  about  the  time  of  the  separation  of  the 
sloughs,  but  it  may  take  place  some  weeks  after  the  defervescence.  In  a 
majorit^^  of  instances  perforations  are  single,  but  two  or  more  may  be 
present.  Their  usual  site  is  within  ten  or  to'elve  inches  of  the  ileo- 
•csecal  valve.  Perforations  of  the  caecum  and  of  the  appendix  are  less 
common.  The  escape  of  intestinal  contents  is  followed  by  infection  of 
the  peritoneum  and  general  peritonitis. 

The  mesextePvIC  glaxds  show  histological  changes  similar  to  those  in 
the  intestinal  Ivmph  structures.  In  the  early  stages  they  are  Inqjertemic 
and  enlarged;  later  they  become  pale,  and  not  infrequently  limited 
necrotic  areas  are  found,  especially  in  the  central  portion  of  the  glands. 
In  the  majorit}^  of  instances  the  lesions  in  the  glands  of  the  mesentery 
imdergo  complete  resolution.  Occasionally  they  soften  or  undergo  cheesy 


176  ENTERIC  OR   TYPHOID  FEVER. 

changes.  They  may  ultimately  be  converted  by  the  deposition  of  lime 
salts  into  hard,  calcareous  masses.  In  other  instances  softening  of  the 
mesenteric  glands  may  result  in  the  formation  of  pseudo-abscesses,  the 
walls  of  which  may  rupture  and  give  rise  to  fatal  peritonitis. 

Other  lymphatic  glands  may  undergo  enlargement,  notably  those  in 
the  fissure  of  the  liver,  the  retroperitoneal  glands,  and  the  bronchial 
glands. 

The  SPLEEN  is  enlarged  in  over  90  per  cent,  of  the  cases  of  enteric 
fever.  Its  structure  shows  changes  analogous  to  those  in  the  lymph 
follicles  of  the  intestines  in  the  earlier  stages  of  the  disease.     It  is  soft, 

pulpy,  and  may  be  even  difflu- 

FiG.  9.  ent.    Upon  section  the  surface 

.  is  brownish  red  in   color,  and 

.  *>-  ..■^',        '"'       > " '  ,;,  hemorrhagic   infarcts    are    fre- 

; .  quently    found.      It   is    liable, 

when    greatly    softened,   to    be 

■    .    ",;n/\i         '^    '  accidentally  ruptured  by  palpa- 

,-\  :  -     ^Vi  ^J^i^  ^A-^'*"  v*  tion,  or  this  accident  may  even 

,.  '"'     :^-'        ■iX^''t^'\>iy^-f'f''   '-^'3       •  occur  spontaneously.     Rupture 

"^  ''^^^^4^'^^^^^th'^^'^ ^  of  the   spleen  occurred  in  five 

-'''f^^^^^i'^oi'ii  instances  among  two  thousand 

"\'WmmW¥}W-:  autopsies  at  the  Munich  Patho- 

7  >{')r:Jv%A',f^V<v^  logical  Institute. 

V-   V  ^^c'^!:^'H'^^V'/'>^i;^^V'^'        ■     ■  The     enlargement    of    the 

,.-',■;      '»^'^-^w!  '       -  spleen  may  be   usually  recog- 

'  '     '  nized   toward    the    end  of  the 

"  *  ,;;  first  week.     It  reaches  its  max- 

■  '  imum  about  the  fourteenth  day, 

Human  spleen,  tenth  day  of  enteric  fever  (Charcot).       when  the  Organ  will  be  found  tO 

be  two  or  three  times  its  normal 
size.  During  the  fourth  week  or  with  the  occurrence  of  defervescence 
involution  rapidly  takes  place,  and  by  the  end  of  the  fifth  week  the  organ 
has  returned  to  its  normal  dimensions.  Persistent  splenic  enlargement 
after  defervescence  points  to  the  possibility  of  a  relapse.  Enlargement 
of  the  spleen  does  not  occur  in  many  of  the  cases  in  advanced  life :  it 
may  also  be  absent  when  the  capsule  has  become  thickened  as  the  re- 
sult of  previous  inflammation,  with  the  formation  of  firm  adhesions  to 
adjacent  structures. 

The  EiVER  early  in  the  course  of  the  disease  is  hypersemic  and  slightly 
enlarged.  Later  it  is  somewhat  pale  and  less  consistent  than  normal. 
The  minute  changes  are  those  of  parenchymatous  degeneration ;  the 
liver  cells  are  granular,  crowded  with  fat,  and  the  nuclei  indistinct, 
often  entirely  absent.  Very  rarely  the  liver  presents  an  appearance 
resembling  that  of  acute  yellow  atrophy. 

Certain  peculiar  changes  occurring  in  the  liver  have  been  described, 
notably  by  Wagner,  who  applied  to  them  the  term  "lymphoid  nodules," 
and  Handford  called  attention  to  the  existence,  late  in  the  disease,  of 
small  necrotic  areas. 

Investigations  recently  conducted  by  Walter  Reed  in  the  pathological 
laboratory  of  the  Johns  Hopkins  University  ^  show  that  the  lymphomata 

^  Am.  Journ.  Med.  Sciences,  November,  1895. 


THE  HEART  AM)   li LOO D VESSELS. 


177 


Human  liver,  tenth  day  of  enteric  fever 
^Charcot). 


of  \\';i»iiu'r  are  in  reality  areas  ol'  iieen»sis.  As  to  whether  tliey  are  duo 
to  the  direct  action  of  the  bacillus  of  Eberth  or  are  caused  by  the  action 
o^f  toxalbuniins  has  not,  as  yet,  been 
definitely  determined.  The  latter  ex- 
planation is  ret;arded  by  Keed  as  the 
more  prol)able,  in  view  of  the  fact  that 
Welch  and  Flexner  ^  have  produced  in 
the  liver  of  guinea-pigs  well  marked 
necrotic  areas  by  the  injection  of  the 
toxalbuniins  of  diphtheria. 

PillvphlcbitU  with  resulting  abscess 
of  the  liver  is  an  exceedingly  rare  c-om- 
plication.  Lannois^  recently  reported 
a  case  of  enteric  fever  in  which  there 
occurred  pylephlebitis  and  multiple 
hepatic  abscesses,  the  presence  of  the 
bacillus  of  Eberth  being  demonstrated 
in  the  pus.  As  a  result  of  his  studies 
of  this  case  and  of  the  literature  upon 
the  subject  the  conclusion  is  reached 
that  the  complication  is  a  rare  one. 
Catarrhal  or  diphtheritic  inflammation 
of  the  gall-bladder  may  be  encountered. 

KiDXEYS. — Parenchymatous  changes  occur.  They  consist  of  cloudy 
swellino;  with  granular  defeneration  of  the  cells  of  the  convoluted  tubules. 
Acute  nephritis  is  an  occasional  complication.  Disseminated  areas  of 
round  cell  infiltration  corresponding  to  the  so  called  lymphomata  of 
Wagner  in  the  liver  and  sometimes  proceeding  to  softening  have  been 
observed.  When  suppuration  occurs  the  appearance  is  that  presented 
by  miliary  abscesses.  Typhoid  bacilli  have  been  found  iu  these  minute 
collections  of  pus.  Diphtheritic  inflammation  of  the  pelvis  of  the  kid- 
ney is  of  rare  occurrence.  The  bacilli  have  been  found  in  the  non- 
albuminous  urine,  more  commonly  when  albumin  is  present  and  in 
cases  of  pyuria. 

Catarrh  of  the  bladder  is  by  no  means  infrequent.  Diphtheritic 
cystitis  is  rare.  Purulent  cystitis  is  usually  due  to  the  use  of  uncleanly 
catheters.  Epididymitis  is  more  apt  to  occur  in  cases  that  have  required 
catheterization. 

The  Heart  and  Bloodvessels. — Endocarditis  occasionally  occurs. 
It  is  usually  sliglit.  Of  two  thousand  post-mortem  examinations  at 
the  Munich  Pathological  Institute^  it  was  present  in  eleven  instances. 
Pericarditis  is  also  a  rare  lesion  in  enteric  fever,  being  found,  according 
to  the  same  statistics,  in  fourteen  cases. 

The  myocardium  shares  in  the  general  wasting  which  accompanies 
the  disease.  The  muscle  of  the  heart  is  relaxed,  flabby,  and  atrophic. 
When  the  organ  is  removed  from  the  body  and  placed  upon  the  post- 
mortem table  it  flattens  out.  Microscopically,  there  is  found  granular 
and  fatty  degeneration  with  small-celled  infiltration  ;  the  fibres  are  iu- 

1  Johns  Hopkins  Hospital  Bulletin,  1892,  vol.  iii.  No.  20. 

2  Revue  de  Medecine,  1895,  No.  11,  p.  909. 

^  Miinehener  medicinische  Wochenschrift,  Nos.  3  and  4,  1891. 
Vol.  I.— 12 


178  ENTERIC  OR   TYPHOID  FEVER. 

distinctly  striated  or  the  striation  is  lost  and  they  are  translucent  and 
granular. 

The  arteries  are  frequently  implicated  in  the  pathological  processes 
of  enteric  fever.  Obliterating  endarteritis  occurs.  It  more  commonly 
affects  the  vessels  of  the  lower  extremities.  Endarteritis  of  the  smaller 
vessels,  especially  of  the  coronary  arteries,  is  not  uncommon.  Prolifer- 
ating endarteritis  involving  the  smaller  vessels  was  found  by  Dewevre 
in  3  of  his  series  of  48  cases.  Venous  thrombi  occur.  They  are  relatively 
common  in  the  femoral  veins  ;  less  so  in  the  cerebral  veins  and  sinuses. 

The  voluntary  muscles  frequently  show  granular  and  fatty  changes. 
These  changes  occur  in  other  infectious  febrile  diseases  and  are  not 
peculiar  to  enteric  fever.  Rupture  of  bundles  of  muscle  fibres  some- 
times takes  place,  giving  rise  to  hemorrhage  into  the  muscles,  and,  less 
frequently,  to  pseudo-abscesses. 

Salivary  Glands  and  Pancreas. — The  cells  of  the  salivary  glands 
and  of  the  paiwreas  frequently  show  granular  degeneration,  and  it  is 
stated  that  these  structures  become  enlarged  and  firmer  in  consistence 
than  normal  early  in  the  disease.  A  suppurative  inflammation  of  the 
parotid  glands — parotid  bubo — sometimes  occurs  as  a  complication  of 
the   disease. 

The  Respiratory  Organs  present  various  and  important  lesions. 
Ulcerative  laryngitis  not  infrequently  occurs.  The  situation  of  the 
ulcers  may  be  in  the  posterior  wall,  upon  the  ary-epiglottidean  folds,  or 
at  the  base  of  the  epiglottis.  Acute  laryngeal  oedema  occasionally 
results,  and  may  necessitate  the  performance  of  tracheotomy.  This 
operation  was  found  necessary  in  8  of  the  20  cases  noted  in  the  statistics 
of  the  Pathological  Institute  of  Munich.  Bronchitis  is  common,  and 
the  bronchial  tubes  show  those  changes  wdiich  underlie  the  various  forms 
of  bronchial  catarrh  in  other  diseases.  The  lungs  show  changes  refer- 
able to  the  twofold  condition  of  an  enfeebled  circulation  and  a  blunted 
condition  of  the  nervous  system.  Broncho-pneumonia  in  enteric  fever, 
as  in  other  so-called  typhoid  conditions  attended  by  an  obtunded  con- 
dition of  the  nervous  system  and  impairment  of  the  laryngeal  reflex,  is 
nearly  always  due  to  the  entrance  into  the  upper  air  passages  and 
bronchial  tubes  of  septic  particles  from  the  mouth  and  pharynx,  either 
by  inhalation  or  during  the  act  of  deglutition.  Such  infection  causes 
bronchial  catarrh,  which  by  extension  involves  the  finer  tubes  and  air- 
vesicles. 

Hypostasis  of  the  dependent  portion  of  the  lung  and  splenization  are 
common.  Many  cases  of  so-called  hypostatic  congestion  are  regarded 
by  Striimpell  as  being,  in  reality,  instances  of  broncho-pneumonia. 
Other  pulmonary  lesions,  more  or  less  frequently  encountered,  are 
putrid  bronchitis,  gangrene,  abscesses,  and  infarction.  Croupous  pneu- 
monia is  a  frequent  complication  due  to  secondary  infection  by  the 
diploGOCCUs  pneumonice,  and  is  usually  encountered  after  the  course  of  the 
disease  has  become  well  established.  Croupous  pneumonia  is,  however, 
in  some  instances  apparently  due  not  to  infection  by  the  diplococcus 
pneumoniae,  but  to  infection  by  the  bacillus  of  Eberth.  Under  these 
circumstances  it  usually  occurs  early  in  the  course  of  the  attack,  and  has 
been  attributed  to  localization  of  the  specific  process.  The  difference 
between  the    two    forms,  however,  is  rather  a  bacteriological  than  an 


,s'>'.i//"/'o.i/,s'  179 

anatomical  one.  la  a  rase  ol"  unnv  in  the  Jc'Hcr.son  Hospital,  Ctjplin 
found  Eberth'.s  bacilli  in  the  pnlnionary  exndate.  Involvement  of  the 
])lenra  is  not  very  common.     Fibrinons  ])lenrisy  and  empyema  occnr. 

The  central  nervous  system  rarely  shows  gross  lesions.  8<^metimes 
sliii'lit  adhesions  of  the  dnra  mater  to  the  craninm  are  found.  Increased 
vascularity  of  the  pia  with  minute  hemorrhages  and  vascular  injection 
of  the  brain  substance  may  occtir  early.  Wlien  death  takes  place  late 
in  the  course  of  the  attack  oedema  and  moderate  distention  of  the  ven- 
tricles are  noted,  and  are  to  be  attributed  to  wasting  of  the  brain  tissue. 
Very  rarelv  large  hemorrhages  or  the  signs  of  a  purulent  meningitis 
are  found.  The  lesions  of  peripheral  neuritis  have  been  frequently 
observed. 

Symptom.s. — General  Clinical  Course. — The  period  of  incubation 
of  enteric  fever  is  variable.  In  general  it  may  be  set  down  as  from 
two  to  three  weeks.  The  incubation  period  in  some  well-authenti- 
cated cases  has  not  exceeded  four  or  five  days.  In  a  case  of  my  own 
in  the  Philadelphia  Hospital  it  was,  so  far  as  could  be  determined, 
only  four  days.  The  onset  is  commonly  so  insidious  that  the  patient  is 
unable  to  designate  the  actual  time  of  the  beginning  of  the  attack. 
Prodromal  symptoms  consist  of  general  lassitude  and  languor,  fatigue 
upon  slight  exertion,  vertigo,  headache,  frontal,  occipital,  or  general, 
but  almost  always  aggravated  toward  evening ;  slight  nausea,  loss  of 
appetite,  and  in  some  cases  fleeting  colicky  pains  in  the  abdomen.  A 
tendency  to  diarrhoea  is  often  present  in  the  prodromal  stage,  or,  if 
absent,  is  easily  induced  by  the  administration  of  mild  laxatives. 

The  facies  soon  becomes  dull,  there  is  slight  impairment  of  hearing, 
and  the  patient  complains  of  aching  of  the  back  and  limbs.  The 
tongue  is  coated,  and  epistaxis,  which  may  consist  of  only  a  few  drops 
of  blood,  a  mere  stain  upon  the  handkerchief,  constitutes  a  sign  of 
diagnostic  importance  at  this  period  of  the  disease. 

These  prodromal  symptoms,  not  well  defined  in  every  case,  continue 
for  a  varying  period,  and  in  some  instances  last  for  a  week  or  more  ;  in 
others,  however,  where  the  infection  is  intense,  characteristic  symptoms 
of  marked  severity  may  develop  within  two  or  three  days  after  the 
occurrence  of  the  primary  symptoms.  In  defeult  of  other  definite  cri- 
teria the  actual  onset  of  the  disease  is  to  be  reckoned  from  the  day  the 
patient  betakes  himself  to  bed,  but,  as  this  event  depends  much  upon 
individual  temperament,  some  difficulty  usually  arises  in  estimating 
definitely  the  date  of  the  beginning  of  the  attack.  The  onset, 
however,  is  rarely  abrupt,  and  is  less  frequently  so  in  adults  than  in 
children ;  it  is  seldom  marked  by  a  decided  rigor,  but  is  in  some 
instances  attended  by  chilly  sensations. 

The  first  iceeh  of  the  disease  is  characterized  by  a  gradual  rise  in 
temperature,  the  subfebrile  temperature  of  the  prodromal  stage  grad- 
ually merging  into  the  steadily  increasing  fever  of  the  first  week. 
The  record  of  each  evening's  temperature  exceeds  that  of  the  previous 
evening  by  a  degree  or  a  degree  and  a  half  of  the  Fahrenheit  scale, 
until  by  the  evening  of  the  fifth  day  it  reaches  1C3°  or  104°  F. 

About  this  time  the  temperature  commonly  attains  the  fastigium,  the 
elevation  which,  in  the  absence  of  complications,  it  is  to  maintain  during 
the  course  of  the  attack. 


180 


ENTERIC  OB   TYPHOID  FEVER. 


The  pulse  is  increased  in  frequency,  and  although  the  volume  is  full 
the  tension  is  low;  it  after  a  time  becomes  dicrotic.  The  skin  is 
usually  hot  and  dry ;  exceptionally  even  at  this  period  it  is  moist  and 
bathed  in  perspiration.  The  headache  of  the  prodromal  stage  increases 
in  severity,  and  epistaxis,  which  may  or  may  not  have  occurred  during 
the  prodromal  period,  is  often  present  during  the  first  week ;  it  is 
usually  slight,  sometimes  considerable.  Muscular  prostration  is  marked  ; 
the  patient's  expression  is  already  dull  and  apathetic,  although  upon 
being  aroused  his  mind  is  clear  and  his  memory  good. 

Sleep  is  restless  and  often  disturbed  by  disagreeable  dreams,  while 
toward  the  end  of  the  first  week  slight  transient  delirium  develops, 
especially  upon  awakening. 

The  lips  are  parched  and  dry,  and  the  tongue,  usually  at  this  period 
moist,  is  swollen  and  covered  with  a  whitish  fur,  thin  or  thick  and 

Fig.  11. 


BOWELS,  NUMBEB 

3 

1 

2 

! 

1 

~ 

1 

1 

_, 

■" 

1 

1 

r 

1 

1 

~ 

~ 

r 

' 

1 

1 

F 

106° 
104° 
103° 
102° 
101° 

Z 

s 

si 

i 

s 

5  3 

i-CL 

i 

i 

< 

i 
< 

S; 

i 

< 

i 

i\i 

< 

s 

< 

s 

s 
<- 

5 

s 

s  : 

=  i 

5 

s 

s 

<■ 

s 

<• 

s 

s 

s 

* 

s 

is 

< 

s 

i 
< 

<■ 

5 

<- 

s 

5 

< 

s 

5 

< 

s 

tt 

a  < 

t  0; 

<■ 

Q.- 

s 

- 

- 

- 

— 

- 

— 

- 

- 

— 

-- 

-- 

s 

^. 

^ 

- 

— 

- 

- 

- 

— 

— 

— 

- 

h 

- 

- 

^ 

^ 

"1— 

- 

" 

nM 

i:: 

1 

2 

r- 

1 

O) 

" 

— 

«a 

— 

CO 

" 

- 

" 

" 

- 

— 

— 

coo 

om 

oo 

^ 

" 

1 

1 

1 

" 

1 

" 

" 

"" 

" 

™ 

- 

^ 

^ 

— 

" 

!!; 

!i! 

- 

:! 

^ 

^ 

^ 

t  _ 

_ 

i 

s 

s 

i 

, 

... 

= 

" 

— 

— 

— 

— 

3 

- 

— 

^- 

p 

— 

— 

— 

— 

— 



-^ 

- 

— 

— 

— 

— 

— 

— 

— 

^ 

~ 

~ 

— 

z- 

— 

— 

= 

E 

V 

z 

E 

E 

V 
- 
- 

1 

r 

I 

E 

-^ 

I 

— 

Z 

- 

- 

- 

^: 

:fi 

t 

/-- 

3 

z\\ 

= 

I 

j 

= 

- 

E 

E 

E 

E 

E 

E 
- 

- 

100° 
99° 
_98° 

I 

~ 

z 

E 

— 

J- 

ff 

} 

1Z 

E 

)1 

- 

E 

E 

[; 

1 

E 

= 

E 

E 

z 

Z 

\ 

1 

1 

E 

n 

E 

E 

E 

- 

z 

_ 

_ 

- 

_ 

II- 

^ 

p- 

— 

^ 

— 

— 

— 

— 

— 

J 

— 

- 

- 

— 

- 

— 

- 

r 

— 

- 

-^ 

4- 

— 

— 

)L 

j- 

- 

- 

i 

-- 

- 

- 

- 

- 

- 

- 

J 

— 

- 

- 

J 

n 

L_ 

r 

— 

, 

_ 

_ 



,_ 



_ 

_ 

J 



L 

c 

_ 

-1 

_ 







_ 







_ 

- 

, 

_ 





_ 

97° 

— 

— 

- 

— 

~ 

— 

— 

— 

— 

— 

S 

— 

^ 

— 

-- 

— 

— 

— 

— 

— 

— 

— 

— 

~ 

p 

ZTT 

— 

K- 

— 

^ 

ki 

— 

~ 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— - 

— 

— 

p- 

— 

— 

— 

— 

— 

■». 

5^ 

1 

^ 

= 

= 

= 

- 

- 

- 

z 

- 

-- 

- 

- 

- 

r 

- 

- 

- 

~ 

- 

- 

z 

- 

z 

;- 

- 

- 

z 

- 

z 

- 

z 

z 

4- 

z 

z 

-^- 

DAY  OF 
DISEASE 

~ 

" 

" 

9 

1 

0 

1 

1 

1 

E 

i:: 

IT 

i.'i 

ir, 

TT 

1 

s" 

1 

9 

20 

-5 

1 

1 

2 

~i 

J 

1 

1 

"2 

5 

26 

"2 

7 

3:: 

28 

^ 

30 

31 

"3 

2 

"3 

3" 

PULSE 
RESP. 

2 

s 

S 

g 

5 

8  58 

s 

2 

s 

f> 

s 

s 

,- 

s 

» 

3 

8S 

~ 

5 

2 

g 

s 

s 

m 

r: 

S 

§ 

Sg 

s 

o 

B 

s 

8 

s 

a  i 

s 

g 

S 

5 

s 

S 

S 

s 

a 

3 

S 

?S 

s 

S 

s 

S 

§ 

s 

sis 

^[s 

r,\-. 

''r 

s|s 

g 

2 

s 

3 

J  S 

?, 

Z 

3 

S 

S! 

s 

?i 

3 

c! 

S 

i  S 

3 

•& 

S 

s 

Si 

£ 

S  ?! 

3 

s 

s 

?; 

S 

s 

85 

26 

27  1 

28 

29 

3'0 

1 

2 

3 

i 

5 

c 

7 

8| 

9 

10 

ii 

12 

13 

M| 

15 

if) 

17 

18 

19 

20 

21 

22  1 

Enteric  fever,  single  relapse  (Pennsylvania  Hospital). 

creamy,  and  limited  to  the  dorsum,  the  margins  and  tip  being  bright 
red.  Appetite  is  lost,  and  there  is  thirst ;  diarrhoea  continues,  although 
in  many  cases  the  bowels  are  confined  at  the  onset.  Diarrhoea  does  not 
at  this  stage  usually  exceed  four  or  five  loose  yellow  stools  in  the 
course  of  twenty-four  hours,  fecal  in  character  and  unattended  by  pain. 
Diarrhoea  may,  however,  be  absent  during  the  entire  course  of  the  dis- 
ease. Toward  the  end  of  the  first  week  tympanites  develops,  and  there 
is  tenderness  elicited  by  pressure  in  the  ileo-csecal  region  or  in  the 
neighborhood  of  the  umbilicus  ;  gurgling  may  also  be  developed  by 
pressure  in  the  right  iliac  region.  Toward  the  end  of  the  first  week  an 
increase  in  the  area  of  splenic  dulness  may  be  detected,  and  the  charac- 
teristic rash  appears  as  rose  colored  spots.  The  urine  is  diminished 
in  quantity,  its  urea  increased,  and  the  chlorides  diminished,  while  fre- 
quently a  trace  of  albumin  is  present.  At  this  period  a  few  scattered 
rales  may  be  heard  over  both  sides  of  the  chest  posteriorly,  especially 


SYMPTOMS.  181 

at  the  ba?^es,  aiul  sliiiht  occasional  cough  may  occur  as  a  symptom  of 
bronchitis  ahnost  from  the  very  onset. 

Tliere  is  usually  pallor  of  the  face,  with  circuuiscrilx'd  flushing  of  the 
checks  ;  the  conjunctivse  are  pale  and  the  pupils  considerably  dilated. 

In  the  f>eco)i(l  ircck  the  symptoms  are  aggravated  ;  the  fever  remains 
high  and  is  continuous  or  subcontinuous  in  type.  The  action  of  the 
heart  is  feeble  and  the  first  sound  weak  ;  the  pulse  varies  in  frequency 
from  90  to  120,  is  less  full  than  during  the  first  week,  and  may  become 
less  dicrotic.  The  expression  is  duller,  the  flush  upon  the  cheeks 
deepens,  and  in  severe  cases  the  face  becomes  slightly  dusky.  The 
headache  now  spontaneously  diminishes.  The  patient  becomes  dull  and 
somnolent,  but  has  little  or  no  sound  sleep ;  he  is  indifferent  and  apa- 
thetic, and  the  dulncss  of  hearing  increases.  When  aroused  and  ques- 
tioned he  commonly  replies  connectedly,  but  usually  in  monosyllables. 
Muscular  movements  are  feeble  and  tremulous  ;  the  tongue  is  dry,  red, 
and  fissured,  often  incrusted  with  sordes  and  protruded  with  difficulty. 
The  patient  lies  upon  his  back,  with  his  eyes  half  closed,  listless,  and 
making  feeble,  wandering  movements  with  his  hands.  The  delirium 
is  usually  wandering  or  muttering  in  character,  and  if  the  case  be 
severe  there  may  be  involuntary  discharges  of  the  urine  and  faeces, 
or  the  urine  may  be  retained.  In  other  cases  delirium  is  active,  even 
maniacal,  and  this  variety  may  develop  suddenly  from  the  wandering 
form.  Tympanites,  diarrhoea,  and  other  abdominal  symptoms  are  more 
marked  ;  fresh  crops  of  the  rash  continue  to  make  their  appearance, 
and  evidences  of  pulmonary  congestion  become  decided.  In  favorable 
cases  defervescence  may  now  set  in. 

In  the  third  iceel:  the  symptoms  are  the  same,  but  more  grave.  The 
loss  of  strength  is  extreme  and  the  emaciation  marked ;  the  muscles  are 
flabby  and  the  cheeks  hollow.  The  pulse  is  feeble  and  accelerated,  and 
sometimes  running  in  character ;  the  rash  continues  to  reappear  in  fresh 
crops ;  free  sweating  is  common  and  sudamina  ajDpear,  especially  upon 
the  abdomen  and  lower  portion  of  the  thorax.  Muscular  movements 
are  tremulous  and  ataxic,  and  subsultus  tendinum  may  occur.  Bed- 
sores may  noM*  make  their  appearance,  and  there  is  danger  of  pul- 
monary complications  and  failure  of  the  circulation.  The  heart's 
action  is  feeble,  the  impulse  faint  or  imperceptible,  and  the  first  sound 
frequently  inaudible.  The  temperature  early  in  the  third  week  usually 
conforms  to  the  remittent  type. 

With  the  fourth  iceel:  the  temperature  range  becomes  intermittent.  This 
period  may  mark,  even  in  grave  attacks,  the  beginning  of  ccmvalescence. 
In  that  case  the  morning  remissions  of  temperature  for  a  few  days  often 
reach  subnormal  ranges.  The  symptoms  ameliorate,  gradual  improve- 
ment takes  place,  the  tongue  cleans,  constipation  replaces  diarrhoea,  the 
area  of  splenic  dulness  decreases,  the  urine  becomes  clear  and  more 
abundant,  and  albumin,  if  present,  disappears ;  the  skin  is  now  bathed 
in  perspiration  •  emaciation,  however,  does  not  stop  until  the  tempera- 
ture -falls  to  normal ;  a  ravenous  hunger  now  develops,  and  is  charac- 
teristic of  the  period.  Convalescence  is  tardy,  and  is  apt  to  be  protracted 
by  complications,  sequels,  or  relapses.  The  temperature  is  at  this  time 
extremely  unstable,  and  recrudescences  of  fever  are  brought  about  by 
slight  causes. 


182 


ENTERIC  OR   TYPHOID  FEVER. 


Special  Symptoms. — Temperature. — In  uncomi^licated  cases  the 
temperature  range  may  be  divided  into  four  periods,  each  of  which  has  its 
special  fever  curve,  the  time  covered  by  each  period  usually  being  one 
week,  but  often  only  five  days,  and  exceptionally  eight  or  nine  days.  This 
typical  temperature  curve  is  modified  by  comj^lications  and  treatment 
and  prolonged  by  relapses  and  sequels.  In  the  stage  of  onset  or  during 
the  first  week  of  the  disease  the  temperature  steadily  rises  until  about 
the  fifth  or  sixth  day,  the  temperature  of  each  evening  being  higher 
than  that  of  the  preceding  evening,  and  the  temperature  of  each  morn- 
ing higher  than  that  of  the  preceding  morning  :  w^hile  this  step-like 
rise,  as  it  has  been  called,  occurs  in  many  cases,  it  must  not  be  regarded 
as  invariable.  In  this  way,  by  the  end  of  the  first  week  a  temperature 
of  104°  or  105°  F.  may  be  reached,  and  the  height  of  the  temperature 
range  established.  This  fever  range,  the  acme  or  fastigium,  indicates 
the  probable  range  of  temperature  in  the  absence  of  complications  through- 

FiG.  12. 


M 

E 

■W 

TJ 

r 

"m 

T 

m" 

— 

M 

E 

M  E 

'me' 

"m 

~ 

M  E 

m" 

- 

M  E 

M 

E 

M  E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

SOWELS     NbMEER 

1 

1 

1 

1 

2 

2 

1 

2 

3   1 

1 

1 

1 

I 

1    1 

1 

1 

1 

2 

1 

1 

105' 

—^ 

-^ 

— 

-^ 

-^ 

-^- 

-U 

— 1 — 

-;- 

—— 

-^ 

- 

-^- 

~^- 

-^- 

-^- 

— 

- 

■— ^? 

■J- 

3::: 

Tl 

7^ 

7^ 

- 

1^ 

^ 

^^:^ 

F'S 

7rj 

T,. 

-^ 

2^ 

s^i 

s^s 

tT^ 

S''5' 

~  ■ 

E 

J 

^ 

■^-' 

■':■'' 

'  ' 

■^ 

'- 

^ 

^ 

■i\ 

% 

^- 

^ 

i 

^ 

(f 

^ 

<- 

1 

± 

f; 

1 

fl- 

f: 

°- 

^ 

1 

<- 

^ 

104' 
103' 
102° 
lOl' 
100° 
99' 

^ 

t;;  . 

3 

"^ 

;. 

J. 

^; 

,^1 

~J_ 

*■* 

^ 

a- 

o 

» 

(» 

o 

= 

o 

<o 

^ 

« 

S^o 

o 

o 

CO 

« 

. 

=■ 

o 

<D 

» 

«■ 

,  - 

^— 

_|- 

^ 

V 

■^ 

^ 

- 

-^ 

- 

- 

- 

- 

— 

- 

- 

p 

— 

^ 

r- 

p 

- 

— 

A 

-y 

-^ 

i 

i 

p 

y 

- 

— 

- 

- 

- 

- 

r- 

- 

p 

-- 

- 

- 

- 

- 

- 

- 

— 

^ 

— 

- 

— , 

— 

- 

— 

-^ 

s- 

- 

- 

— 

- 

- 

- 

— 

- 

-I 

— 

— 

P 

- 

- 

- 

— 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 



J— 

_ 

— 



— 

— 

— 1 

— 

— 

— 

1 

E 

\ 

E 

E 

E 

E 

E 

E 

E 

- 

V 

I 

- 

E 

E 

E 

E 

E 

= 

E 

E 

— 

^ 

E 

= 

E 

= 

E 

— 

1 

E 
= 

E 

98' 
97° 

1 

E 

~ 

E 

E 

? 

E 

— 

r 

E 

r 

To" 

1 

1 

T 

E 

~ 

- 

T 

1 

s 

1 

17 

T 

8 

2 
1 

9 

5 

0 

i 

T 

^ 

S 

F 

1 

3 

21 

1 

5 

PULSE 

" 

= 

s 

s 

^ 

?  ~ 

s 

j-g 

■g 

= 

S5- 

p: 

ss 

■g 

« 

s 

3 

5 

; 

sN 

s 

s 

s 

5 

sb 

g 

t 

RESP. 

g 

^ 

= 

u 

2 

t; 

= 

s  2 

s 

?l 

?i 

S 

s 

2 

SS 

s 

s 

5  S 

s 

5 

%:s 

-. 

S 

s 

3 

?. 

- 

s|s 

- 

- 

S 

S 

?;- 

7, 

' 

DATE 

26 

27 

28 

29 

30 

1 

2 

3 

i 

5 

G 

T_ 

s 

0 

10 

U_ 

12 

13 

IJ^ 

15 

1 

B 

Abortive  form  of  enteric  fever,  complete  defervescence  on  the  13th  day  (Pennsylvania  Hospital). 

out  the  course  of  the  case.  Thus,  if  the  temperature  range  be  high  upon 
the  fifth  or  sixth  day,  the  case  is  likely  to  prove  one  characterized  by 
severe  pyrexia ;  on  the  other  hand,  if  at  this  period  the  fever  be  of 
moderate  degree,  the  case  is  likely  to  pursue  a  mild  febrile  course. 
After  the  fastigium  is  attained,  and  during  the  course  of  the  second 
week,  the  temperature  becomes  subcontinuous  in  type,  the  variations 
between  the  morning  remissions  and  evening  exacerbations  correspond- 
ing to  the  diurnal  variations  of  the  normal  temperature.  Toward  the 
end  of  the  second  week  or  at  the  beginning  of  the  third  week  marked 
variations  between  the  morning  and  evening  temperatures  usually  occur, 
and  the  fever  curve  becomes  distinctly  remittent  in  type,  the  extent  of 
the  remissions  being,  at  times,  as  much  as  three  or  four  degrees.  It 
is  at  this  period  of  the  disease  that  free  sweating  with  sudamina  is  apt 


S)MI'1'()MS. 


183 


to  (U'ciir.  With  the  (Iccliiic  <il'  the  I'cln'ilc  jji-occss  the  tcinpfratiirc 
raiiiiT  a^suiiu's  at  the  cud  ol"  thr  thii'd  week  or  (lurin<i'  the  ioiirth 
week  an  iiitcnnittcnt  type.  At  this  ju'riod,  while  the  evenin";-  tempera- 
ture may  sliow  a  marked  febrile  rise,  the  morning  temperature  is  nor- 
mal or  even  below  normal.  The  evcninjr  temperature  upon  each  suc- 
ceeding day  shows  a  progressively  diminished  rise,  until  the  range  of 
health  is  reached,  the  establishment  of  convalescence  not  takiiiu-  place 
until  the  evening  temperature  ceases  to  rise  above  the  normal. 

Departures  from  the  tyj)e  of  the  fever  curve  frequentlv  occur.  In 
some  cases,  instead  of  the  gradual  rise  in  the  temperature  charac- 
terizing the  first  week  of  the  disease,  an  abrupt  rise  takes  place,  and 
it  is  in  this  class  of  cases  especially  that  the  onset  of  the  disease  is 
accompanied  by  a  chill  or  chilliness.  Again,  the  defervescence,  in.stead 
of  occurring  during  the  fourth  week  and  occupying  several  days,  may 

Fig.  13. 


mTF 

mIT 

MjE 

^ 

j?]r 

N? 

T 

ME 

mTT 

mT 

ME 

mT 

M  E 

m.'e 

w 

V 

1^ 

M  E 

mT 

M  E 

wTi 

m"F 

''^'JijAT.^' 

1 

l| 

1 

ill 

1 

1  1 

ill 

1 

1  1 

ll 

1 

ill 

1 

\ 

1 

■'2 

I 

1 

TEMP. 
105' 

104" 

P03° 

102' 

lor 

lOO' 

- 

-    " 

-,- 

_!_ 

_'_ 

___ 







_ 



_^ 

, 

1 



j 

—J 

-; 

i 

^  •- 

_; 

-<-r 

fi 

S_J 

TX 

S^ 

|1 

5_^ 

-H 

H 

H- 

H 

it; 

?    5 

S-J 

zr:2 

2  ^ 

:sr^ 

- 

=j| 

?» 

<•- 

<    1 

•«  - 

<  - 

« 

- 

Z'^ 

_,„ 

a  = 

i..n 

»!i 

:D.3 

JtO 

a.s 

a. a 

r-i 

S'S 

a-i: 

-•3 

a   = 

«)■« 

a    - 

a   a 

a  a 

- 

z 

— 

— 

— 

^Z 

= 

2.1 

^ 

El 

^- 

— 

^ 

zc 

EE 

^ 

za 

~^ 

z^ 

^z 

z'z" 

zn 

Zjii 

z:z 

zp 



t 

— 

— 

— / 

— 

U^ 

-i- 

; 

-7 

/ 

/ 

% 

_„ 

' 

! 

. 



. 





1 

V 

h 

—j- 

—  f 



—r- 





^— 

1 

— 

—r- 

s 

ir- 

S^ 

k 

= 

= 

= 

^ 

= 

= 

^ 

99' 
98' 

^ 

— 

^ 

^ 

r- 

__ 

f 

i 

g 

i 

b 

P 

^ 

rf~ 

^ 

^ 

1 

1 

97' 

^ 

zzz 

lr= 



— 

^— 

— 



— 

T=. 

1:;= 

:^ 

= 

3= 

§,il&% 

0 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

IS 

19 

20 

21 

32 

23 

24 

25 

26 

PULSE 

1° 

=,s 

sis 

ils 

^\s 

g'f-' 

g';: 

s's 

j's 

.^,f-' 

Si 

s  = 

SIS- 

=  lj. 

s,s 

i;  ■- 

S   5 

SS 

,^  -1 

ss 

t 

S 

RESP. 

^js? 

?M 

?;js 

fk: 

s~ 

"?: 

r^  ?. 

i'H 

£  E 

i  E 

E  S 

£  E 

eIs 

-=Ie 

=  E 

E  E 

E  2 

S,s 

-?^ 

S 

3 

DATE 

c 

■ 

..s 

0 

10 

11 

12 

13 

14 

15 

16 

17 

IS 

19 

■^^.. 

21 

22 

23 

24 

±6J 

Mild  enteric  fever,  Typhus  levissimus  i  Pennsylvania  Hospital). 

set  in  very  much  earlier  and  be  much  shorter  in  duration,  the  tempera- 
ture declining  by  a  rapid  lysis,  exceptionally  by  crisis — the  abortive  form. 
In  a  group  of  cases  in  which  the  clinical  phenomena  are  well  marked 
the  fever  terminates  by  a  gradual  fall  during  the  course  of  the  second 
or  early  in  the  third  week — typhus  levissimus.  These  aberrant  forms  of 
the  temperatm-e  curve  are  rare.  Still  more  rare  are  cases  characterized 
by  an  inverse  temperature,  the  morning  temperature  being  for  some 
days  or  occasionally  higher  than  that  of  the  evening,  in  the  absence  of 
complications.  It  is,  however,  very  common  for  the  temperature  curve 
to  be  interrupted  by  intercurrent  diseases ;  thus,  if  pulmonary  com- 
plications occur  the  temperature  may  assume  a  higher  range  and  its 
course  be  protracted  and  irregular.  As  a  rule,  the  temperature  range 
corresponds  to  the  intensity  of  the  infective  process,  and  when  a  high 
temperature  is  continuously  maintained  the  prognosis  must  be  regarded 


184 


ENTERIC  OR   TYPHOID  FEVER. 


as  unfavorable.  Tlae  converse  of  this  statement  is,  however,  not  to 
be  assumed,  since  grave,  even  fatal,  cases  occasionally  occur  in  which 
the  temperature  does  not  rise  above  102°-103°  F.  during  the  whole 
course  of  the  attack.  A  sudden  drop  in  the  temperature,  especially 
when  occurring  in  the  course  of  the  second  or  third  week  of  the  attack, 
must  be  regarded  with  anxiety,  as  it  usually  indicates  the  presence 
of  some  serious  complication.  Thus  intestinal  hemorrhage  is  almost 
always  attended  by  a  sudden  fall  in  temperature,  often  of  several  degrees, 
and  frequently  before  the  blood  makes  its  appearance  in  the  discharges 
from  the  bowel.  The  same  phenomenon,  accompanied  by  symptoms  of 
shock,  may  also  attend  the  occurrence  of  intestinal  perforation,  and  the 
onset  of  croupous  pneumonia  as  a  complication  of  enteric  fever  is  occa- 

FiG.  14. 


M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

u 

E 

M 

f 

M 

I' 

M 

P 

17 

P 

" 

M 

E 

M 

F 

M 

-■ 

M 

f 

m'f 

i 

1 

1 

1 

I 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

TEMP. 
105° 

104° 

103° 

102' 

101° 

100° 

99° 

98° 

5" 

rs 

s 

^ 

2 

5 

^ 

? 

^ 

::= 

? 

E 

^ 

5 

^ 

s 

S 

^ 

^ 

:^ 

5 

J 

3'S 

- 

~ ':? 

5 

s 

5^ 

o 

< 

1 

o 

^ 

* 

ax 

< 

■>■- 

<- 

< 

0- 

< 

0- 

< 

t 

•"   - 

■'  - 

<.a 

•*— 

i 

^.- 

h,- 

^ 

o 

a> 

m 

»:■ 

^• 

-^ 

OJ 

to 

«; 

, 

to 

lO 

to 

» 

ai 

-•x 

■c     r 

i'tr 

^l— 

— 

— 

— 

- 

i— 

- 

— 

n 

— 

-^- 

A 

^^- 

^— 

-^— 

— ;— 

-Jf— 

_ 

l~ 

— 



i 

- 

z 

2- 

^ 

1 

ztz 

=P 

— 

fe 

- 

-^ 

i 



— 

— * 

A 

F 

-}— 

-"■- 

_L_ 

- 

■ 





_ 



_ 



_ 

. 

._ 

_ 

. 

E 

E 

E 

E 

~ 

E 

E 

E 

E 

E 

E 

^ 

3. 

7^ 

EE 

zrz 

EE 

-   k- 

E 

- 

ztz 

= 

E 

- 

1 

£ 

5 

a;_ 

f\— 

~_ 

z 

*iz 

z 

- 

- 

Z 

z 

z 

z 

z 

z 

z 

z 

z 

- 

z 

z 

z 

z 

z 

Z 

zjz 

'V 

V 

'l 

; 

97° 

= 

E 

EE 

E 

E 

E 

E 

E 

E 

E 

E 

E 

E 

E 

= 

E 

= 

= 

- 
Z 

— 

-j/ 

]l 

i 

DAY  OF 

1 

1 

12 

1 

3 

1 

4 

15 

1 

6 

1 

7 

1 

8 

1 

r 

20 

"tr 

~~' 

Zi 

IT 

4 

au 

^ 

PULSE 

lis 

s 

g 

g 

S 

s 

g 

g 

s 

s 

■g 

ss 

s 

s 

g 

s 

f2 

s 

» 

g 

g 

g 

.?: 

;j 

s 

,- 

,T 

ga 

g 

RESP. 

S 

T, 

S 

S 

fi" 

s: 

T. 

?, 

j; 

S 

ss 

SJ 

H 

s 

s 

s 

s 

s 

S 

s 

2 

s 

s 

S 

s 

? 

2 

5S 

s 

DATE 

24 

25 

26 

27 

28 

29 

30 

31 

1 

2 

3 

4 

5 

0 

7 

8 

0 

Enteric  fever,  subnormal  temperature  after  defervescence  (Pennsylvania  Hospital). 

sionally  attended  by  a  brief  fall  in  temperature.  Very  high  tempera- 
ture, so  common  in  typhus  fever,  relapsing  fever,  and  in  other  acute 
infectious  diseases,  observed  as  an  early  manifestation,  is  to  be  regarded 
as  an  evidence  of  intense  infection  or  of  the  occurrence  of  an  early 
complication.  Hyperpyrexia  may  occur  as  a  preagonistic  phenomenon. 
During  convalescence  the  temperature  for  the  first  few  days  fre- 
quently remains  below  normal.  Its  chief  characteristic,  however,  at 
this  period,  is  its  instability,  its  liability  to  be  disturbed  by  trifling 
causes.  Thus,  even  after  the  temperature  has  been  normal  for  a  number 
of  days  rises  may  take  place  as  the  result  of  dietary  errors,  constipa- 
tion, the  visits  of  friends,  emotional  disturbances,  and  like  simple  causes. 
Such  recrudescences  of  fever  commonly  last  some  hours,  very  rarely 
more  than  a  day  or  two.  As  recrudescences  sometimes  follow  the 
first  taking  of  solid  food,  this  brief  fever  of  convalescence  has  been 
called  febris  carnis.  In  other  instances  after  the  establishment  of 
convalescence  the  temperature  continues  to  range  at  subfebrile  levels — 


SYMPTOMS. 


185 


100°-101°  F.  This  l)0(l-fV'vor,  ns  it  has  I)o(mi  tormod,  is  to  bo  ascrihcl 
to  the  influence  U])()n  an  unstable  teniperatiu-c  of  the  retention  witliiii 
the  body  of  tlie  pnxhiets  of  waste,  the  elimination  of  which  has  been 
interiered  with  by  the  inactivity  of  the  skin  and  the  constipation  cha- 
racterizing early  convalescence.  So  soon  as  the  ])atient  is  allowed  to  be 
out  of  bed  constipation   usually  ceases,  the  skin   becomes  more  active, 

Fig.  15. 


104° 

103° 

102 

101 

100= 

99° 

NORMAL 

98' 

97- 

DAY  OF 

DISEASE 

PULSE 

DATE 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

? 

M 

E 

M 

F 

M 

E 

1 

1 

1 

II 

1- 

= 

1 

1 

1 

1 

1 

1 

= 

- 

1 

_ 



_ 

_ 

^_ 

_^ 

_ 

_. 

^ 

^_ 



_,^_ 

^_ 

_ 

i 

r 

— 

z 

z 

Zj 

H 

Z 

- 

^ 

\~f\ 

^ 

^ 

=! 

p-; 

— 

~ 

— 

— ] 

— 

— 

— 

— 

^ 

v/ 

— 

Vt/ 

\i/ 

i 

0 

6 

7 

S 

9 

10 

11 

12 

13 

u 

15 

16 

17 

18 

19 

|l 

S|  = 

5  S 

5|S 

=  1= 

s's 

'\~- 

^¥ 

-|Si 

S|. 

U\i 

-  - 

s|S 

^ 

i!S 

^1= 

29 

I 

2 

3 

] 

5 

c 

7 

8 

'J 

10 

11 

12 

13 

H 

Enteric  fever,  mild  case :  normal  temperature  11th  day ;  recrudescence  loth  day,  due  to  constipa- 
tion, and  terminating  after  movement  of  bowels  on  the  17th  day  (German  Hospital). 

and  elimination  in  general  more  effective.  Under  these  influences  the 
subfebrile  temperature  rapidly  falls  to  normal.  Cases  of  enteric  fever 
pursuing  an  afebrile  course,  although  the  disease  possesses  otherwise 
characteristic  features,  have  been  described.  This  must  be  regarded  as 
a  very  rare  form  of  the  disease.  Such  cases  are  certainly  almost 
unknown  in  this  country. 

The  temperature  range  of  the  relapse  usually  corresponds  to  that  of 
the  original  attack  ;  the  fastigium  is,  however,  more  quickly  attained 
and  defervescence  occurs  earlier. 

Circulatory  System. — The  pulse-frequency  corresponds  to  the  in- 
tensity of  the  fever,  but  not  so  closely  as  is  usual  in  febrile  diseases. 
Enteric  fever  is  a  fever  of  relatively  slow  pulse.  Its  frequency  is  ex- 
tremely susceptible  to  variations,  and  may  be  greatly  modified  by  slight 
causes,  such  as  change  in  posture  or  movements  in  bed.  In  severe  eases 
it  becomes  irregular  in  rhythm  and  force — phenomena  of  unfavorable 
prognostic  import.  In  the  first  week  the  volume  of  the  pulse  is  full, 
but  its  tension  low,  and  at  this  period  the  pulse  is  freqnentlv  alreadv 
dicrotic.  Dicrotism  is  important  from  a  diagnostic  standpoint ;  it  is 
rarer  in  childhood  than  in  adult  life.  During  the  first  week  the  pulse 
is  usually  though  not  invariably  above  100,  but  later,  in  severe  cases, 
it  may  become  greatly  accelerated  and  very  weak.  Coldness  of  the 
extremities  and  lividity  of  the  surface  are  also  indications  of  enfeebled 
circulation,  and,  as  collapse  may  develop  from  this  condition,  are  always 
to  be  regarded  as  symptoms  of  immediate  gravity. 

With  the  onset  of  convalescence  the  pulse  gradually  returns  to  nor- 


186  ENTERIC  OR   TYPHOID  FEVER. 

mal.  Its  frequency  is  usually  accelerated,  but  a  slow  pulse  is  not  un- 
common, and  instances  of  a  fall  so  low  as  forty  or  even  thirty  beats  to 
the  minute  are  occasionally  observed  (bradycardia). 

The  heart's  action  in  mild  cases  and  during  the  early  period  of  the 
disease  is  but  little  disturbed,  but  in  severe  cases  the  force  of  the 
impulse  progressively  diminishes  until,  toward  the  close  of  the  second 
week,  it  becomes  extremely  feeble  or  almost  imperceptible,  and  the  first 
sound  very  faint  or  inaudible.  Occasionally  there  develops  a  faint 
systolic  bruit  at  the  apex.  Pericarditis  and  endocarditis  are  of  rare 
occurrence.  Myocarditis,  however,  is  more  frequent,  and  the  cardiac 
weakness  shown  in  the  feeble  impulse  and  faint  first  sound  is  due  in 
part  at  least  to  degenerative  changes  taking  place  in  the  myocardium, 
and  in  part  to  functional  disturbance  of  the  nervous  system.  Under 
these  circumstances  sudden  death  may  take  place  as  a  result  of  car- 
diac failure.  Slight  oedema  of  the  ankles,  dependent  upon  cardiac 
weakness  and  anaemia,  may  occur  in  early  convalescence. 

The  blood  has  been  carefully  studied  by  Thayer,^  who  found  the 
number  of  red  corpuscles  at  the  beginning  of  the  fever  usually  normal. 
During  the  first  weeks  the  number  of  corpuscles  falls  gradually,  but  to 
a  relatively  slight  extent.  The  fall  is  more  rapid  upon  defervescence, 
reaching  its  lowest  point  about  the  first  week  of  convalescence.  Re- 
covery from  this  anaemia  is  gradual.  As  a  rule,  the  decrease  in  the 
number  of  red  corpuscles  bears  direct  relation  to  the  severity  of  the 
case,  but  grave  anaemia  may  follow  cases  that  appear  to  be  mild.  Severe 
post-typhoid  anaemia  may  constitute  a  grave  sequel  of  the  attack. 

The  haemoglobin  diminishes  with  the  red  corpuscles  and  to  a  greater 
proportionate  extent.  Its  return  to  the  normal  is  less  rapid.  The  leu- 
cocytes are  at  the  beginning  about  normal,  but  their  number  gradually 
falls,  reaching  the  lowest  point  about  the  end  of  defervescence.  The 
diminution  is  slight ;  the  return  to  normal  is  gradual.  The  absence  of 
leucocytosis  may  in  a  suspected  case  be  of  diagnostic  value. 

Venous  thrombosis,  especially  affecting  the  veins  of  the  lower 
extremities,  and  most  frequently  a  crural  vein,  occurs  in  about  1  per 
cent,  of  the  cases.  Its  time  of  occurrence  is  usually  late  in  the  course 
of  the  disease  or  during  convalescence.  It  is  manifested  by  rapidly  on- 
coming oedema  of  the  extremity,  with  pain.  The  acute  phenomena 
usually  subside  in  the  course  of  a  few  weeks ;  permanent  oedema  with 
difficulty  in  walking  often  results.  It  sometimes  happens  that  a  portion 
of  the  thrombus  becomes  dislodged.  The  left  crural  vein  is  more  fre- 
quently involved  than  the  right. 

Respiratory  System. — The  frequency  of  the  respiratory  movements 
varies  with  the  intensity  of  the  febrile  process.  Pulmonary  symptoms 
are  among  the  most  frequent  and  important  manifestations  accompany- 
ing enteric  fever,  although  for  the  most  part  they  are  to  be  regarded  as 
complications  rather  than  as  direct  results  of  the  specific  infection. 

Bronchitis  is  very  common.  It  is  usually  an  early  manifestation, 
and  therefore  may  have  diagnostic  importance.  Its  existence  is  revealed 
by  rales,  usually  at  first  dry  and  scattered.  In  cases  of  moderate  sever- 
ity the  bronchitis  has  no  important  bearing  upon  the  course  of  the  dis- 
ease ;  in  the  graver  cases  it  often  extends  to  the  finer  tubes. 

^  Johns  Hopkins  Hospital  Reports,  vol.  iv.  No.  1. 


DldESTI 1 7-;  SYSTEM.  1 87 

Bro)irlio-p)}eiimo))!(i  may  (Icvoloj)  in  I'literic  fever,  as  in  other  diseases 
attended  hy  ui-eat  jji-ostnitioii  ot"  the  nervous  system,  as  an  inlialation  or 
deglutition  jjueuniouia.  Ilypostatie  congestion  and  o-dema  in  tlie  Uit<'r 
periods  of  the  disease  are  common,  and  are  to  be  ascribed  to  enfeeble- 
ment  of  the  circuhition  and  the  lowered  tone  of  the  nervous  system. 
Striimpcll  is  inclined  to  look  upon  many  of  the  instances  usually 
rejranled  as  cases  of  hypostatic  congestion  as  in  reality  broncho-|)neu- 
monia.  The  physical  signs  are  impairment  of  resonance  at  the  bases 
posteriorly,  feeble  and  distant  respiratory  murmur,  and  tine,  moist  rales, 
chiefly  inspiratory. 

Croupous  pneainonia  may  occur  as  a  complication  of  enteric  fever, 
usuallv  in  the  second  and  third  weeks.  In  the  majority  of  instances  it 
is  to  be  regarded  as  a  true  complication  dependent  upon  a  secondary 
infection  with  the  pncumococcus.  It  may  be  overlooked  unless  the 
chest  be  systematically  examined,  as  the  subjective  symptoms  are  not 
marked.  Croupous  pneumonia  may  develop  early,  the  onset  of  the 
affection  being:  abrupt,  with  a  chill,  and  the  pulmonary  phenomena  so 
dominating:  the  clinical  picture  as  to  obscure  the  signs  of  enteric  fever. 
After  the  first  week,  however,  intestinal  phenomena,  enlargement  of 
the  spleen,  rose  spots,  and  the  subsidence  of  lung  symptoms  enable 
the  diagnosis  of  enteric  fever  to  be  made.  In  such  cases,  known  as 
pneumo-typhus,  the  pulmonary  lesion  is  probably  due  not  to  infection 
by  the  pneumococcus,  but  to  an  early  pulmonary  localization  of  Eberth's 
bacillus. 

Pleurisy  occasionally  occurs  as  a  complication  of  enteric  fever. 

Catarrhal  laryngitis  is  sometimes  met  with,  and  laryngeal  perichon- 
dritis, with  or  without  accompanying  ulceration,  may  occur,  the  lesions 
usually  involving  the  posterior  wall  or  the  base  of  the  epiglottis, 
CEdema  is  liable  to  occur  in  association  with  ulceration  or  perichondritis, 

Epistaxis  is  a  common  symptom.  It  may  appear  in  any  period  of  the 
disease.  It  is  commonly  slight,  but  profuse,  even  serious,  nose  bleeding 
may  occur.  Striimpell  mentions  a  case  in  which  a  fatal  issue  resulted. 
Very  commonly  during  the  period  of  prodromes,  and  often  during  the 
course  of  the  disease,  it  amounts  to  nothing  more  than  a  stain  upon  the 
handkerchief  caused  by  picking  at  the  nostrils.  Ulceration  of  the 
nasal  mucous  membrane  is  occasionally  seen,  and  the  fact  that  the  nasal 
septum  may  be  perforated  or  necrosis  of  the  cartilages  may  follow  with 
resulting  deformities  should  be  borne  in  mind,  lest  subsequently  the 
lesions  may  in  any  case  give  rise  to  the  suspicion  that  the  patient  has 
had  s^i^hilis. 

Dig-estive  System. — Marked  disturbance  of  the  digestive  system 
occurs,  and  symptoms  referable  to  the  gastro-intestinal  tract  very  often 
for  a  time  dominate  the  clinical  picture,  while  those  dependent  upon  the 
general  constitutional  infection  assume  a  subordinate  role. 

Anorexia,  as  a  rule,  occurs  early  and  is  complete.  It  usually  persists 
until  defervescence.  At  this  time,  however,  hunger  is  often  urgent. 
Thirst  is  a  prominent  symptom,  and  even  when  the  patient's  mental 
condition  becomes  such  that  he  fails  to  demand  fluids,  he  drinks  them 
with  avidit}"  when  proffered. 

The  tongue  early  in  the  course  of  the  attack  is  moist,  swollen,  and 
usually  covered  with  a  whitish  fiir ;  later,  the  coating  clears  off  from  the 


188  ENTERIC  OR   TYPHOID  FEVER. 

edges  and  tip,  which  are  often  of  a  bright  red  color.  The  tongue  may- 
remain  moist  throughout,  but  in  severe  cases  it  soon  becomes  dry  and  is 
covered  with  a  dark  brown  coating  with  numerous  cracks  and  fissures. 
Such  a  tongue  may  bleed,  and  this,  together  with  oozing  from  the  gums, 
leads  to  the  accumulation  upon  the  teeth,  lips,  and  gums  of  a  collection 
of  material  consisting  of  clotted  blood,  retained  food,  and  cast-off  epi- 
thelium, to  which  the  name  of  sordes  is  given.  This  condition  may  be 
to  a  large  extent  averted  by  careful  and  systematic  cleansing  of  the 
mouth.     The  tongue  cleans  off  upon  the  occurrence  of  convalescence. 

The  lips  are  cracked  and  dry,  and  the  buccal  mucous  membrane  dry 
and  sticky. 

The  pharynx  is  not  infrequently  the  seat  of  a  catarrhal  inflammation. 
Membranous  pharyngitis  occurs  in  rare  cases  and  is  of  serious  import : 
the  false  membrane  may  extend  into  the  oesophagus. 

Faucial  angina,  occurring  coincidently  with  a  diffused  erythema 
upon  the  surface  of  the  body,  as  happens  in  a  small  proportion  of  the 
cases,  may  give  rise  to  a  suspicion  of  scarlet  fever. 

From  the  pharynx,  by  extension  of  the  infection  through  the  Eusta- 
chian tubes,  the  middle  ear  may  become  involved,  and  suppurative  otitis 
media  take  place  with  perforation  of  the  tympanum.  This  condition 
may,  owing  to  the  patient's  mental  condition,  be  overlooked.  Not  infre- 
quently, and  usually  in  the  third  week  of  the  disease,  parotitis — parotid 
bubo — develops  in  consequence  of  infection  by  Avay  of  the  duct  of  Steno. 
This,  though  usually  unilateral,  may  involve  both  glands.  Its  usual 
termination  is  by  suppuration,  and  its  occurrence  adds  greatly  to  the 
gravity  of  the  prognosis.  Inflammation  of  the  middle  ear  and  of  the 
parotid  gland  is  the  result  of  secondary  infection. 

Nausea  and  vomiting  occasionally  occur  early  in  the  disease.  They 
are  much  more  common  as  manifestations  of  enteric  fever  during  child- 
hood than  during  adult  life.  Repeated  vomiting  is  a  serious  symptom 
and  of  unfavorable  import,  since  it  is,  as  a  rule,  to  be  ascribed  to  a 
complication,  such  as  nephritis,  a  cerebral  lesion,  or  developing  peri- 
tonitis. Vomiting  under  these  circumstances  does  not  occur  early, 
but  is  a  late  manifestation  of  the  disease.  In  certain  rare  instances 
vomiting  is  so  persistent  that  death  from  exhaustion  may  ensue,  and 
in  some  of  the  cases  ulceration  of  the  stomach  has  been  found  after 
death. 

Symptoms  referable  to  the  intestinal  tract  are  constant.  In  the  early 
days  of  the  disease  constipation  is  the  rule,  and  in  not  a  few  cases  this 
condition  continues  throughout  the  entire  course  of  the  attack.  The 
diarrhoea  is  usually  proportionate  to  the  severity  of  the  attack  and  to 
the  extent  of  the  local  intestinal  lesions.  This  is  not,  however,  inva- 
riably the  case.  Even  extensive  lesions  of  the  glands  of  the  small  intes- 
tine may  be  present,  while  the  colon  contains  solid  fgeces. 

Diarrhoea  is  common  toward  the  end  of  the  first  and  during  the  course 
of  the  second  week.  It  may  not,  however,  occur  until  toward  the  close 
of  the  attack.  It  is  to  be  ascribed  in  part  to  the  local  ulceration,  but  is 
chiefly  due  to  the  accompanying  intestinal  catarrh,  especially  to  catarrh 
of  the  large  intestine.  The  number  of  stools  in  the  course  of  twenty- 
four  hours  varies  from  four  or  six  to  fifteen  or  twenty.  They  are  usu- 
ally copious,  in  odor  offensive,  in  consistency  thin,  in  color  yellowish  or 


DIGESTIVE  SYSTEM. 


189 


ochre  yellow,  soinctinies  u;reenisii,  in  reacti(»ii  alkaliiie,  and  arc  V(»i(l('<l 
without  pain.  They  tVeijiieiitly  contain  milk  curds,  and  later  in  the 
course  of  the  attack  shreds  of  necrotic  tissue  from  the  slou(j:hs.  Micro- 
sco])ically,  the  stools  contain  frajiiuents  of  food,  lar^c  nunihers  of  crystals 
of  tri])le  ])hos|)hatc,  epithelia,  and  various  bacteria.  The  bacillus  of 
Ebertli  is  not  usually  found  in  the  intestinal  discharges  earlier  than  the 
tenth  day,  frequently  not  until  the  sixteenth  day. 

T(/mpan!fe.s  is  common.  It  usually  occurs  during  the  second  week. 
It  is,  as  a  rule,  slight,  but  may  be  excessive.  Great  abdominal  disten- 
tion is  sometimes  associated  with  deep  ulceration,  and  must  always  be 
regarded  as  of  unfavorable  })rognostic  import. 

Abdominal  tenderness  may  be  elicited  upon  gentle  pressure  in  the 
majority  of  the  cases.  Its  most  common  seat  is  in  the  right  iliac  fossa ; 
sometimes  it  is  restricted  to  the  neighborhood  of  the  umbilicus;  rarely 
it  is  general.  Pressure  in  the  right  iliac  fossa  very  often  elicits  gur- 
gling— a  sign  of  minor  importance  from  the  standpoint  of  diagnosis, 
since  it  is  present  in  many  other  conditions. 

Spontaneous  abdominal  pain  is  not  common  in  enteric  fever,  It  may, 
however,  arise  in  consequence  of  extensive  or  deep  ulceration,  and  is  pres- 
ent in  local  peritonitis. 

Fig.  16. 


a-i«ELS.KU«BtP. 

1    ! 

j 

I- 1 

1  1 

\  i  1 

!     t     1     1 

1           1  1  ■ 

1 

Mill 

iii:ii 

F 

'  >  i 

-forrT;- 

2- 

s-j-s- 

pr 

?J 

L^t^ 

fe 

3? 

s  sl-s^s-;-s-s-s 

i^i^i^i 

S 

■i'-i 

S 

■2 

s 

E    S 

S 

s 

-s 

■k-i^ii^ 

S^*2-S- 

„ 

U 

:?- 

•5- 

!f4? 

^^o 

EJ- 

^n.-io   3--olo^o-o 

?•?-?-? 

-£ 

r^.^ 

tf>. 

s+ 

0.0 

*S 

o 

.*-:*'.}- 

a 

< 

O  105° 

E  »- 

°103° 
102" 
101° 

100° 

1- 

5     89° 

S 
< 

S     98° 

1- 

O          ^ 

3     97' 

< 

1-  * 

UJ 

a 

DAY  OF 

DISEASE 

PULSE 
RESP. 

—  -^ia 

2121 

^ 

m4*- 

J.i<- 

o|~-|cJ- 

.■:\^^^im 

* 

^ 

a>- 

o-.< 

v«- 

*- 

['^ 

■"-f'rS";:^- 

' 

;       : 

'           '           1 

! 

1      1 

I    1    1                 ■    ■■, 

l.i      ; 

i   1   A            /\ 

A 

~^ 

— 1 

!    1    M    1 

^-^— ^-^»^ 

-/\ ^^ 



-1— 1 

— , 

- 

— 

— 

- 

- 

y\^  '  '     V  '  :  :  i   -^   :•; 

V">     \        ;   ' 

— 

— 

^ 

L 

- 

^>b>i 

*r^ 

^          A            1 

/  V 

^    m.     /\                     / 

\ 

/    • 

T 

N/  \       M 

r 

\    VI   / 

V                    ' 

* 

•     7 

\ 

\    /    \  / 

A'  / 

1           ' 

i_i;\/      ^i 

\ 

'   / 

\    ' 

•       1           \/ 

■s 

,T 

\.       '    1    J 



, 

H 

~ 

- 





1 , 

^ 







V- 

1 

^'    2^2 

— 

— ' 

-^ 

r^ 

— 

— 



— 

— 

— 

— 

— 

:;i^;z= 

o  .  o  ,  o         1  V       1 

1       1       ■       \ 

Il 

i 

1 

'■1:1 

1 

>?                 V 

J 

1 

!         'T                                         '*V. 

t 

*" 

1 

^g' ':  -"' 

1 

1 

I 

!       1    M 

I 

1 

1    !    [    1    1 

!          ,          : 

(     ! 

— -s-- 

-^-t^SttI — ^^ 

z- — s,_    .s,.    - 

-_- 

z 

- 

f 

d 

1  ^1  - 

' — ^i-'  - 

^    z~Z 

i       ^        -'i        £         •     i       □•!       -V       3,     -■     T      Q-!    ,^     =       ^      ~ 

l'it<pr<  -s-^ 

-I — r 

'^t^£i^:3'^^ 

:i_i— Z-_E_--S_5_t 

2,    2    - 

.3^^,^^^S_^ 

-, 

;^ 

5_^»^5-^Ji.S-5+^ 

' 

! 

111'  t 

li                                           1        1 

13           Ml 

11         1 

•  U  I  'I 

I  s  1  1  I  1  1  2      .;          I  I  I  5  i  5 

J  ;  i  1  1 1  =  =  ^  i'ti''--'l'l  lill'l 

I'S  I  1 

?.  -  r. 

r   -    -    -   r    S    =     -     ^     :.    '    ?,S    rr   S    - 

-    I',     f.     ^.     I    r.     :      '     ^-     ^     -     -     ^    -    H     ^    r.    -    Z     - 

-  n  ?,  -. 

Kapid  fall  of  temperature  clue  to  hemorrhage  on  the  13th  day  of  the  attack   (Peunsylvania 

Hospital). 


Intestincd  hemorrhage  occurs  in  3  to  5  per  cent,  of  all  cases.  It  must 
always  be  regarded  as  a  serious  complication.  It  usually  ajjpears  at  the 
time  of  the  separation  of  the  sloughs,  toward  the  end  of  the  second 


190  ENTERIC   OR   TYPHOID  FEVER. 

and  during  the  third  week  of  the  attack.  The  cases  are,  as  a  rule, 
otherwise  serious,  and  the  bleeding,  even  when  slight,  should  be  re- 
garded with  anxiety,  as  constituting  an  additional  element  of  danger. 
The  amount  of  blood  varies  from  a  slight  trace  in  the  stools  to  a  copious 
evacuation  of  bright  red  blood.  Death  may  occur  from  rapid  blood 
loss.  There  are  cases  in  which  hemorrhage  takes  place  into  the  bowel 
without  the  blood  at  once  appearing  in  the  stools — concealed  hemorrhage. 
The  symptoms  of  internal  bleeding  are  present,  and  after  a  time  blood 
appears  in  the  stools,  usually  in  dark  clots.  The  occurrence  of  hemor- 
rhage is  manifested  by  an  abrupt  fall  of  the  temperature,  amounting  to 
several  degrees,  sometimes  eight  or  ten  degrees  of  Fahrenheit's  scale. 
This  decline  of  temperature  is  very  often  attended  by  temporary  ameli- 
oration of  the  symptoms,  especially  those  relating  to  the  nervous  system. 
Thus,  if,  as  frequently  happens,  in  the  second  or  third  week  of  the 
disease  the  patient  is  delirious,  somnolent,  or  stuporose,  or  even  coma- 
tose, and  with  subsultus  tendinum,  ataxic  muscular  movements,  and 
grasping  at  invisible  objects  in  the  air,  the  occurrence  of  a  hemorrhage 
from  the  bowels  may  be  followed  by  a  striking  change.  The  delirium 
disappears,  consciousness  may  be  regained,  and  the  ataxic  phenomena 
cease.  If,  however,  the  loss  of  blood  be  large,  the  pulse  becomes  rapid 
and  feeble,  coldness  of  the  extremities  occurs,  there  are  sensations  of 
faintness,  great  prostration,  pallor,  and  frequently  death  may  follow  in 
collapse.  If  the  patient  rallies,  the  temperature  rises  again  and  the 
disease  resumes  its  regular  course,  with  a  reappearance  of  the  nervous 
symptoms.  In  concealed  hemorrhage  the  blood  may  not  make  its 
appearance  in  the  stools  for  some  time,  even  a  day  or  two,  after  the 
occurrence  of  the  hemorrhage.  In  these  cases  the  diagnosis  of  hemor- 
rhage is  made  by  the  sudden  fall  of  the  temperature,  amounting  to 
several  degrees,  rapid  and  feeble  pulse,  pallor  and  faintness,  great  pros- 
tration, amelioration  of  the  nervous  symptoms,  and  tendency  to  collapse. 
Further,  an  examination  of  the  abdomen  reveals  upon  palpation  a  sen- 
sation of  resistance  or  a  doughy  feeling  in  the  neighborhood  of  the 
right  iliac  fossa  and  frequently  extending  up  along  the  line  of  the 
ascending  colon,  and  percussion  over  the  same  area  yields  an  area  of 
dulness  in  a  region  of  the  abdomen  previously  and  usually  tympanitic. 
Later,  usually  with  the  next  evacuation  from  the  bowels,  evidences  of 
bleeding  in  the  form  of  large  dark  clots  are  found,  the  evacuation  of 
Avhich  is  comjnonly  followed  by  the  reappearance  of  the  tympanitic  per- 
cussion sound  over  the  right  iliac  region.  It  occasionally  happens  that 
the  amelioration  of  the  general  symptoms  occurring  after  moderate 
hemorrhage  from  the  bowels  persists,  and  this  accident  marks  the 
beginning  of  convalescence.  Some  observers  have  gone  so  far  as  to 
regard  hemorrhage  as  not  in  itself  a  very  dangerous  occurrence.  Modern 
statistics  show  that  from  30  to  50  per  cent,  of  cases  in  which  hemor- 
rhage takes  place  die  in  consequence  of  exhaustion  supervening  upon 
uncontrollable  bleeding  or  from  subsequent  perforation  and  peritonitis. 
Hemorrhage  occurs  with  such  frequency  that  Ave  may  almost  consider 
it  a  symptom,  rather  than  a  complication,  of  the  graver  forms  of  the 
disease. 

Perforation  of  the  intestinal  wall,  with  extravasation  of  the  intestinal 
contents  into  the  peritoneal  cavity,  constitutes  the  most  serious  complica- 


DIGESTIVE  SYSTEM.  191 

tion  ol'  the  disease.  It  occiirs  in  about  11  per  cent,  of  the  latal  cases, 
and  is  a  cause  of  death  in  about  2  or  3  per  cent,  of  all  cases :  it  is  more 
common  in  males  than  in  females,  and  is  extremely  rare  in  childhood 
and  in  the  a^icd,  not  often  occurrino;  after  the  fortieth  year.  I  have, 
however,  seen  double  perforation  of  the  bowel  in  a  man  (jver  tiftv  vcars 
of  age.  It  is  more  apt  to  occur  in  cases  otherwise  severe  than  in  mild 
cases,  and  especially  in  those  cases  marked  by  jjrofuse  diarrhoea,  large 
tymjianites,  and  great  abdominal  tenderness,  and  is  often  preceded  by 
hemorrhage.  It  is  more  frequent  in  the  third  and  fourth  ^^•eeks,  but  is 
liable  to  occur  during  the  second  week,  and  may  ap])ear  as  late  as  the 
ninth  or  tenth  week.  The  situation  of  the  ]X'rforation  is  usuallv  the 
lower  ]>art  of  the  ileum,  but  it  may  be  in  the  caput  coli  or  in  the 
appendix.  It  is  immediately  followed  by  an  acute  septic  peritonitis, 
almost  always  diffuse,  although  in  rare  instances  localized  by  the  imme- 
diate formation  of  adhesions  to  an  adjacent  loop  of  gut,  or  other  viscus. 
Death  may  result  immediately  from  shock.  Usually  the  occurrence  of 
perforation  is  manifested  by  intense  pain  in  the  abdomen,  commenc- 
ing in  the  neighborhood  of  the  right  iliac  fossa,  and,  as  peritonitis 
develops,  extending  over  the  entire  surface  of  the  abdomen ;  symp- 
toms of  collapse,  characterized  by  subnormal  temperature,  shallow,  fee- 
ble breathing,  cold  clammy  sweats,  a  feeble  running  pulse,  great  thirst, 
frequent  vomiting,  and  partial  suppression  of  urine.  If  death  do  not 
then  occur,  symptoms  of  peritonitis  devolop ;  the  temperature  again 
rises,  the  abdomen  becomes  extremely  tympanitic,  and  the  lower  seg- 
ment of  the  liver  dulness  is  effaced — a  very  important  diagnostic  sign 
as  indicating  the  escape  of  the  gases  from  the  intestines,  through  the  per- 
foration, into  the  abdominal  cavity ;  the  abdominal  walls  become  rigid, 
tenderness  is  extreme,  and  the  legs  are  dra^Ti  up  ;  vomiting  sets  in,  the 
pulse  becomes  rapid,  small,  and  thready,  and  the  physiognomy  that  of 
intense  suffering.  Death  takes  place  in  the  course  of  from  two  to  four 
days,  exceptionally  later.  Peritonitis,  local  or  diffuse,  may  originate 
without  actual  perforation  by  extension  of  inflammation  at  the  seat  of 
ulceration  from  the  mucous  to  the  serous  coat  of  the  intestine,  the  latter 
structure  remaining  intact  so  far  as  perforation  is  concerned.  It  may 
also  be  caused  by  the  rupture  of  a  pseudo-abscess  follo^ving  soften- 
ing of  a  mesenteric  gland,  and  occasionally  as  a  result  of  the  burst- 
ing of  abscesses  of  other  structures,  as  of  the  liver,  gall  bladder,  spleen, 
or  the  abdominal  wall. 

Splenic  enlargement,  according  to  Leube,  occurs  in  over  90  per  cent, 
of  the  cases  of  enteric  fever  :  it  is  first  detected  toward  the  end  of  the 
first  week,  coincidently  with  the  appearance  of  the  rash,  and  continues 
to  increase  in  size  until  about  the  fourteenth  day.  With  the  beginning 
of  the  fourth  Aveek — i.  e.  with  defervescence — a  diminution  of  vol- 
ume takes  place.  Splenic  enlargement  persisting  after  the  establish- 
ment of  convalescence  should  be  regarded  with  suspicion  as  indicating 
the  possibility  of  a  relapse.  Usually  the  large  spleen  can  be  felt  below 
the  costal  margin,  but  if  the  colon  be  greatly  distended  with  gas  it  may 
be  so  pushed  back  that  even  the  normal  area  of  dulness  cannot  be  made 
out  for  the  sm-rounding  t^'mpany.  It  should  also  be  remembered  that 
enteric  fever  in  the  aged  is  frequently  unaccompanied  by  an  increase  in 
the  size  of  the    spleen.     Accidental  rupture    of  the  organ,  as  from  a 


192  ENTERIC  OR   TYPHOID  FEVER. 

blow  or  from  undue  force  in  efforts  at  palpation,  has  been  observed ; 
spontaneous  rupture  is  uncommon. 

Jaundice  is  not  frequently  present  in  enteric  fever,  and  symptoms 
referable  to  the  liver  are  uncommon.  Occasionally  the  organ  is  some- 
what enlarged,  but  the  parenchymatous  degeneration  gives  rise  to  no 
clinical  manifestations. 

Nervous  System. — Morbid  phenomena  relating  to  the  nervous 
system  are  very  common  and  diverse  in  enteric  fever.  Not  rarely 
they  dominate  the  clinical  picture. 

Headache  is  frequent,  both  in  children  and  in  adults  ;  it  is  an  early 
symptom,  appearing  during  the  period  of  prodromes  and  may  vary  in 
intensity  from  a  dull  supraorbital  pain  to  a  severe  neuralgic  and  per- 
sistent headache.  It  is  usually  most  severe  in  the  frontal  region,  and, 
at  least  early  in  the  course  of  the  disease,  becomes  aggravated  toward 
evening.  So  intense  may  be  the  headache  that  it  sometimes  suggests 
meningitis,  especially  if,  as  sometimes  happens,  it  is  associated  with 
vomiting,  muscular  twitchings,  and  retraction  of  the  neck.  It  usually 
ceases  spontaneously  about  the  middle  of  the  second  week,  and  very 
often  gives  place  to  mild  delirium.  Headache  may  be  associated  with  or 
alternate  with  somnolence  and  apathy.  On  the  other  hand,  distressing 
Avakefulness  may  be  present  during  the  early  course  of  the  disease.  In 
a  majority  of  the  cases,  under  expectant  methods  of  treatment,  the 
patient's  mental  condition  as  the  attack  advances  is  peculiar  :  he  is 
drowsy,  dull,  and  apathetic,  and  indifferent  to  his  surroundings.  The 
hebetude  may  be  so  marked  that  drink,  though  partaken  of  eagerly 
when  offered,  is  not  asked  for  during  long  periods.  The  patient  pays 
little  heed  to  his  surroundings  and  rarely  volunteers  a  remark.  When 
aroused,  however,  he  replies  to  questions  intelligently,  but  slowly  and 
in  monosyllables,  and  almost  immediately  falls  again  into  a  somnolent 
state.  An  evidence  of  the  extreme  apathy  of  the  patient's  mental  state 
is  observed  in  the  manner  in  which  he  responds  to  the  request  to  put  out 
his  tongue  :  the  organ  is  protruded  slowly,  and  only  in  response  to  sev- 
eral sharp  requests  ;  it  is  often  not  retracted  at  once,  but  held  out  until 
the  order  to  put  it  in  again  is  given. 

In  some  instances  hebetude  is  present  from  the  early  days  of  the 
attack ;  in  others  the  mind  remains  clear  throughout  the  whole  course 
of  the  sickness.  The  latter  condition  is  the  rule  in  cases  treated  by 
systematic  cold  bathing,  Avhich  also  favorably  modifies  delirium  and 
other  nervous  symptoms. 

Delirium  is  present  in  a  majority  of  the  cases.  As  a  rule,  it  does  not 
commence  before  the  middle  of  the  second  week,  about  the  period  when 
the  headache  subsides.  In  a  small  proportion  of  the  cases  it  does  not 
appear  until  late  in  the  course  of  the  disease,  and  lasts  only  a  few  days. 
In  rare  cases  maniacal  delirium  occurs  at  the  beginning  of  the  attack, 
and  may  be  the  first  symptom  to  attract  the  attention  of  the  friends  of 
the  patient. 

The  character  of  the  delirium  varies  greatly.  It  is  often  slight  and 
occasional,  occurring  chiefly  in  the  night-time  or  on  waking  from  sleep 
in  patients  who  are  at  other  times  entirely  rational.  More  commonly  it 
is  continuous,  and  usually  of  a  quiet  form.  It  may  be — though  this  is 
not  common — active   and  noisy,  passing  as  prostration  becomes  more 


NERVOUS  SYSTEM.  193 

marked  into  the  low,  miittcriiiii"  loi'in  known  as  typho-niania,  oi-  into  a 
waiulcrino-,  fatuous  state  with  treinWlinn-  lil<o  that  of  alcoliolism.  Tlie 
last  form  is  common  in  heavy  drinkers.  'J'he  delirium  of  enteric  fever 
is  often  accompanied  with  suicidal  impulses,  and  the  patient  should 
never  after  delirium  has  a|)peared  be  left  alone.  In  the  oraver  eases 
delirium  oradually  oives  way  to  unconsciousness.  The  [)atient  can  be 
roused  with  diHiculty  or  not  at  all.  Urine  is  retained,  or  both  urine  and 
faeces  are  voided  unconsciously.  The  lips  are  tremulous  ;  there  is  twitch- 
ing of  the  fingers  and  hands ;  subsultus  tendinum  and  picking  at  the 
bed  clothing  or  grasping  at  invisible  objects  in  the  air — carphologia. 
Sometimes  the  condition  known  as  coma-vigil  develops  :  the  jwtient's 
eyes  are  open  and  he  appears  to  see,  or  even  to  follow  the  movements 
of  his  attendants  ;  he  mutters  indistinctly,  but  he  is  unconscif»us  and 
oblivious.     These  are  symptoms  of  the  gravest  import. 

The  well-known  tendency  of  delirium  to  take  its  form  from  the 
intellectual  development  and  mental  habit  of  the  individual  in  sickness 
of  every  kind  serves  to  explain  the  fact  that  in  enteric  fever  in  child- 
hood apathy,  somnolence,  and  stupor  are  much  more  common  than 
active  or  even  wandering  delirium. 

Convulsions  are  rare.  The  onset  of  the  attack  is  gradual  in  children 
as  in  adults,  and  the  convulsions  so  common  at  the  beginning  of  the 
other  acute  infections  do  not  occur. 

Muscular  tveakness  is  marked  in  all  cases  and  progresses  with  the 
disease.  Many  patients  are,  however,  able  to  assist  themselves,  to  sit  up 
in  bed,  or  even  to  rise  to  stool  during  the  whole  course  of  the  attack. 
In  the  milder  cases  the  patients,  though  very  weak,  are  often  able  to  go 
about,  and  it  is  not  uncommon  for  walking  cases  to  present  themselves 
at  the  out-patient  services  of  hospitals  in  the  second  or  third  week  of 
the  attack.  In  grave  cases  muscular  debility  is  complete.  In  such 
cases,  if  recovery  take  place,  there  is  some  oedema  of  the  legs  and 
ankles  during  convalescence. 

Tremor  is  present  in  many  of  the  severer  cases.  The  tongue 
trembles  as  it  is  protruded,  the  lips  quiver,  and  the  movements  of  the 
hands  are  trembling  and  uncertain.  This  phenomenon  is  more  common 
in  those  addicted  to  alcohol  and  in  aged  persons.  More  rarely  it  may 
occur  in  young  and  temperate  persons,  and  it  is  occasionally  observed  in 
cases  in  which  there  is  no  impairment  of  the  mental  faculties.  Rigid 
contractions  of  groups  of  muscles  of  the  neck,  trunk,  or  extremities  are 
met  with  in  rare  instances,  and,  as  a  rule,  in  females.  The  knee  jerks 
and  the  cutaneous  reflexes  are  slightly  increased.  In  deeply  soporose 
conditions  they  may  be  enfeebled  or  absent  altogether. 

The  organs  of  special  sensation  present  symptoms  that  are  important. 
Deafness  is  very  common.  As  a  symptom  it  affects  both  ears,  and  is  of 
nervous  origin.  It  appears  toward  the  end  of  the  first  or  during  the 
second  week.  As  a  complication  middle-ear  inflammation  may  cause  one- 
sided deafness. 

Vertigo  sometimes  occurs  as  an  early  symptom.  Subjective  auditory 
sensations,  ringing  and  humming,  often  annoy  patients  during  the  early 
days  of  the  attack. 

Dilatation  of  the  pupils  occurs  in  at  least  three-fourths  of  the  cases. 
It  is  apt  to  come  on  during  the  second  week,  together  with  the  delirium. 

Vol,  I.— 13 


194  ENTERIC  OB    TYPHOID  FEVER. 

It  is  often  present,  however,  Avlien  there  is  no  delirium  or  other  marked 
nervous  phenomenon.  The  pupils  are  not  widely  dilated,  and  respond 
slowly  to  the  stimulus  of  light.  In  comatose  cases  the  pupils  may  be 
contracted.     Injection  of  the  bloodvessels  of  the  conjunctiva  is  rare. 

Neurak/ias,  chiefly  trigeminal  and  intercostal,  occur  during  conva- 
lescence. 

Cutaneous  hypercesthesiu  is  common  in  children  and  women.  It  may 
occur  during  the  course  of  the  attack  or  not  until  convalescence.  It  is, 
as  a  rule,  restricted  to  the  abdomen  and  the  lower  extremities.  It  is 
often  associated  with  rhachialgia,  and  points  of  spinal  tenderness. 

Localized  teiulerness  of  muscles  may  be  encountered.  It  is  probably 
due  to  myositis. 

Neuritis  may  occur  during  the  course  of  the  attack  or  as  a  sequel. 
Local  neuritis  may  affect  an  arm  or  leg.  There  is  great  pain  upon 
movement,  tenderness  in  the  line  of  the  nerve-trunk  and  of  the  muscles. 
If  the  extremities  are  involved,  wrist-drop  or  foot-drop  may  result. 

The  burning  pains  in  the  feet  and  ankles  and  the  tenderness  of  the 
toes  without  sweating  or  discoloration,  occasionally  present  during  con- 
valescence, are  manifestations  of  local  neuritis.  These  painful  phe- 
nomena, as  a  rule,  pass  away  in  the  course  of  t^vo  or  three  weeks ; 
exceptionally  they  persist  for  several  weeks.  Multiple  neuritis  may 
affect  the  upper  and  lower  limbs  or  the  legs  alone.  The  paraplegic 
type  is  much  the  most  common.  Recovery  takes  place  very  slowly,  but 
is,  in  most  of  the  cases,  ultimately  complete. 

Aphasia,  without  hemiplegia,  may  occur ;  it  is  more  common  in  chil- 
dren than  in  adults. 

Insanity  may  develop  after  the  defervescence — post-febrile  insanity. 
It  terminates,  as  a  rule,  in  recovery  in  the  course  of  some  weeks  or 
months. 

The  Urinary  System. — The  urine  presents  the  physical  and  chemical 
changes  observed  in  the  other  acute  infectious  diseases.  It  is  diminished 
in  quantity  during  the  first  and  second  weeks.  Notwithstanding  the  in- 
creased amount  of  fluid  consumed  by  the  patient,  the  urine  excreted  may 
not  exceed  one  half  or  even  one  fourth  the  normal  quantity.  In  many 
cases  it  is  diminished  until  convalescence,  when  it  becomes,  as  a  general 
rule,  copious  and  of  low  specific  gravity.  Its  color  is  at  first  darker  than  in 
health.  In  the  advanced  stages  of  the  disease  and  during  convalescence 
it  is  pale.  Modifications  of  the  odor  take  place  which  are  difficult  to 
describe  and  are  probably  not  constant.  According  to  Robin,  it  is  more 
aromatic  than  normal  at  the  beginning,  ammoniacal  or  even  fetid  toward 
the  close  of  the  attack,  and  regains  its  normal  character  during  conva- 
lescence. The  reaction  is,  as  a  rule,  acid  throughout  the  attack.  At  its 
close,  however,  the  acid  reaction  becomes  less  intense,  and  in  some  in- 
stances it  is  feebly  alkaline.  The  specific  gravity  in  the  early  periods 
ranges  from  1020  to  1030.  After  the  close  of  the  second  week  in  some 
instances,  and  almost  invariably  during  convalescence,  the  specific 
gravity  falls  to  a  point  considerably  below  the  normal.  The  abun- 
dant, limpid  urine  of  early  convalescence  has  occasionally  a  specific 
gravity  as  low  as  1010.  The  quantity  of  urea  present  in  the  urine  has 
been  the  subject  of  ranch  discussion.  Some  observers  have  found  it 
invariably  increased  during  the  early  course  of  the  disease  ;  others  have 


URINARY  SYSTEM.  l{>o 

t'oiiiid  it  (liiuiiiishcd.  The  iiiMc  iicid  is  always  increased.  Diirinti,-  the 
latter  part  ol'  the  attack,  howes'er,  the  anumiit  I'alls  (<»  iioniial,  and  diir- 
m^y  convalescence  it  is  less  than  in  health.  Copions  deposits  of  the 
unites  may  occur  at  any  time  in  the  course  of  the  disease.  They  are 
not  critical  and  are  without  ]iro<>;nostic  value.  The  chlorides  are  j:;reatly 
<liminished.  Sometimes  they  do  not  exceed  a  mere  trace.  This  diminu- 
tion in  the  chlorides  cannot  he  wholly  ex])lained  either  by  the  diminished 
iunount  ingested  or  by  the  increased  amount  voided  in  tlu^  stools.  A\'ith 
the  advent  of  convalescence  the  chlorides  are  greatly  increased. 

The  Dkizo-veadiou. — Ehrlich  in  1882  described  a  test  which  is  in 
<loubtful  cases  of  diagnostic  value.  The  reaction  consists  of  a  ]^eculiar 
color  developed  in  the  urine  and  foam  by  the  action  of  dia/o-benzine- 
sulphonic  acid  in  ])res(mce  of  an  excess  of  ammonia.  Two  solutions  are 
i»mplovcd  :  (1)  A  5  per  cent,  solution  of  sulphanilic  acid,  and  (2)  a  h  per 
cent,  solution  of  sodium  nitrate.  To  make  the  test  40  c.c.  of  the  first 
and  1  c.c.  of  the  second  are  mixed  together.  Equal  parts  of  this  mixed 
solution  and  the  urine  are  shaken  together  in  a  test-tube.  Strong  solu- 
tion of  the  ammonia  is  then  allowed  to  flow  down  the  side  of  the  tube. 
The  reaction  consists  of  the  development  at  the  junction  of  the  ammonia 
Avith  the  fluid  of  a  dark  garnet  or  cherry-red  ring.  Upon  brisk  shaking 
ii  uniform  red  color  is  imparted  to  the  fluid,  while  a  delicate  pink  tinge 
is  seen  upon  the  foam.  After  standing  for  some  hours  an  olive  green 
])recipitate  is  deposited.  With  normal  urine  the  red  color  is  lacking  and 
the  foam  is  brownish  yellow.  The  diagnostic  value  of  this  test  arises 
Irom  the  fact  that  the  reaction  occurs  in  the  urine  of  the  greater  number 
■of  cases  of  enteric  fever  at  some  time  during  the  course  of  the  attack. 

In  14  cases  in  which  this  reaction  was  studied  in  my  last  term  of 
service  in  the  wards  of  the  Pennsylvania  Hospital  it  was  noted  in  11, 
the  examinations  being  made  between  the  tenth  and  twenty-second  days 
of  the  attack.  In  15  additional  cases  in  which  the  test  was  made  later 
than  the  tAventy-second  day  of  the  attack  the  response  did  not  occur. 
The  reaction  occurs,  however,  in  many  other  diseases,  especially  acute 
miliary  tuberculosis,  chronic  tuberculosis,  measles,  scarlet  fever,  malarial 
fever,  and  pneumonia. 

The  toxicity  of  the  urine  is  much  increased.  This  increase  is  not 
dependent  upon  the  elevation  of  temperature,  and  continues  throughout 
the  course  of  the  fever  and  during  convalescence.  In  cases  systemati- 
cally treated  by  cold  bathing  the  elimination  of  toxins  is  increased,  in 
some  instances,  according  to  Roque  and  Weill,  to  five  or  six  times  that 
of  the  normal. 

Albuminuria  is  of  frequent  occurrence.  The  albumin  in  many  cases 
amounts  to  a  mere  trace — febrile  albuminuria.  It  may,  however,  be 
present  in  large  amounts,  together  with  tube  casts  and  sometimes  with 
blood,  indicating  the  development  of  an  acute  nephritis.  This  compli- 
cation may  be  so  prominent  as  to  merit  consideration  as  a  special  variety 
of  enteric  fever — the  renal  form.  These  cases  are  always  severe.  In 
the  majority  of  them  recovery  takes  place,  the  symptoms  of  nephritis 
completely  disappearing  during  or  after  convalescence.  The  signs  of 
nephritis  may  not  develop  until  after  the  fall  of  temperature — nephritis 
of  convalescence. 

Pus  in  the  urine  is  not  uncommon.     It  is  sometimes  associated  with 


196  ENTERIC  OR   TYPHOID  FEVER. 

blood.  Pyuria  may  be  due  to  a  pyelitis  or  to  cystitis.  Blumer  ^  iso- 
lated from  ten  cases  the  following  bacteria,  usually  in  pure  culture  :  the 
colon  bacillus,  the  typhoid  bacillus,  the  staphylococcus  albus,  and  a 
coccus  that  was  not  identified. 

Retention  of  urine  occurs  in  a  considerable  proportion  of  the  cases. 
Urethritis,  cystitis,  and  orchitis  may  arise  as  the  result  of  infection 
from  catheters  that  have  been  improperly  cared  for. 

The  Skin. — The  eruption  appears,  as  a  rule,  between  the  seventh 
and  tenth  days.  Exceptionally  it  is  met  with  as  early  as  the  fourth  or 
not  discovered  until  as  late  as  the  twelfth  day.  In  children  it  appears 
somewhat  earlier  than  in  adults.  It  is  not  invariably  present.  Murchi- 
son  states  that  the  spots  are  more  frequently  absent  in  patients  under 
ten  and  over  thirty  years  of  age  than  between  ten  and  thirty 
years.  There  is  no  relation  between  the  abundance  of  the  rash  and  the 
severity  of  the  symptoms.  The  typhoid  eruption  is  characteristic  of 
the  disease,  and  when  found  establishes  the  diagnosis.  It  is  maculo- 
papular,  consisting  of  small,  slightly  elevated,  rounded  or  oval  isolated 
spots  of  a  rose  pink  color.  Their  diameter  is  from  1  to  4  millimetres. 
They  are  indistinctly  marginate,  and  alike  to  the  eye  and  touch  faintly 
rounded  and  convex,  but  not  accuminate,  though  a  minute  vesicle  may 
occasionally  be  discovered  at  their  centre.  They  have  been  compared 
to  flea-bites,  from  which,  however,  they  differ  in  the  absence  of  the 
central  mark  and  in  their  paler  color.  They  disappear  upon  pressure, 
and  return  immediately  when  the  pressure  is  removed.  They  may  be 
made  to  disappear  and  reajDpear  under  the  eye  by  placing  a  finger  upon 
each  side  of  a  spot  and  making  traction.  As  the  skin  becomes  tense 
they  disappear;  when  it  is  relaxed  they  return.  The  exanthem  is 
developed  in  successive  crops,  each  spot  lasting  three  or  four  days  and 
leaving  upon  fading  a  faint  patch  of  pigmentation.  The  spots  rarely 
appear  after  the  middle  of  the  third  week.  They  are  not  found  during 
convalescence,  but  reappear  along  with  the  other  characteristic  symptoms 
of  the  disease  upon  the  occurrence  of  relapse.  The  eruption  is  never 
present  upon  the  dead  body.  The  spots  are  most  commonly  present 
upon  the  abdomen  and  lower  part  of  the  chest  anteriorly.  They  are 
frequently  met  with  on  the  back,  especially  between  the  scapulae,  and 
are  occasionally  present  upon  the  upper  part  of  the  thigh.  In  some 
instances  they  are  present  upon  the  back  alone,  and  in  doubtful  cases 
should  be  sought  for  in  this  situation.  The  typhoid  rash  is  in  rare 
instances  sparsely  scattered  over  the  arms  and  legs,  and  may  be  found 
upon  the  face.  The  spots  are  usually  few  in  number.  It  often  happens 
that  not  more  than  six  or  eight  can  be  discovered,  and  in  many  cases 
the  number  present  at  one  time  does  not  much  exceed  a  score.  They 
are  never  confluent. 

Erythema. — A  scarlet  rash,  sometimes  faint,  sometimes  bright,  is 
occasionally  observed  during  the  course  of  the  first  week,  especially  in 
patients  whose  skin  is  fair  and  delicate.  This  rash  is  not  very  common  ; 
it  is  not  peculiar  to  enteric  fever,  but  is  met  with  in  other  febrile  aifec- 
tions.  If  well  marked,  and  particularly  if  it  be  associated  with  slight 
sore  throat,  as  sometimes  happens,  the  disease  may  be  mistaken  for 
scarlet  fever. 

'  Johns  Hopkins  Hospital  Reports,  vol.  v. 


OSSEOUS  SYSTEM.  197 

^  V//(vf/'/«  oci'Jisioiially  (n-ciirs.  JldjH.s  also  occurs,  hut  is  niuc.li  loss 
coninion  in  ontoric  fever  than  in  some  other  febrile  diseases.  Peteeltke  are 
rare.  Si((l(iiiuii(i  aj)i)ear  at  a  hiter  period  of  tlie  disease,  es|K'eially  in  cases 
in  which  there  is  profuse  sweatino'.  They  consist  of  minute  trans|)arent 
vesicles  scattered  pk'ntifnlly  over  the  body,  es])ecially  upou  the  ab(h)men. 
The  faclic  (rrebralc,  as  in  other  febrile  diseases,  can  be  readily  produced. 

During  the  active  febrile  movement  the  skin  is  usually  dry.  The 
palms  of  the  hands  are  dry  and  yellow  in  color.  Sivcdthif/  is,  however, 
not  rare  ;  it  is  sometimes  profuse  and  may  be  associated  with  chilliness. 
Slight  <h's(jit<iin<(fio)i  is  occasionally  observed  dnring  convalescence,  and 
changes  occur  in  the  nails,  transverse,  lustreless  bands  indicating  the 
iirrest  of  nutrition  that  has  attended  the  course  of  the  attack.  The  Iiair 
fjdls  out,  but  after  a  time  it  grows  again.  The  new  hair  is  often  lacking 
in  lustre,  but  gradually  acquires  its  normal  appearance.  Emaciation  is 
nsually  great,  often  extreme. 

FKruncks  and  abscesses  of  the  skin  occur  during  convalescence. 
They  may  be  distributed  on  the  back,  buttocks,  arras,  and  outer  aspect 
of  the  thighs.  Pustular  eruptions  sometimes  occur.  In  4  of  a  series 
of  71  cases  occurring  during  a  recent  term  of  service  in  the  Penn- 
sylvania Hospital  there  appeared  at  the  time  of  defervescence  circum- 
jseribed  groups  of  pustules  symmetrically  arranged  on  the  inner  side  of 
both  legs  just  below  the  knee. 

Bed-sores  may  occur  in  the  severer  cases.  Very  often,  but  not 
invariably,  they  may  be  avoided  by  proper  nursing. 

Taehes  bleudtres — spots  of  a  delicate  bluish  or  bluish  gray  tint, 
irregularly  rounded  form,  from  4  to  12  millimetres  in  diameter,  not 
raised  above  the  surrounding  surface  nor  aifected  by  pressure — are  met 
with  in  enteric  fever  and  in  some  other  diseases.  The  lesion  is  sub- 
cuticular. When  present  the  individual  spots  are  numerous  and  ob- 
served chiefly  upon  the  abdomen,  thighs,  and  legs.  They  appear  to 
occur  only  upon  the  skin  of  patients  who  have  body  lice. 

The  physiognomy  of  persons  ill  of  enteric  fever  is  peculiar.  In  mild 
attacks  there  may  be  but  little  change  of  expression.  More  commonly 
the  expression  is  dull,  weary,  the  face  pale,  often  with  dusky  flushing 
over  one  or  both  cheek  bones.  The  dilatation  of  the  pupils  adds  to  the 
peculiarity  of  the  facies. 

Osseous  System. — Inflammatory  changes  in  the  bones  are  not  un- 
common. Keen  reported  in  1876  an  important  series  of  cases  of  disease 
of  the  bones  occurring  after  enteric  fever.  These  cases  occur  frequently 
in  childhood  and  adolescence.  Of  41  cases  studied  by  Murchison,  the 
age  of  the  patient  was  under  twenty  years  in  19  cases,  between  twenty 
and  thirty  years  in  11  cases,  between  thirty  and  forty  years  in  6  cases, 
and  over  forty  years  in  5  cases.  The  symptoms  may  first  appear  during 
the  course  of  the  attack,  but  are  more  common  in  convalescence.  There 
is  pain,  at  first  vague,  speedily  becoming  localized,  usually  severe,  lanci- 
nating, aggravated  at  night.  There  is  great  local  tenderness  with  tume- 
faction, with  or  withoutredness.  After  a  time  fluctuation  appears,  and 
one  or  more  fistulous  openings  are  formed  which  discharge  a  small 
quantity  of  pus.  These  sinuses  frequently  close  spontaneously,  to  re- 
open in  a  short  time.  Some  of  the  cases  are  due  to  streptococcus  infec- 
tion, most  of  them  to  infection  by  Eberth's  bacilli. 


198  ENTERIC  OR   TYPHOID  FEVER. 

Synovitis  may  occur.  It  is,  however,  a  rare  complication.  As  a  rule, 
a  single  joint,  exceptionally  several  joints,  are  implicated.  Spontaneous 
dislocations  are  among  the  rare  accidents  of  enteric  fever.  They  are  of 
the  nature  of  "  distention  luxations,"  and  are  probably  due  to  subacute 
synovitis  with  gradual  serous  distention  of  the  capsular  ligament. 

Intercurrent  and  Concurrent  Diseases. — Enteric  fever  dur- 
ing its  course  confers  no  immunity  from  other  infectious  processes- 
Erysipelas  occurs  as  a  rare  complication,  usually  during  convalescence. 
Scarlatina  may  precede,  coexist  with,  or  follow  enteric  fever.  Taupin,, 
Murchison,  and  others  have  reported  instances  in  which  patients  suffer- 
ing from  scarlet  fever  have  developed  enteric  fever,  or  in  which  scar- 
latina has  developed  during  the  course  of  enteric  fever,  and,  again, 
instances  in  which  the  eruptions  of  the  two  diseases  have  coexisted. 
Measles  may  also  develop  during  the  course  of  enteric  fever,  either  as 
an  intercurrent  malady  or  during  convalescence. 

Pertussis  and  varicella  have  been  observed  during  the  course  of 
enteric  fever.  Diphtheria  and  pseudo-diphtheria  occur  with  frequency 
in  the  course  of  enteric  fever,  especially  in  childhood.  The  false  mem- 
brane may  develop  upon  the  pharynx,  larynx,  or  on  the  mucous  surface 
of  the  genitalia.  Noma  may  also  occur.  This  accident  is  apparently 
much  more  common  in  Europe  than  in  this  country.  It  is  more  liable 
to  appear  in  childhood  than  in  adult  life.  Tuberculous  infection  often 
occurs  during  or  immediately  after  enteric  fever,  or  the  latter  disease 
may  call  into  activity  a  latent  tuberculosis.  Miliary  tuberculosis  or 
forms  of  pulmonary  phthisis  are  sequels.  Tuberculous  meningitis  and 
tuberculous  ulceration  of  the  intestine  also  occur  as  late  sequels. 
Enteric  fever  frequently  attacks  those  suffering  from  chronic  diseases. 
I  have  on  several  occasions  seen  patients  in  the  early  stage  of  pulmonary 
consumption  recover  from  an  attack  of  enteric  fever  without  intensifica- 
tion of  the  tuberculous  process.  In  epilepsy  it  is  unusual  for  the  fits  to 
occur,  and  choreic  movements  usually  cease  during  an  attack  of  enteric 
fever.  The  disappearance  of  sugar  in  the  urine  of  diabetic  patients 
during  an  attack  of  enteric  fever  may  be  in  part  at  least  accounted  for 
by  the  character  of  the  diet. 

The  term  typho-malarial  fever  has  been  applied  to  two  essentially  dif- 
ferent conditions.  First,  true  typhoid  fever  occurring  in  persons  recently 
subject  to  malarious  influences  or  in  malarious  districts ;  and  second,, 
remittent  fever.  The  term  is  an  unfortunate  one,  and  has  given  rise  ta 
no  little  confusion  concerning  the  nosological  conditions  of  the  various 
forms  of  disease  to  which  it  has  been  applied. 

W.  Gilman  Thompson  has  demonstrated  by  concurrent  clinical  data 
and  microscopical  examination  of  the  blood  the  association  in  the  same 
case  of  the  typhoid  and  malarial  infections  ^    (Figs.  17-19,  pp.  199,  200). 

Varieties. — Enteric  fever  is  a  disease  of  complex  symptomatology. 
The  prominence  of  certain  symptoms,  the  evidences  of  intense  implica- 
tion of  special  organs  and  modifications  in  the  course  of  the  disease,  have 
led  authors  to  describe  numerous  special  forms.  Thus,  cases  beginning  with 
prominent  symptoms  of  gastro-duocVnal  catarrh  have  been  called  bilious  ; 
those  in  which  the  nervous  system  is  early  and  intensely  involved  have 
been  regarded  as  cerebrospinal  forms.     Early  and  severe  implication 

^  American  Journal  of  the  Medical  Sciences,  August,  1894. 


VARIEIII.s. 


litf) 


of  the  kidneys  lias  led  to  the  classiticatioii  oi"  a 
under  the  head  of  ncphro-fuphuti ; 
the  early  manifestation  of  marked 
pulmonary  sy m}>toms,  to  the  arrange- 
ment of  another  <2:ronj)  of  cases  as 
pncumo-fi/jjIiKs,  with  pleurisy  as  yjfea- 
ro-fi/phnx,  and  where  profuse  sweat- 
ing has  occurred  to  the  .siulora/  form. 
Others  have  sought  to  distinguish 
ataxic  forms  and  adynamic  forms 
and  varieties  based  upon  the  promi- 
nence of  particular  symptoms.  Such 
nosoloo-ical  arranoenients  are  neither 
scientific  nor  convenient.  Without 
attempting  a  closer  analysis  of  the 
forms,  the  cases  may  be  divided  into 
typical  and  atypical.  The  former 
present  the  coniplexus  of  symptoms 
already  described  as  constituting  the 
clinical  history  of  the  disease,  and 
further  illustrated  in  the  analysis  of 
the  symptoms  and  in  the  considera- 
tion of  the  complications  and  se- 
quels. The  atypical  or  imperfect 
forms  constitute  in  most  epidemics 
a  large  proportion  of  the  cases.  The 
following  special  forms  require  sep- 
arate consideration  : 

1.  The  Mild  Form,  Typhus  Levis- 
simus. — The  symptoms  are  those  of 
the  typical  disease  modified  as  re- 
spects intensity,  and  in  particular 
as  to  the  febrile  movement,  which  is 
of  lower  intensity.  The  commence- 
ment of  the  attack  is  usually  grad- 
ual. There  are  prodromes ;  chilly 
sensations  occur ;  there  are  headache, 
diarrhoea,  epistaxis,  and  a  scanty  or 
well-marked  eruption  of  rose  spots. 
On  the  fourth  or  fifth  day  the  tem- 
perature reaches  103°  F.,  but  rarely 
exceeds  that  level.  The  deferves- 
cence is  by  lysis,  and  may  occur  at 
the  end  of  the  second  or  during  the 
course  of  the  third  week. 

2.  The  Latent  or  Ambulatory  Form, 
Walking  Typhoid. — All  the  symp- 
toms are  mild.  There  is  general  ma- 
laise, prostration,  and  elevation  of 
temperature,  slight  diarrhoea.  The  patient  i 
and  does  not  regard  himself  as 


certain   <iroii])  (»i   cases 


Q 

veSSoSS'So 

p 

\ 

- 

> 

-- 

~ 

^ 

O 

/ 

f 

II 

\ 

(" 

-' 

\ 

7 

- 

-- 

^ 

— 

/ 

Y- 

/ 

- 

- 

/ 

\ 

1 

i 

f 

"" 

-. 

n 

■^ 

^^ 

^ 

O 

-- 

^ 

;: 

> 

:3    g 

< 

i^ 

c 

^    o 

■* 

-^ 

^ 

— 

— 

— 

3    = 

..^ 

»• 

=   '^ 

■~ 

-I     2= 

— 

■:^  3 

u 

=    3i 

■^ 

^ 

c 

\» 

c 

^ 

i 

5^      ^ 

•= 

n 

:  ^ 

vT     ■^• 

*■ 

— 

■^ 

<: 

■n 

— 

— 

— 

ra 

,-— 

' 

^     < 

.!- 

c 



"™ 

~ 

- 

-•     ■<   1 

__ 

_  . 



_ 

- 

::». 

5-   ?^ 

z 

:  = 

= 

- 

■2.    C 

^ 

I 

<H 

■ 

> 

o-   2 

:» 

H 

<. 

f 

^    =! 

'^ 

-" 

= 

. 

I" 

s     ^ 

s 

75 

o    S 

^- 

— 

— 

2.    3' 

"^ 

p    — • 

J 

— 

n     - 

(^ 

_ 

^    M 

— 

p 

k 

Zl.    5' 

<' 

■^ 

_^ 

"~ 

> 

^ 

<; 

■^ 

-. 

^ 

_ 

^ 

-4 

• 

^ 

—■ 

f 

n 

'Z       ^ 

— 

— 

— 

^ 

n 

r* 

>:;■ 

— 

— 

" 

■1 

-Z 

- 

^ 

•  > 

ni. 

:;. 

"" 

,. 

^ 

•  s; 

— 

_ 

>. 

■< 

■ : 

;  ^ 

i 

*■ 

> 

^ 

-  — 

-' 

-: 

=» 

» 

- 

rf' 

Z, 

■^« 

* 

~ 

s 

n 

H" 

>: 

r 

■— • 

^ 

-5 

^■^ 

^• 



3 

-L^ 

_L 

■  s; 

1 

about,  attends  to  his  work, 
ufficientlv  ill  to  o^o  to  bed.     The  attack 


200 


ENTERIC  OB   TYPHOID  FEVER. 


extends  over  three  or  four  weeks,  and  the  intestinal  lesions  proceed  to 
sloughing  and  ulceration.     Herein  lies  the  danger  of  this  form  of  the 


Fig.  18. 

4THvyEEK  . 


Cold  tub-baths. 


Abundant  malarial 
organisms. 
Dr.  W.  Oilman  Thompson's  second  case  of  malarial  fever  associated  with  enteric  fever. 

disease.     Hemorrhage  or  symptoms  of  perforation  may  at  length  reveal 
the  true  nature  of  the  attack,  or  sudden  maniacal  delirium  may  occur. 


.avwttK 

Fig.  19. 

•*l".WEtIV                                                    STI-WEEK                  3ST"  DAV                           41»'D«V 

ins"  ,| 

IE 

oT 

104    J_^      _         -. 

o-tS-             1 

103°  r1        I 

o  y-   f         - 

3 

T       ~       :S 

102°  i_  Q  ^  r 

tt/-      -r                T       -.-^                          -^ 

T       tr 

5  T          R  2 

t: 

101        d       X-> 

\       ^         Lit 

+  "  u 

u  \\    \t 

-    XCI^    L    t    ^               it    it 

<!             t 

100°         I    [       j^ 

4:,.l:,  V  XA^^ 

4  n-4 

\X  1      \i  ttt^  it 

^J    4 

99" 

_    J.I  I     ^^  tX\-^v^^-.^ 

,  -=c        Pv 

J     ^L              rv\,\>^^ 

2^s:5,i2K=.QLiJt  —  ^v>.^> 

Cold  tub-baths.  Pigment  found  in  blood-corpuscles, 

C.  C.  =  chills.  but  no  germs. 

Same  as  Figure  18.    Third  case. 

3.  Tlie  Abortive  Form. — Prodromes  are  of  short  duration  or  absent 
altogether.  The  attack  begins  abruptly  with  rigors  or  a  chill.  The 
temperature  rapidly  attains  its  maximum.  By  the  evening  of  the  third 
or  fourth  day  it  may  reach  104°  or  105°  F.  Rose  spots  appear  as  early 
as  the  second  or  third  day.  At  the  end  of  the  first  or  early  in  the  second 
week  defervescence  takes  place  by  lysis,  often  being  completed  in  from 
twenty-four  to  seventy-two  hours,  the  fall  of  temperature  being  accom- 
panied bv  profuse  sweating.  Convalescence  is  rapid,  but  relapses  may 
occur.  This  form  of  enteric  fever  appears  to  be  not  uncommon  in 
Europe.     In  this  country  it  is  certainly  rare. 

4.  Hemorrhagic  typhoid — a  very  rare  form,  commonly  fatal,  charac- 
terized by  hemorrhages  into  the  skin  and  from  mucous  surfaces.  This 
form  corresponds  to  the  hemorrhagic  forms  of  variola,  measles,  and  other 
infectious  diseases,  and  is  not  to  be  confounded  with  ordinary  cases  of 
enteric  fever  in  which  hemorrhage  from  the  bowels  occurs. 

5.  Afebrile  Typhoid  Fever. — Dr.  Cayley  states  that  many  cases  and 
even  epidemics  of  typhoid  have  been  met  with  in  which  the  temperature 
has  been  normal  or  subnormal  throughout  the  whole  course  of  the  dis- 
ease. He  cites  an  epidemic  observed  by  Strube  at  the  siege  of  Paris. 
The  symptoms  are  those  of  ordinary  enteric  fever.  The  duration  of  the 
attack  was  short.     Of  23  fatal  cases,  death  took  place  in  20  during  the 


\'.u!Ii:tii:s. 


201 


ooiirso  of  tlu'  lii'st  fourteen  dny.-.       The  alxloiiiiual  symptoms  were  slight, 
but  the  lesions  were  found  upon  post-mortem  examination. 

6.  Infantile  Remittent  Fever. — This  term  lias  heen  applied  to  enteric 
fever  as  it  occurs  in  children,  for  the  reason  that  the  pyrexia  often 
assumes  a  distinctly  remittent  type  throuulioiit    (lie  whole  course  of  the 


Fk;.  'JO. 


M  E 

M  E 

M  t    M 

E    M  E 

M  E    M  E   M  E    M  E 

M  E    M  E    M  E    M  L   M   E   M  E    M  E    M  E 

103 
102 

J 

4--- 

r 

1       ■       ;■ 

■:             ■     ■   -    -  -E 

100 
99 
98' 
97' 

~ 

— 

M 

-/ 

TTT 

iiil 

1 

T 

iiiBiii 

Cii  Or  :>:SIKI 

^ 

^ 

1"  1 

1     1:; 

1:;     H     1.-.      10 

1;      K^      19     -^o      21      -2-2     ■-':;     24 

Enteric  fever  in  child  asred  nine  vears. 


attack.  The  disease  is  rare  in  the  first  year  of  life,  but  not  infrequent 
during  later  infancy  and  childhood.  The  symptoms  and  complications 
are  modified  by  the  age  of  the  patient.  Nose-bleeding  is  not  common ; 
the  rise  of  temperature  to  the  fastigium  is  abrupt ;  nervous  symptoms 
are  prominent ;  diarrhoea  is  uncommon.    Other  abdominal  symptoms  are, 


Fig.  21. 


M 

E 

M  E 

MIE 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E  N 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

104 
103 
102 
101° 
100° 

— 

— 

— 

— 

— 



— 

— 

' — 

— 

— 

— 

— 

_ 

_ 

_i 

_;• 

JL  _ 

_ 

_ 

_ 

1 

_] 

_ 

_ 

— 

— 

in 

~TE 

7T  ~ 

— 

—J 

— 

—1 

— 

— 

— 

— 

— 

- 

~ 

Z 

ZI 

_ 

|z: 

viz 

- 

T 

-1 

^ 

V^ 

: 

~ 

I 

- 

z 

= 

- 

- 

Z 

99° 
98° 

- 

ZZ 

d 

Z 

- 

-; 

i_ 

H 

_ 

: 

r 

t 

r 

- 

- 

r 

z 

L 

_ 

_ 

,. 

_ 

_ 







w. 

Ii 



, 

f\ 

_ 

97° 

— 

— 

— 

— 

— 

— 

— 

— 

— 

l— - 

^^^ 

— 

— 

♦  — 

-V 

— 

— 

V 

— 

— 

— 

— 



_ 









_ 



_ 

* 

— 

— 

— ' — 





— 

— 

— 

— 

— 

— 

— 

— 

— 





— 

— 

-t- 

— 

0A»  JF 

- 

9 

10 

11 

12 

y-i 

14 

1^1 

10 

17 

18 

19 

20 

21 

22 

2a 

^ 

Enteric  fever  in  child  aged  four  years,  remittent  type. 

as  a  rule,  less  prominent  than  at  later  periods  of  life.  On  the  whole, 
the  reaction  to  the  infection  is  less  marked.  Nevertheless,  grave  cases 
occur.  Exceptionally,  fatal  hemorrhage  and  perforation  have  been  noted. 
Fatal  intestinal  hemorrhage  occurred  in  a  child  twenty-two  months  old, 
in  which,  upon  post-mortem  examination,  the  characteristic  lesions  of 


202 


ENTERIC  OB   TYPHOID  FEVER. 


Ph 


m 

T        T 

-O                      O 

s 

1     '  '■I 

'^    09    02    •' 

u  r.     vwaga 

i 

5,    PJ    "2    .» 

s 



°    29    n   " 

LU 

„    OS    02   ^ 

s 

"^    9C    02    " 

al    «       Vl\l3N^ 

r'" 

o    W    02    t. 

S 

^J 

'"^    06   02    ^' 

111 

,  --' 

Ci    OS   02    ,v, 

E 

■"    05    02    " 

111  n-       v;\3N3 

(»    0»   02    rt 

2                                    '■: 

-' 

'"    8C    f2    ^' 

UJ 

"l 

w    «8    (IZ    o 

S 

i  >-^ 

■"    U    02    ■' 

u  "     vniaNa 

3=  ' 

o    09   02    ci 

E 

s: 

'"    21    02    "^ 

UJ 



o    09    02    oo 

s 

"::::::^:; : 

•=■    09    n   ^ 

UJ    ^       VW3N3 

,-:=' 

f     SL   SZ    r. 

E 

---,.. 

'"    !iOI  02    " 

UJ 

„  m  92  „ 

S                                            IS 

—' 

'"   001  92    " 

UJ  "       VW3N3 

Z' 

CI    001  02    ,„ 

E                     !■=: 

'^   021   92    "^ 

UJ 

Z^i' 

rt   211  92    ^ 

s             ...j^; 

' 

"■'   90!   OS    " 

l:>  : 

o   001  02    M 

E                                                " 

'"  m  02  ■" 

UJ 

'  ° J                                                     o    ""  OZ    M 

s 

<<:_                                                   -^    ns   22    -^ 

UJ    -"I        VW3N3 

;;5'""    1                             «0<.I02    „ 

S 

'C                   '    SC   f2    " 

UJ 

,-  sll  fZ   o 

5 

"*•  911  93    ^ 

UJ    ^        VW3N3 

o    9B   OZ    ^ 

E 

«;_                                                            '^    06    f3 

UJ 

'"--.•                            o    8R   ''2 

S 

«;'                                            '*'    SS    22 

UJ             VW3J3 

;  »                               -„    96   02 

S 

i::.-'™^^ 

UJ 

;                               -,  001  ^2   ^ 

E 

<C;                                                   "^   POI  f.2 

UJ   -       VW3Np 

""  t                                        ^1    06   l-S    ^ 

S         T 

'^  i^                                 ^    8B   fZ 

UJ 

^                           ^    96    t2 

E 

»J=:; "                              "^loni  w. 

UJ   "       VW3<3 

~~  =  »i                            o    f*8    ^2 

S 

1  =  :;''                                 ^  oo[  K 

UJ 

11  =  ^'                            o''6    92 

E 

=  ; '                                            "  MI  ^2 

UJ    r-         VB3N3 

;=ii                                   »  S6  n2  ^  > 

E                           (-4=f--- 

" "  ■                                                                         "  901  82         : 

;::=-         T          1-90I9EO 

S  -■ 

^ KII   82 

UJ 

><                                                                         o  ■■"'I  S£    ci 

E 

f'                                                                                      •'   001  f2    ^* 

UJ  -       mm 

T                                                              o  i-oi  ze  o) 

s 

^                                                                                             "  101   2E    " 

UJ 

^5  1                                                         ^  ee  92  ,- 

E                    -I-     ""' 

"   h)I  2E    °' 

UJ            Vl^3Nb             ^k. 

^    96    J'S    u> 

E 

*;                                                                                          "96   fZ    " 

UJ 

^  >  '                                                                                  51  001  82    ,n 

s 

<'                                                                                         ■'   mi  82    "^ 

UJ   -       Vl^3N3 

'l  s                                                                                          r^  001  82    ^ 

E 

Ji                                                                                  "^001    2S   " 

''                                                                                         o  "01    82    m 

E 

"■  ran  82    •' 

■uj  -■    VW3N3'   ""     'i 

Ov    S«l    fS     (M 

E        ^^"1 

'X3j_                                                ^'  <^"  "'  '■' 

--'"                                                              OT  ft"  fz  ^ 

E        ' 

i,                                                                                               ^'  001   1-2    "' 

UJ 

\                                                                ^  101  re  o 

E 

^ "'  ^ol[^^  '•' 

UJ 

~;sA                                     o  inijzt:  o 

E 

:g: 

^'  26  n 

UJ    rt        YW3N3 

~  '1 

^    06    82    CO 

.  -.,d--  --  _ 

"    96    02    " 

.?        1 

<.    96    02    ^ 

E               1 

^:;:: ::::: 

"    tS    iZ    '^ 

:?- 

^    88    OC   -J, 

S 

—   -^--- 

='    96    91    '^ 

UJ 

. 

„    88    lb-    ^ 

--i^ 

r                    ■='   "01  82   " 

'  p«t ' 

„    96    82   ^, 

S 

"  ts  re  '^ 

+      ='  + 

-,   021   02   n 

E 

::=L 

^'  noi  ^^  ^ 

UJ    r-. 

c  96  re  „ 

E 

.  ^=  =  " 

'^  001  re  '^ 

UJ                                                           < 

a,    »2[  9E    rt 

5 

:>[::::::::: 

'-'   821  82   " 

UJ                                    »  -  -  '' 

^   SO!  2E    c3 

E             '■:;"" 

'^     96   2C    '-' 

UJ                       ^  "^  I. 

,-,    00!  02    ^ 

E             := 

-^   901  OS 

UJ  ^ -r- 

,„   02!   82 

E 

:;::::::::::::: 

^ 

t     '      ' 

VARIF/riES.  203 

enteric  lever  were  Ibiind.  lleiioeh  lias  re])urted  a  ea^e  in  wliieli  lieiuor- 
rliage  occurred  in  a  girl  ten  years  old  in  the  course  of  a  relapse  whicli 
took  })lace  in  tlie  third  week.  There  was  at  first  an  insignificant  hh.'ed- 
ing,  which  was  followed  u])()n  the  next  day  hy  a  very  copious  hemorrhage 
with  fatal  ct)llapse, 

Henocii  observed  perforation  in  a  boy  aged  eleven  in  tlie  fifth  week 
after  convalescence  had  been  apparently  established.  Statistics  present 
a  wide  range  of  variation  in  regard  to  the  frecpiency  of  perforation  in 
children.  Among  232  cases,  according  to  Barthez  and  Killiet,  it  occurred 
in  3  only  ;  among  73  persons  in  whom  this  accident  was  noted,  Murchison 
found  14  to  be  inider  fifteen  years  of  age. 

Certain  secpiels  appear  more  frequently  in  cliildren  than  in  adults. 
Among  these  are  noma,  lesions  of  the  bones,  and  aphasia.  The  death- 
rate  in  children  in  the  first  year  is  high,  especially  among  the  new-born. 
The  mortality  in  childhood  after  the  first  year  is  decidedly  lower  than 
in  adults. 

7.  Enteric  Fever  in  the  Aged. — In  the  advanced  periods  of  life  enteric 
fever  runs  a  modified  course.  Its  onset  is  insidious  ;  the  febrile  move- 
ment is  less  intense,  and  during  convalescence  the  temperature  falls  to 
markedly  subnormal  ranges.  The  eruption  is  frequently  absent  and 
diarrhoea  is  less  common.  Perforation  rarely  occurs.  Murchison  en- 
countered it  twice  in  patients  over  forty  years  of  age,  and  I  saw  it  in 
the  body  of  a  man  aged  fifty-three.  Complications  are  frequent  and 
grave.  Broncho-pneumonia  and  croupous  pneumonia  occur,  and  there 
is  especial  danger  of  collapse  from  cardiac  asthenia.  The  mortality  of 
enteric  fever  after  the  fortieth  year  of  life  is  high. 

8.  Enteric  Fever  in  Pregnancy. — Pregnant  women  seem  to  enjoy  a 
relative  immunity.  This  immunity  would  appear  to  be  greater  during 
the  last  than  during  the  first  half  of  the  pregnancy.  Of  women  who 
in  this  condition  contract  enteric  fever,  more  than  50  per  cent,  abort, 
this  accident  occurring  usually  in  the  second  week  of  the  attack.  The 
foetus  has  been  found  to  be  infected,  and  successful  cultures  of  the 
bacillus  of  Eberth  have  been  made  from  the  viscera. 

Relapse. — The  relapse  of  enteric  fever  is  the  manifestation  of  rein- 
fection. It  is  attended  by  a  repetition,  with  some  modifications,  of  the 
fever  and  associated  phenomena,  a  new  eruption  of  rose  spots,  fresh 
glandular  infiltration,  and  enlargement  of  the  spleen.  The  relapse  is, 
as  a  rule,  of  more  abrupt  onset  and  of  shorter  duration  than  the  primary 
attack.  It  is  commonly  separated  from  the  latter  by  an  interval  of 
some  days,  during  which  the  temperature  range  is  subnormal  or  normal. 
During  this  period  in  cases  in  which  relapse  occurs  the  spleen  remains 
enlarged.  The  relapse  is  not  invariably  separated  from  the  primary 
attack  by  an  interval  of  apyrexia,  but  may  develop  during  its  course. 
It  is  then  termed  an  intercurrent  relajjse,  and  to  intercurrent  relapse 
must  be  ascribed  many  of  the  cases  of  unusual  prolongation  in  the 
absence  of  com})lications.  Two  or  more  relapses  may  occur.  As  many 
as  five  relapses  have  been  reported  (DaCosta).  I  have  observed  four 
well  characterized  relapses  in  a  young  adult. 

The  frequency  of  relapse  is  variable.  It  ranges  from  3  per  cent. 
(Murchison)  to  15  or  18  per  cent.  (Immerman).  In  284  cases  under 
fifteen  years  of  age  observed  in  the  Boston  City  Hospital  from  1882  to 


204 


ENTERIC  OR   TYPHOID  FEVER. 


1895  and  analyzed  by  Morse  relapse  occurred  in  11  per  cent.  A  large 
proportion  of  the  cases  of  enteric  fever  in  infancy  and  childhood  are 
of  mild  intensity.  The  statistics  of  hospital  and  private  practice  with 
reference  to  this  disease  in  the  earlier  periods  of  life  are  at  variance. 
In  private  practice  relapse  appears  to  be  much  less  common  in  child- 


FiG.  23. 


'o¥"ilVE"«%"fs'                        1                 3               II        -'                ■'•                       W       -2       ■:        -2       2       2        ]        3       3       3       3      ',i        1       •  L'      In      11        0 

uRiNE^              5^     ^     g     f,'     ^    ];;           51           5:     S     ?.            ^     s     ^     S           t;     S     s     fj     ;.-:    -,-,     L;     a     ;?,'     :; 

-sssssss^s^isr^s^ssssisssssissss^s'ssss  s's  s  5  s  s  sis  sjs  s|s  s  s  s;s  s's  s's  s  s  ss  s- 

1Q^^        q:<  QJ  <^,cc<-CL  <  cl  <q1  <  cl  <  q:  <  q^  <  q:  <  X  <  oI  <^cl  <  q:  <  q!  <  cl  <^Cl  < d.  <^cl  <cl  <\d.  <'cl  <'cl  <'q!  <'cl"  <Iq.*  <Jq:  <:x  <  o:  <  CL  < 

^tO  X  0  =0.,n  CD  »,«.  «   CO^   »  -^  »  »  tC,»  a,  .i=   =0  -0  CO  I.  CO  -JS    mm  CO  CO  COM  CO  <n=3  ,n   CO,CO   CO  CO    X,,B    coco   colco  0=  CD  coco    C0,CO  .CO  CO   coco    CO  CD  coco   00_ 

^°^                '^U-lU               in   V--  n  ri                          -k^Mqrq 

^^■^^^4_^--^  ^        ^^^^  \4].            J  ^^::_  i/^     l^b^^HHH  H~  rrFFFFFFFFFR 

103'                                         '^ ,  ?  Ki-4-^^ 

1  k/  ^rr^-        M"^-"  :  -H  i 

:*.    V     _^    :---'      :      ;    ,1:  "r-iz;-  ^ 

'°'  H  -        -ll~h^  "\^  — [-Wi     1  kM  M  i  k  k             ■  ^  '\  A  -;44^j         M4-M=^ 

"1     H  ■  TV  '  H"irHHHTr-H  m  '   ^       ^^            \/'\  M  rU      km=H 

lorh  r  rrh  -W':       n+H  +  ^Hrrr^              v^"  \^  ■  /  vmt'  m 

1  \  /" \i -'\  \   \l\^\   [-  r^rfi  i         i         '      '       \   7         \ 

^^r^yt^Ty :;_-  ^       M  UlW-    -:- '  4 1                                         M              W                 ^ 

100  y_^j^  Jlj^  \  ^  ^     *       /-'^   A  -  ,1^  /    ^'                                                              1      1                  \Vf^ 

1  Hl    Mm    '    i\ nntm  hn+rr+rn^++4^-nm-R  ivA   \   m 

ooi       M       1    M  r        /  V  ^+H~H+  rm+H-rr    rrT+rr+rn^TiVrrn 

1 y-       J *\ — 

msEA°sE   10  JJL  i2__iiL  II   J;'.  ;,'L  V--V'    i.'-'   '•"    '-.'    v  -";L -''    ■';'    ■''■'    "■!■-«   ■-:••■*"   -'.i    -■    •-.  r.i    :'.•'_■->!'    »'    ■^,^.  ■»    ^JL 

PULSE  is=¥^^,jii  i|3;,.z,g^,j;-;'o;ip'  :--p  zisjs  :^'',:i  ^i?  ?,'  -i^^k  -  ?'  -;-?.'  ',5  ',-  i,'- ^-='  -.,*  i's  i""  akiT 

Intercurrent  relapse  following  mild  primary  attack  (Philadelphia  Hospital). 


hood  than  in  adult  life.     This  discrepancy  is  to  some  extent  due  to  dif- 
ference of  opinion  among  practitioners  as  to  what  constitutes  a  relapse. 

Relapse  has  been  confounded  with  recrudescences  of  fever  occurring 
during  convalescence.  Such  rises  of  temperature  are  usually  brief,  not 
lasting  more  than  a  day  or  two.  Occasionally  they  are  of  longer  dura- 
tion, and  are  due  to  infectious  or  inflammatory  sequels.  Under  these 
circumstances  careful  investigation  will  usually  reveal  the  nature  of  the 
pathological  process.  Elevation  of  temperature  during  convalescence, 
unattended  by  rose  spots,  enlargement  of  the  spleen,  intestinal  symptoms, 
and  of  brief  duration  on  the  one  hand  or  protracted  duration  on  the  other, 
should  not  be  regarded  as  constituting  true  relapse.  The  relapse  declares 
itself  by  a  step-like  rise  in  temperature.  Sometimes  the  rise  is  abrupt 
and  progressive ;  at  others  morning  remissions  occur,  but  usually  the 
maximum  is  attained  in  the  course  of  from  three  to  five  days.  The 
subsequent  course  of  the  fever  corresponds  very  closely  to  a  primary 
attack,  except  that  it  is,  as  a  rule,  of  shorter  duration.  Of  53  cases 
noted  by  Murchison,  the  mean  duration  of  the  primary  attack  was 
about  twenty-six  days,  of  the  interval  about  eleven,  and  of  the  relapse 
about  fifteen  days.  There  is  danger  of  the  fatal  issue  from  the  stress 
of  the  disease  when  the  attack  is  protracted  by  relapse  or  repeated 
relapses,  but  death  may  occur  in  consequence  of  any  of  the  events 
which  bring  it  about  in  primary  attacks.  Post-mortem  examination 
of  the  bodies  of  those  who  have  died  in  relapse  of  enteric  fever  has 
revealed  the  lesions  of  the  primary  disease.  The  individual  intestinal 
lesions  are  less  numerous,  for  the  reason  that  only  those  glands  and 


SECOND  ATTACKS.  "-iO.j 

patches  ot"  l^cyer  arc  involved  that  escaped  during  tlic  first  attack.  Tlie 
ulceration  is  tlicrelore  higher  ii[)  in  the  ileum  and  coexists  with  the 
recent  cicatrices  of  the  j)riniary  attack,  which  are  most  numerous  and 
extensive  just  above  the  ileo-ciecal  valve.  Relapse  is  due  to  reinfection 
from  within  the  body  of  the  patient.  It  is,  in  fact,  a  repetiticui  of  the 
primary  attack.  To  the  (piestion  why  the  primary  attack  confers 
immunitv  in  a  luajority  of  instances,  fails  to  confer  a  lasting  immunity 
in  a  few,  and  rentiers  the  patient  liable  to  prompt  reinfection  in  from  o 
to  15  ])er  cent.,  no  satisfactory  reply  has  yet  been  made. 

Second  A.ttacks. — The  attack  of  enteric  fever  in  a  great  majority 
of  instances  confers  complete  innii unity  against  subsequent  attacks.  To 
this  rule  there  are,  however,  exceptions.  Many  cases  have  been 
recorded  in  which  a  second  or  even  a  third  well  authenticated  attack 
of  enteric  fever  has  occurred  in  consequence  of  remote  independent 
infection  in  the  same  individual.  I  have  personal  knowledge  of  a  case 
in  which  the  patient  suffered  from  three  attacks  of  enteric  fever  at 
intervals  of  some  years,  the  third  proving  fatal.  To  the  immunity 
acquired  in  infancy  and  childhood  must  be  attributed  the  insuscepti- 
bility of  many  adults  upon  exposure. 

Diagnosis. — AVell  developed  cases  of  enteric  fever  after  the  first  week 
may  be  usually  recognized  without  difficulty.  During  the  first  week  it 
is,  however,  often  impossible  to  form  a  positive  diagnosis,  but  even  then 
the  nature  of  the  disease  may  be  suspected  if  there  be  febrile  movement 
with  nocturnal  exacerbations,  each  night  attaining  a  higher  temperature, 
and  especially  if  there  be  headache,  epistaxis,  diarrhcea,  either  sponta- 
neous or  readily  produced  by  laxatives,  progressive  asthenia,  and,  toward 
the  end  of  this  period,  appreciable  enlargement  of  the  spleen.  The  direct 
diagnosis  of  the  developed  disease  finds  its  support  in  the  continuance 
of  the  febrile  movement  and  the  appearance  of  abdominal  s%Tnptoms — 
namely,  diarrhoea,  pain,  enlarged  spleen,  moderate  tympany,  and  len- 
ticular rose  spots.  In  doubtful  cases  the  coincident  occurrence  of  ca.ses 
in  the  same  house  or  locality  is  of  diagnostic  importance. 

The  differential  diagnosis  from  certain  other  acute  febrile  disorders 
is  sometimes  attended  with  difficulty.  The  diseases  with  which  enteric 
fever  is  liable  to  be  conf(junded  may  be  divided  into  two  groups — first, 
those  which  resemble  it  in  the  first  week  of  its  course,  and,  second,  those 
which  resemble  it  in  its  more  advanced  stages.  To  the  first  group  belong 
febricula,  influenza,  and  in  children  certain  of  the  exanthemata  in  the 
pre-emptive  stage.  Differences  in  the  mode  of  onset,  the  short  duration 
of  febricula,  the  epidemic  prevalence  of  influenza,  are  facts  of  importance 
in  diagnosis.  The  prominence  of  coryza  and  bronchial  catarrah  A^ould 
suggest  the  possibility  of  measles,  and  erythematous  angina  would  lead 
us  to  suspect  scarlet  fever,  while  intense  headache  and  the  presence 
of  lumbar  pains  would  serve  to  distinguish  variola  from  enteric 
fever. 

To  the  second  group  belong  certain  forms  of  malarial  fever,  acute 
miliary  tuberculosis,  appendicitis,  peritonitis,  trichinosis,  and,  in  children, 
entero-colitis. 

Jlalarial  fever  and  enteric  fever,  as  has  been  demonstrated  by  W. 
Gilman  Thompson,'  may  coexist  in  the  same  patient.     This  association 

^  Trans.  Assoc.  Amer.  Phys.,  1894 


206  ENTERIC  OR   TYPHOID  FEVER. 

is  unquestionably  rare,  and  cannot  be  regarded  as  establishing  the  exist- 
ence of  such  a  nosological  entity  as  typho-malarial  fever.  Some  forms 
of  malarial  fever  closely  resemble  enteric  fever,  especially  when  the 
marked  abdominal  symptoms  are  present.  Vomiting,  diarrhoea,  splenic 
enlargement,  cerebral  symptoms,  and  the  condition  known  as  the  typhoid 
state  may  occur  in  both  diseases.  The  more  important  points  of  dis- 
tinction are  to  be  sought  in  the  presence  of  the  eruption  and  the  discovery 
of  malarial  bodies  upon  examination  of  the  blood.  The  absence  of  the 
characteristic  rash  of  enteric  fever  is  without  positive  diagnostic  value 
in  doubtful  cases,  since  in  a  small  proportion  of  the  cases  the  eruption 
does  not  show  itself  during  the  whole  course  of  the  attack. 

Acute  tuberculosis  presents  in  some  instances  a  close  resemblance  to 
enteric  fever.  In  the  latter  disease,  however,  the  temperature  in  a 
majority  of  instances  conforms  more  or  less  closely  to  a  definite  type, 
whereas  that  of  tuberculosis  is  extremely  irregular.  In  enteric  fever 
diarrhoea  and  tympany  are  common ;  in  tuberculosis,  diarrhoea  when 
present  is  of  a  different  character  and  the  abdomen  is  flat,  often  scaphoid. 
In  enteric  fever  nose-bleeding  and  enlargement  of  the  spleen  occur  ;  in 
tuberculous  processes  these  symptoms  are  rare  or  absent  altogether.  The 
headache  of  enteric  fever  is  usually  dull ;  that  of  tuberculous  meningitis  is 
acute  and  frequently  associated  with  intolerance  of  light  and  sound.  In 
enteric  fever  vomiting  is  much  less  common  than  in  tuberculous  menin- 
gitis. Convulsions  are  likewise  rare  in  enteric  fever,  and  the  headache 
usually  disappears  upon  the  occurrence  of  delirium,  whereas  in  tubercu- 
lous meningitis  headache  and  delirium  may  alternate  from  the  beginning. 
In  this  connection  it  is  important  to  emphasize  the  fact  that  in  rare 
cases  of  the  so-called  cerebro-spinal  form  of  enteric  fever  the  onset  of  the 
attack  is  abrupt,  with  intense  headache,  photophobia,  painful  retraction 
of  the  muscles  of  the  back  of  the  neck,  twitching,  delirium,  and  vomit- 
ing. Under  these  circumstances  the  diagnosis  of  enteric  fever  cannot  be 
made  until  about  the  end  of  the  first  week,  when  the  appearance  of  ab- 
dominal symptoms  and  rose  spots,  very  often  coincidently  with  subsi- 
dence of  the  cerebro-spinal  symptoms,  declares  the  true  nature  of  the 
infective  process. 

Croupous  pneumonia  may  also  occur  early  in  the  course  of  the  attack, 
or  pulmonary  localization  may  cause  enteric  fever  to  simulate  pneumonia. 
In  certain  cases  it  is  not  possible  to  determine  whether  the  pulmonary 
phenomena  are  the  results  of  an  intercurrent  process  or  of  an  early 
localization  of  the  enteric  fever  infection. 

A^jpendicitis  in  rare  instances  may  simulate  enteric  fever.  The  course 
of  the  temperature,  the  absence  of  splenic  enlargement,  the  localization 
of  the  abdominal  phenomena  in  the  right  iliac  region  are  of  diagnostic 
importance. 

Peritonitis  due  to  other  causes  than  perforation  is  to  be  discriminated 
from  that  occurring  in  the  course  of  enteric  fever,  by  the  antecedent  his- 
tory of  the  case.  If  the  patient,  however,  does  not  come  under  obser- 
vation until  after  the  appearance  of  the  symptoms,  it  may  be  impossible 
to  determine  whether  they  are  due  to  perforation  or  not.  The  presence 
of  the  rose  spots  would  be  of  importance  in  the  decision  of  this  question. 

Trichinosis  is  attended  with  pyrexia,  vomiting,  and  diarrhoea.  Epis- 
taxis  and  splenic  enlargement  are  rare  ;  rose  spots  do  not  occur.     On 


ri'j )(!  SdSlS—TREATMEyT.  2(  )7 

the  other  hand,  ihc  .-yiuptunir-  oi'  the  myositis  and  the  h»eal  and  general 
anlenia,  so  freijiient  in  trichinosis,  are  absent  in  enterie  lever. 

Entero-voliti.s  may  in  chikh'en  be  confounded  with  enteric  fever. 
The  fever  and  constitutional  disturbances  are  symptomatic  of  the  local 
trouble.  The  spleen  is  not  commonly  enlar^red,  abdominal  pain  is  con- 
spicuous and  severe,  and  rose  spots  are  absent. 

Prognosis. — The  death-rate  is  much  influenced  by  treatment.  It 
ranges  inider  ordinary  c<»nditions  from  about  7  per  cent,  under  system- 
atic cold  bathing  to  about  15  per  cent,  under  expectant  symptomatic 
treatment.  Murchison  found  in  27,051  cases  collected  from  various 
sources  a  death-rate  of  17.45  per  cent. ;  Jaccoud,  in  a  collection  of 
80,140  cases  treated  on  the  expectant  plan,  a  mortality  of  19,23  per 
cent. ;  17,000  cases  in  Vienna  showed  a  mortality  of  22.5  per  cent. 
According  to  Caylev,  the  principal  Continental  hospitals  have  a  mortal- 
itv  varving  between  16  and  25  per  cent.  Some  years  ago  Delafield  col- 
lected from  the  records  of  the  New  York  hospitals,  extending  over  a 
period  of  about  five  years,  1305  cases,  with  a  mortality,  estimated  by 
years,  varving  between  a  minimum  of  20.1  per  cent,  in  1879  and  a 
maximum  of  30  per  cent,  in  1880.  The  available  statistics  of  recent 
vears  unquestionably  show  a  reduction  under  various  plans  of  treat- 
ment. 

The  mortality  in  childhood,  taking  all  the  cases  together,  is  decidedly 
lower  than  in  adults.  Enteric  fever,  like  all  the  acute  infectious 
diseases,  shows  an  extremely  variable  intensitv^  in  children,  the  severe 
cases,  however,  being  the  exception  rather  than  the  rule. 

The  prognosis  in  individual  cases  must  be  guarded,  since  it  not 
infrequently  happens  that  in  cases  running  an  apparently  favorable 
course  death  occurs  toward  the  end  of  the  third  or  during  the  fourth 
week  from  some  unforeseen  accident  or  complication.  The  prognosis  is 
unfavorable  in  cases  in  which  the  intensity  of  the  infection  is  manifested 
by  the  rapid  development  of  severe  symptoms — intense  p}Texia,  cardiac 
asthenia,  ataxic  phenomena,  and  the  occiu*rence  of  multiple  cases  in  the 
.same  house  or  in  the  immediate  locality ;  it  becomes  unfavorable  like- 
wise upon  the  development  of  intestinal  symptoms  of  high  grade,  such 
as  copious  diarrhoea,  abdominal  pain,  or  meteorism.  Recurrent  vomiting 
has  also  an  unfavorable  prognostic  import.  Finally,  intestinal  hemor- 
rhage, perforation,  and  such  complications  as  ulcerative  endocarditis, 
meningitis,  diphtheria,  large  pleural  effusions,  and  in  children  the  exan- 
themata arising  as  intercurrent  or  consecutive  affections,  render  the 
prognosis  extremely  grave. 

Sudden  death  may  occur  about  the  time  of  defervescence  or  in  early 
convalescence  in  consequence  of  extreme  cardiac  asthenia. 

Corpulent  persons  bear  enteric  fever  badly.  Those  whose  habits 
have  been  intemperate  and  those  who  suffer  from  disease  of  the  kidney 
and  the  gouty  are  especially  liable  to  the  gravest  accidents  of  the  disease. 
The  death-rate  is  slightly  greater  in  women  than  in  men. 

Treatment. — («)  Prophylaxis. — Enteric  fever  is  theoretically  a 
preventable  disease.  The  objects  of  prophylaxis  are  (1)  to  prevent  any 
case  of  the  disease  from  becoming  a  focus  of  infection,  and  (2)  to  correct 
such  faulty  sanitary  arrangements  as  lead  to  the  pollution  by  fecal 
matter  of  water  used  for  drinking  and  domestic  purposes.     The  success- 


208  ENTERIC  OR   TYPHOID  FEVER. 

ful  pursuit  of  these  objects  wherever  the  disease  prevails  would  certainly 
be  followed  immediately  by  a  notable  decrease  in  the  morbidity. 
Rational  preventive  measures,  even  though  imperfectly  carried  into 
eifect,  have  been  followed  by  remarkable  results.  Their  general  adop- 
tion and  rigid  execution  would  be  followed  by  a  very  gi'eat  reduction  in 
the  prevalence  of  the  disease. 

The  first  measure  of  prophylaxis — namely,  the  prevention  of  the 
spread  of  the  disease  from  any  patient  as  a  focus  of  infection — consti- 
tutes an  important  duty  of  the  physician  in  attendance.  The  typhoid 
bacilli  in  the  fecal  discharges  can  be  at  once  and  absolutely  destroyed 
upon  the  spot.  They  do  not  appear  in  the  stools  until  some  time  after 
the  period  at  which  under  ordinary  circumstances  the  patient  comes 
under  the  care  of  the  physician.  It  follows  from  the  facts  now  estab- 
lished in  regard  to  the  transmission  of  the  disease  that  any  given  case 
may  be  prevented  from  becoming  not  only  a  source  of  infection  to  those 
in  his  immediate  vicinity,  but  also  to  those  at  a  distance.  Upon  those 
in  immediate  attendance  devolves  the  duty  of  protecting  alike  persons 
in  the  vicinity  of  the  patient  and  those  to  whom  the  disease  may  be 
conveyed  by  the  contamination  of  running  streams  or  other  sources  of 
water  supply  or  in  cities  by  way  of  sewer  systems  transmitting  the  in- 
fecting principle. 

To  this  end  the  fecal  discharges  of  every  case  and  the  urine  should 
be  at  once  and  effectually  disinfected.  For  this  purpose  a  solution  of 
chlorinated  lime  of  the  best  quality,  containing  at  least  25  per  cent,  of 
available  chlorine,  of  the  strength  of  6  ounces  (192.)  to  the  gallon  (4 
litres),  may  be  employed.  Commercial  sulphuric  or  hydrochloric  acid 
and  water  in  equal  parts  will  disinfect  a  stool  in  two  hours.  A  solution 
of  mercuric  chloride,  1  :  500,  acidulated  with  tartaric  or  hydrochloric 
acid,  will  disinfect  an  enteric  fever  stool  in  six  hours.  Carbolic  acid  in 
5  per  cent,  solution  is  less  efficient  and  requires  twenty-four  hours. 
Milk  of  lime,  prepared  by  slaking  freshly  burned  quicklime  and  stir- 
ring up  the  powder  with  twice  its  volume  of  water,  is  an  efficient  and 
rapid  disinfectant  for  enteric  fever  stools.  This  preparation  should  be 
freshly  made  and  added  to  the  stool  in  equal  bulk.  When  the  bed-pan 
is  to  be  used,  it  should  contain  one  half  pint  (250  c.c.)  of  the  solution 
employed.  Directly  after  the  movement  of  the  bowels  a  pint  (500  c.c), 
or  as  much  as  a  quart  (1000  c.c),  of  the  solution,  according  to  the  amount 
of  the  dejection,  should  be  poured  over  it.  The  contents  of  the  pan 
should  then  be  thoroughly  mixed  by  agitation  of  the  vessel,  and  solid 
masses  should  be  broken  up  with  a  glass  rod,  which  can  be  thoroughly 
disinfected.  If  a  stick  is  used,  it  should  be  forthwith  burned.  The 
pan  should  then  stand  two  or  three  hours  before  it  is  emptied  into  the 
water  closet  or  privy  vault.  The  nurse  should  be  made  to  understand 
that  prolonged  exposure  is  necessary  to  complete  disinfection. 

Clear  solutions  like  that  of  the  mercuric  chloride  should  be  colored 
by  the  addition  of  potassium  permanganate,  and  the  disinfectants 
employed  must  be  kept  in  a  place  by  themselves  and  conspicuously 
labelled  "  Poison."  Commercial  preparations  placed  upon  the  market 
under  various  names  for  the  purpose  of  household  and  sick-room  disin- 
fection are  not  to  be  prescribed.  They  are  of  unknown  and  doubtless 
inconstant  composition,  and  unduly  expensive.     When  acid  disinfect- 


TREATMENT.  209 

ants  arc  emplovod  tlio  water  closet  is  to  he  tiiished  for  some  minutes 
several  times  diiriiio-  the  »hiy  to  (hminish  their  action  upon  the  tittin<rs 
and  connections.  In  country  phiccs  the  thorouiihly  disinfected  stools 
may  be  emptii'd  into  an  ordinary  privy  without  risk,  or  they  may  be 
mixed  with  fresh  earth  and  buried  in  a  trench  at  a  distance  fr(»m  all 
sources  of  water  supply.  It  is  imperative  that  they  be  thoroughly  dis- 
infected. In  some  localities  it  is  the  custom  to  dispose  of  enteric  fever 
stools  by  mixino-  them  Avith  sawdust  and  burning-  them.  Privy  vaidts 
that  are  to  be  disinfected  may  be  treated  by  slowly  pouring  into  them 
a  solution  of  mercuric  chloride  (I.;)—!  kg.  in  several  gallons  of  water), 
or  by  freely  scattering  over  the  contents  of  the  well  quick-lime  or 
chlorinated  lime  from  day  to  day. 

The  danger  of  the  spreading  of  the  infection  by  way  of  the  acciden- 
tal soiling  of  the  patient's  clothing  or  bed-clothing  with  the  fecal  dis- 
charges is  not  to  be  disregarded.  It  is  important  that  the  mattress  of 
an  enteric  fever  patient  should  be  covered  by  a  rubber  sheet,  and  that 
articles  of  bedding  and  the  patient's  clothing  should,  when  accidentally 
soiled,  be  immediately  removed.  Should  fecal  discharges  have  become 
dried  upon  these  articles,  the  stain  should  be  moistened  with  a  disinfec- 
tant solution  before  removal.  There  should  be  in  the  sick-room  a  tub 
into  Avhich  the  garments  of  the  patient,  his  bed-linen  and  towels,  should 
be  immediately  placed  and  moistened  with  a  5  per  cent,  solution  of 
carbolic  acid  before  removal  to  the  laundry,  where  they  must  without 
handling  be  at  once  boiled  for  half  an  hour.  They  should  then  be 
washed  with  soft  soap  and  thoroughly  rinsed.  After  drying  they  must 
be  aired  and  exposed  to  the  sun  for  several  hours  before  being  again 
used.  In  fatal  cases  the  corpse  must  be  enveloped  in  a  sheet  wet  with 
a  carbolic  acid  solution,  1  :  20.  After  the  recovery  of  the  patient  the 
bedstead  and  furniture  of  his  room  are  to  be  washed  with  a  solution  of 
mercuric  chloride,  1  :  1000.  Bedding,  towels,  and  the  like  are  to  be 
thoroughly  boiled.  The  rubber  coverings  are  to  be  first  disinfected  and 
then  destroyed.  In  a  private  house  the  room  should  be  aired  daily  for 
a  fortnight  before  it  is  again  occupied. 

At  the  time  of  an  epidemic  of  enteric  fever  all  drinking  water  and 
milk  used  in  families  should  be  subjected  to  boiling  for  thirty  minutes. 
New  comers  and  temporary  sojourners  in  a  locality  in  which  enteric 
fever  is  prevalent  should  drink  only  boiled  water  and  milk  and  should 
avoid  the  use  of  uncooked  vegetables.  In  sporadic  cases  search  should 
be  made  for  the  source  of  the  infection.  In  the  great  centres  of  popu- 
lation such  investigations,  except  in  so  far  as  they  indicate  general 
defects  in  the  water  supply  or  in  the  sewage,  are  not  attended  with 
satisfactory  results,  but  when  enteric  fever  occurs  in  the  form  of  an 
epidemic,  limited  to  a  locality  supplied  with  water  from  a  jxirticular 
source  or  to  a  neighborhood  served  with  milk  from  the  same  dairy,  the 
results  are  often  in  the  highest  degree  significant.  They  show  defects 
in  the  water  supply  or  milk  contamination,  and  point  to  the  circum- 
stances under  which  pollution  has  taken  place,  and  even  indicate  with 
precision  the  measures  by  which  further  infection  is  to  be  prevented. 
The  results  of  such  investigations  are  especially  valuable  in  restricted 
localities  into  which  the  cause  of  the  disease  has  been  conveyed  by  the 
advent  of  cases  of  enteric  fever. 
Vol.  I.— 14 


210  ENTERIC  OR   TYPHOID  FEVER. 

The  second  object  of  prophylaxis — namely,  the  correction  of  faulty 
sanitary  arrangements  by  which  the  pollution  of  water  used  for  drink- 
ing and  domestic  purposes  by  fecal  matter  or  the  infection  of  milk  and 
other  articles  of  diet  by  such  water  is  rendered  possible — falls  clearly 
within  the  scope  of  the  health  organizations  of  local  governments.  The 
inadequate  powers  vested  in  State  and  local  boards  of  health,  the  ignor- 
ance of  officials,  and,  above  all,  the  apathy  of  the  people,  conspire  to 
render  hope  of  the  attainment  of  this  object,  even  in  enlightened  com- 
munities, remote.  No  outlay,  however,  will  prove  more  profitable  for 
the  taxpayer.  The  actual  money  cost  of  a  polluted  water  supply  and 
bad  drainage  as  factors  in  the  production  of  disease  cannot  be  computed. 
It  is  certain,  however,  that  the  value  of  the  lost  time,  cost  of  support, 
nursing,  and  the  like  would  amount  in  a  large  city  to  much  more  than 
sufficient  to  rectify  the  unsanitary  conditions  to  which  endemic  enteric 
fever  is  directly  due. 

An  abundant  and  good  water  supply  is  of  first  importance.  The 
natural  history  of  the  water  is  better  evidence  of  its  purity  than  the 
response  in  occasional  samples  to  chemical  and  biological  tests.  The 
most  desirable  sources  of  supply  are  to  be  found  in  mountain  lakes  or 
streams  in  unpopulated  districts  or  in  artesian  wells.  The  impossibility 
of  protecting  streams  that  floAv  through  populous  valleys  or  in  prevent- 
ing the  contamination  of  ordinary  wells  is  obvious.  It  constitutes, 
therefore,  an  essential  measure  of  prophylaxis  in  cities  and  towns  to 
abandon  wells,  and  those  communities  which  derive  their  water  supply 
from  streams  receiving  the  sewage  of  other  towns  and  villages  can 
escape  the  endemic  and  occasionally  epidemic  prevalence  of  enteric 
fever  only  by  filtration  upon  a  large  scale  and  in  accordance  with 
scientific  methods  before  distribution. 

Mosny  showed  that  the  death-rate  from  enteric  fever  in  Vienna 
diminished  from  11.5  per  10,000  to  1.1  per  10,000  after  the  introduc- 
tion of  water  from  the  neighboring  mountains.  AVhen,  however,  a  few 
years  later,  owing  to  a  defect  in  the  waterworks,  it  became  necessary 
to  again  use  the  water  of  the  Danube  for  a  short  period,  an  epidemic 
brok^  out  which  was  confined  to  those  jsarts  of  the  city  to  which  this 
water  was  distributed.  Similar  results  followed  the  use  of  the  Avater 
of  the  Seine  for  drinking  purposes  in  Paris. 

A  supply  of  good  water  is  not  in  itself,  however,  sufficient  to  reduce 
the  endemic  prevalence  of  enteric  fever  to  the  lowest  point.  A  corre- 
spondence between  the  morbidity  from  this  disease  and  the  drainage 
exists  which  has  not  yet  been  fully  explained.  This  correspondence 
has  been  especially  demonstrated  by  the  observations  of  E.  F.  Smith 
and  Osier.  The  introduction  of  thorough  drainage  systems  constitutes 
a  means  of  general  prophylaxis  against  enteric  fever  second  in  import- 
ance only  to  that  of  a  poor  water  supply.  Such  drainage  systems,  how- 
ever, discharge  usually  into  running  streams,  and  therefore  transfer  the 
danger  to  other  localities  more  or  less  remote.  Thus  outbreaks  of  enteric 
fever  have  occurred  in  the  crews  of  ships  lying  at  anchor  near  the  sewer 
outlets  of  large  cities  in  consequence  of  using  water  for  drinking  pur- 
poses. Exact  facts  as  to  the  distance  to  which  typhoid  bacilli  may  be 
transported,  and  the  length  of  time  during  which  they  retain  their  viru- 
lence under  these  circiunstances  in  large  bodies  of  water,  have  not  yet 


TREATMEST.  211 

been  definitely  fixed.  The  oecnrrenee  of  loeal  epidemics  of  enteric  fever 
in  c(>nsc(]Uence  of  tiie  c()nsunij)ti()n  of  oysters  taken  from  waters  jjolluted 
bv  the  sewaiic  of  cities  is  most  imjiortant.  It  is  therefore  obvions  that 
the  immediate  and  efficient  disinfection  of  all  the  stools  in  every  ease  of 
enteric  fever  in  the  sick-room  is  an  imperative  measure  of  prophylaxis. 

(/>)  The  General  Management  of  the  Patient. — The  result  of  the 
treatment  in  enteric  fever  is  laruely  influenced  Ijy  the  details  given  to 
the  general  managi'nient  and  nursing  of  the  case.  The  patient  should 
not  be  exj)osed  t(j  continued  infection.  Obvious  faults  connected  with 
the  water  supply  or  milk  supply  should  be  immediately  corrected.  Under 
these  circumstances  it  is  necessary  to  remove  the  patient  to  more  favor- 
able surroundings.  In  hospitals  enteric  fever  patients  have  usually 
been  treated  in  the  ward  side  by  side  with  other  patients.  This  prac- 
tice is  without  danger  if  precautionary  measures  are  taken  to  secure  the 
immediate  disinfection  and  removal  of  the  dejections  and  the  cleanliness 
of  the  patient's  person  and  bedding.  It  is,  however,  at  present  consid- 
ered better  to  place  enteric  fever  patients  together  in  separate  wards. 
In  general  practice  patients,  as  a  rule,  come  under  observation  during 
the  period  of  prodromes  or  early  in  the  first  stage  of  the  disease.  If  the 
symptoms  are  such  as  to  give  rise  to  a  suspicion  that  the  disease  is  enteric 
fever,  the  patient  should  be  ordered  at  once  to  bed.  In  the  event  of  the 
malady  not  being  enteric  fever,  the  patient's  interests  do  not  suffer.  If, 
however,  the  symptoms  be  those  of  developing  enteric  fever,  rest  in  bed 
\\\\\  favorably  influence  the  later  progress  of  the  attack.  The  general 
course  of  cases  treated  from  the  beginning  of  the  attack  is  more  favor- 
able than  that  of  those  coming  under  medical  care  after  the  disease  has 
made  some  progress.  Persons  who  struggle  against  the  early  symptoms 
of  the  attack,  or  who  continue  to  go  about  until  the  intensity  of  the 
febrile  movement,  diarrhoea,  or  sheer  prostration  obliges  them  to  betake 
themselves  to  bed,  constitute  the  worst  cases  of  the  disease.  The  fatigue 
of  long  journeys  undertaken  to  reach  home  after  the  development  of  the 
symptoms  has  frequently  exerted  an  unfavorable  influence  upon  the  sub- 
sequent course  of  the  attack.  Rest  in  bed  from  the  beginning  of  the 
sickness  is  important.  Patients  treated  upon  the  expectant  or  expectant- 
symptomatic  plan  shoidd  not  be  allowed  to  rise  until  some  days  after 
defervescence  has  been  completed. 

The  urinal  and  bed-pan  must  be  regularly  used.  Many  patients  who 
declare  that  it  is  impossible  to  empri'  the  bowel  in  the  recumbent  pos- 
ture find  upon  trial  that  it  is  less  difiicult  than  they  supposed.  Strict 
rules  in  regard  to  rest  in  bed  and  the  employment  of  the  bed-pan  and 
urinal  cannot  always  be  carried  out  in  the  case  of  young  children. 

The  room  should  be  large,  well  ventilated,  and,  if  practicable,  have 
a  southern  exposure.  All  curtains,  hangings,  and  pictures  shoidd  be  at 
once  removed.  Only  such  simple  furniture  as  is  necessary  for  the  attend- 
ants should  be  retained.  An  open  fireplace  is  advantageous.  Free  ven- 
tilation is  necessary.  Drafts  are  to  be  avoided,  but  the  fever  patient  is 
with  ordinary  care  little  liable  to  take  cold.  In  grave  cases  the  patient 
mav  be  with  advantage  removed  at  intervals  from  one  to  the  other  of 
communicating  rooms.  In  cities  a  back  room  removed  from  street  noises 
is  desirable.  When  the  weather  permits  the  patient  may  with  advantage 
be  removed  during  the  day  for  a  few  hours  to  a  porch  or  gallery  in  the 


212  ENTERIC  OR   TYPHOID  FEVER. 

open  air  and  sunshine.  A  narrow  single  bed,  not  too  high,  greatly  light- 
ens the  labor  of  nursing.  The  mattress  must  be  smooth,  firm,  and  elastic. 
A  rubber  cloth  or  mackintosh  must  be  placed  under  the  sheet.  The 
covering  should  be  light  and  varied  from  time  to  time  according  to  the 
sensations  of  the  patient.  Bedding  or  bed-clothing  soiled  by  the  invol- 
untary evacuation  of  urine  or  faeces  should  be  immediately  changed  and 
disinfected.  In  very  severe  cases  it  is  desirable  to  use  two  beds,  placed 
side  by  side,  from  one  to  the  other  of  which  the  patient  when  necessary 
may  be  lifted. 

The  wants  of  the  patient  are  to  be  attended  to  quietly,  noiselessly, 
without  conversation  or  comment.  During  convalescence  the  visits  of 
friends  are  to  be  restricted  in  number  and  should  be  very  brief.  At 
this  period  tact  and  caution  in  the  communication  of  details  of  business 
aifairs  and  matters  of  annoyance  are  most  important. 

Patients  who  have  been  delirious  must  under  no  circumstances, 
though  at  the  moment  apparently  rational,  be  left  alone  until  convales- 
cence has  been  fully  established.  Suicidal  impulses  may  develop,  and 
many  patients  have  destroyed  themselves  during  the  momentary  absence 
of  the  attendant.  Good  nursing  is  of  the  highest  importance.  It 
means  to  the  physician  accurate  and  systematic  information  at  his  visits, 
alertness  and  responsibility  in  his  absence.  To  the  patient  it  means 
quietude,  gentleness,  neatness,  diminished  suffering.  To  both  the 
physician  and  patient  it  means  the  best  use  of  the  resources  of  medicine. 

The  free  administration  of  fluid  is  necessary.  Many  patients, 
apparently  fully  conscious,  fail  to  obtain  the  necessary  amount  of  drink. 
Fluid,  therefore,  should  be  offered  in  small  amounts  at  short  intervals. 
A  judicious  nurse,  administering  fluid  in  small  amounts  at  a  time,  is- 
not  likely  to  give  in  the  aggregate  too  much. 

Pure  cold  water  is  the  best  drink  for  fever  patients.  The  aerated 
mineral  waters  afford  an  agreeable  change. 

The  diet  throughout  the  attack  should  be  nutritious,  easy  of  diges- 
tion, and  liquid.  Definite  and  explicit  directions  as  to  kind,  quantity, 
and  the  intervals  of  administration  are  necessary.  The  details  must  be 
systematically  recorded.  General  directions  on  the  part  of  the  physician 
and  general  reports  on  the  part  of  the  nurse  are  inadmissible.  The 
amount  is  to  be  regulated  by  the  requirements  of  individual  cases. 
Indigestion  and  an  aggravation  of  the  symptoms  of  intestinal  catarrh 
result  from  over-feeding.  On  the  other  hand,  under-feeding  increases 
the  asthenia  and  prolongs  convalescence.  As  a  rule,  the  mental  condi- 
tion is  such  that  the  patient  takes  without  objection  whatever  is  prof- 
fered in  the  way  of  food  or  medicine.  Enteric  fever  patients  are 
usually  rather  over-fed  than  under-fed.  The  signs  of  gastric  indiges- 
tion, increased  diarrhoea,  and  the  presence  of  milk  curds  in  the  stools 
will  call  the  attention  of  the  physician  to  the  fact  that  the  patient  is 
receiving  too  great  an  amount  of  food.  Despite  theoretical  considera- 
tions, milk  holds  the  first  place  among  fever  foods.  It  supplies  the 
liquid  required  for  the  chemical  processes  of  nutrition  ;  it  is  in  most 
cases  readily  digestible  ;  it  is  diuretic ;  it  may  in  a  majority  of  the  cases 
constitute  the  sole  diet  or  at  all  events  the  basis  of  the  diet.  Used 
alone,  milk  should  not  much  exceed  in  daily  amount  for  an  adult  3 
pints  (1500  c.c.)  during  the  first  period  of  the    disease,  or   2  quarts 


TREATMENT.  213 

(2  litres)  subsequently.  This  quantity  must  l>c  given  in  divided  ])or- 
tions  at  intervals  during  the  twenty-four  hours.  Milk  as  a  fever  food 
may  be  raw  or  boiled,  warm,  cold,  or  iced,  or  now  and  then  given 
coagulated  into  soft  curds  by  nieans  of  rennet.  It  may  be  diluted  with 
lime-water  in  tlie  proportion  of  1  ])art  to  5,  or  mingled  with  one-third 
its  vohnne  of  Viehy  water.  The  repugnance  evinced  by  some  ])atients 
to  a  milk  diet  may  be  overcome  in  jxirt  l)y  the  addition  of  coffee  or 
spirit,  such  as  brandy,  whiskey,  or  rum  ;  the  inability  of  others  to  digest 
it  may  be  overcome  by  partial  peptonization  or  by  its  administration  in 
the  form  of  koumyss,  kefir,  or  matzoon.  Sterilized  milk  may  be  used 
for  a  time  with  advantage,  but  it-s  continuous  employment  cannot  be 
recommended.  The  occasional  administration  of  buttermilk  or  wine 
"whey  may  vary  an  otherwise  monotonous  diet.  A  raw  egg  beaten  up  in 
the  milk,  ■with  or  without  spirit,  reinforces  the  diet,  and  in  the  German 
Hospital  we  frequently  administer  three  or  four  raw  eggs  during  the 
course  of  the  twenty-four  hours  to  cases  under  the  bath  treatment.  If 
there  be  irritability  of  the  stomach,  the  white  only  of  the  egg,  mixed 
with  an  equal  volume  of  water  and  flavored  with  a  little  brandy  or 
sherry,  is  better  borne.  It  is  usually  desirable  to  vary  the  diet,  and  in 
some  cases  it  is  impossible  to  administer  milk  continuously.  We  may 
then  employ  broths  or  soups  prepared  from  beef,  mutton,  chicken,  or 
veal  flavored  with  vegetable  juices  and  containing  a  little  rice  or  barley. 
These  should  be,  however,  systematically  strained.  Consomm^,  either 
hot  or  frozen  according  to  the  fancy  of  the  patient,  clam-juice,  oyster 
soup,  thin  barley  gruel,  arrowroot,  and  the  commercial  malt  foods,  pep- 
tonoids,  and  the  freshly  expressed  juice  of  partly  broiled  beef,  may  be 
included  in  the  dietary.  A  cup  of  hot  coffee  or  cocoa,  well  diluted  with 
milk,  may  be  given  once  in  the  twenty-four  hours,  preferably  in  the 
early  part  of  the  day.  Food  should  be  systematically  administered 
every  two  or  three  hours  during  the  day  and  at  intervals  of  three  or 
four  hours  at  night.  In  grave  cases,  where  the  amount  taken  at  a  time 
is  small  or  the  prostration  is  extreme,  these  intervals  must  be  shortened. 
A  restless  patient  who  has  just  fallen  into  a  quiet  sleep  must  not  be 
disturbed  for  food.  Patients  who  are  very  somnolent  or  soporous  must, 
if  possible,  be  roused  before  food  is  given,  in  order  to  diminish  the 
danger  of  inhalation  pneumonia. 

Solid  food  is  not  to  be  administered  until  the  evening  temperature 
has  been  normal  for  a  week.  The  change  even  then  must  be  tentative 
and  gradual  by  way  of  milk  toast,  custards,  light  puddings,  and  similar 
articles  of  diet  to  the  ordinary  every-day  food.  The  details  of  the  diet 
in  voung  children  must  be  regulated  in  accordance  with  the  asje  of  the 
patient  and  the  previous  plan  of  feeding,  no  radical  departure  from  the 
usual  nourishment  being  necessary  beyond  the  avoidance  of  every  kind 
of  solid  food. 

Alcoholic  stimulants  constitute  an  essential  element  of  the  routine 
procedure  in  the  treatment  of  enteric  fever  by  systematic  cold  bathing, 
and  their  administration  will  be  discussed  in  connection  with  that  plan. 
In  other  forms  of  treatment  the  circumstances  under  which  alcohol  is  to 
be  administered  demand  careful  consideration.  Those  who  recall  the 
method  of  its  employment  some  years  >ago  agree  that  it  was  very  often 
given  as  a  matter  of  course  when  not  required,  and  nearly  always  in  un- 


214  ENTERIC  OR   TYPHOID  FEVER. 

necessarily  large  amounts.  At  the  present  time  alcohol  is  frequently 
used  too  freely  in  the  sick-room.  In  mild  cases  of  enteric  fever  and  in 
young  persons  of  previously  good  health  and  habits  it  is,  as  a  rule,  not 
required.  In  persons  of  feeble  constitution  and  those  past  middle  life, 
and  in  all  severe  cases,  alcohol  should  be  systematically  but  cautiously 
administered.  To  those  who  have  previously  been  accustomed  to  its  use 
it  should  be  given  from  the  onset  of  the  attack,  and  to  a  guarded  extent 
in  amounts  suggested  by  the  habits  of  the  patient.  It  is  important  that 
alcoholic  stimulants  should  be  given  in  guarded  amounts  during  the 
early  period  of  the  attack  prior  to  the  subsidence  of  the  headache — an 
event  that  commonly  occurs  between  the  end  of  the  first  and  the  middle 
of  the  second  week.     After  this  time  alcohol  may  be  used  more  freely. 

Alcohol  is  clearly  indicated  in  all  cases  in  which  there  is  great 
general  prostration.  Its  administration  is  essential  where  there  is  weak- 
ness of  the  heart's  action,  as  shown  by  a  small,  feeble,  and  irregular 
pulse,  a  feeble  cardiac  impulse,  and  a  faint  first  sound.  It  should  be 
administered  with  a  free  hand  upon  the  development  of  delirium,  tremor, 
or  other  ataxic  symptoms.  Its  use  is  especially  important  when  diarrhoea, 
tympanites,  and  great  tenderness  indicate  extensive  and  deep  ulceration. 
The  administration  of  alcohol  is  imperatively  demanded  in  all  severe 
cases  and  upon  the  development  of  serious  complications,  such  as  bron- 
chitis of  the  smaller  tubes,  broncho-pneumonia,  croupous  pneumonia, 
pleurisy,  or  peritonitis.  The  amount  must  be  regulated  according  to  its 
influence  upon  the  symptoms  for  which  it  has  been  prescribed  in  in- 
dividual cases.  The  character  of  the  first  sound  of  the  heart  and  the 
pulse  and  the  nervous  symptoms  constitute  the  best  guide  for  the  dose 
and  the  frequency  of  its  administration.  If  the  urine  be  albuminous,  and 
particularly  if  it  contain  casts,  alcohol  is  to  be  given  cautiously,  and  its 
effect  upon  the  amount  and  character  of  the  renal  excretion  is  to  be 
studied  from  day  to   day. 

Under  ordinary  circumstances  the  administration  of  alcohol  should 
begin  with  small  quantities,  to  be  increased  according  to  the  require- 
ments of  particular  cases.  Four  to  eight  ounces  (125-250  c.c.)  of  spirit 
or  from  a  pint  to  a  pint  and  a  half  (500-750  c.c.)  of  claret,  burgundy, 
or  champagne  in  the  course  of  twenty-four  hours  yield  the  best  results. 
In  serious  cases  much  larger  quantities  may  be  required.  Whiskey  or 
brandy  may  be  given  with  milk  in  the  form  of  punch,  or,  if  the  patient 
prefer  it,  diluted  with  water.  Where  small  amounts  of  alcohol  are 
indicated  wine  whey  constitutes  an  agreeable  means  for  its  administra- 
tion. 

(c)  The  Special  Manag-ement  of  Individual  Cases. — The  milder 
cases  do  well  without  drugs.  Rest  in  bed,  skilled  nursing,  and  a  care- 
fully regulated  dietary  comprise  all  that  is  necessary  in  the  management 
of  the  case.  With  moderate  fever,  a  good  heart,  no  signs  of  serious 
intestinal  lesions,  and  the  absence  of  pulmonary  complications  beyond 
a  slight  bronchitis,  the  administration  of  medicines  is  needless.  The 
treatment  may  with  advantage  be  commenced  with  laxative  doses  of 
castor  oil  or  of  calomel,  which  should  be  repeated  at  intervals  of  three 
or  four  days  until  the  middle  of  the  second  week  of  the  attack.  Later 
than  this  constipation  may  be  relieved  by  enemata  of  lukewarm  water 
in  which  is  dissolved  common  salt  in  the  proportion  of  a  teaspoonful  to 


TREATMI'JXT.  215 

the  pint,  or  by  soapsuds  or  by  tliin  ^riK-l.  In  tlu'  event  of"  constipation 
not  being  thus  relieved,  euenuita  of  glycerin  and  water  or  glycerin  sup- 
positories may  be  employed.  These  measures  to  secure  the  action  of  tiie 
lower  bowel  do  not  require  repetition  at  intervals  shorter  than  every 
third  dav.  There  are  those  who  upon  theoretical  grounds  regard  the 
svstematic  washing  out  of  the  lower  bowel  by  large  enemata  of  normal 
salt  solution  once  or  twice  in  the  course  of  twenty-four  hours  as  of 
advantage. 

Cases  treated  with  so-called  fever  mixtures  or  with  small  doses  of 
quinine,  the  mineral  acids,  turpentine,  silver  nitrate,  or  other  drugs  that 
have  no  effect  upon  the  course  of  the  disease  must  be  regarded  as  man- 
aged in  accordance  with  the  expectant  method.  Fortunately,  such 
medicaments  are  usually  well  tolerated  by  the  patient.  The  great  varia- 
tion in  the  intensity  of  the  attack  in  different  cases  must  put  us  on  our 
guard  against  ascribing  to  therapeutic  measures  results  that  are  really  to 
be  attributed  to  the  course  of  the  disease  in  individual  cases. 

(d)  Treatment  of  Special  Symptoms  and  Complications. — The 
headache  of  the  period  of  onset  requires,  as  a  rule,  but  little  treatment ; 
it  disappears  spontaneously  between  the  end  of  the  first  and  the  middle 
of  the  second  week.  Quietude,  the  exclusion  of  light,  compresses  to 
the  head  wet  with  cold  or  hot  water  according  to  the  sensations  of  the 
patients,  are  very  often  sufficient  to  control  the  headache.  Applications 
of  Cologne  water,  of  spirit  of  camphor,  of  menthol,  or  of  chloroform 
are  sometimes  acceptable.  If  headache,  however,  persists,  or  is,  despite 
the  foregoing  measures,  distressing,  antipyrine,  acetanilid,  or  pheuacetin 
given  in  small  doses  repeated  at  short  intervals  are  efficacious.  Drugs 
of  this  class  are,  however,  to  be  used  in  enteric  fever  with  caution. 

Sleejjlessness  may  become  a  troublesome  symptom  in  the  early  course 
of  enteric  fever.  It  very  often  diminishes  during  the  course  of  the 
second  week.  It  may,  however,  be  persistent  and  exhausting.  The 
insomnia  of  the  early  course  of  the  attack  may  be  usually  readily  con- 
trolled by  appropriate  doses  of  sodium  bromide  or  chloral,  used  either 
separately  or  in  combination.  Sulphonal,  trional,  urethan,  and  chloral- 
amide  are  hypnotics  of  inferior  value.  Opium  and  its  derivatives  must 
be  regarded  as  objectionable  in  the  early  stage  of  the  disease  by  reason 
of  their  unfavorable  influence  upon  the  digestion  and  the  secretions,  and 
their  liability  to  be  followed  by  disagreeable  after-effects,  such  as  nausea, 
vertigo,  and  the  intensification  of  headache.  Later  in  the  course  of  the 
disease  opiiun  becomes  at  once  the  most  efficient  and  safest  means  of 
controlling  insomnia  and  excitability,  its  effect  upon  the  secretions  being 
less  unfavorable  than  early  in  the  attack,  while  its  disagreeable  after- 
effects are  less  marked. 

Somnolence,  stupor,  and  delirium  must  be  treated  by  stimulants  and 
external  antipyretics.  Among  stimulants  alcohol  takes  the  first  place 
and  stands  almost  alone ;  the  spirit  of  chloroform  and  caniphor  prove, 
however,  useful  in  emergencies.  The  latter  may  be  administered  h}-]30- 
dermically  in  5  per  cent,  solution  in  ether,  10  minims  (0.6),  being 
repeated  once  or  twice  at  intervals  of  several  hours.  Ether  alone  in 
10-minim  doses,  given  hypodermically,  is  of  advantage.  Ammonium 
carbonate  and  the  aromatic  spirit  of  ammonia  are  of  inferior  value. 
They  are,  however,  frequently  employed  in  the  treatment  of  pulmonary 


216  ENTERIC  OB   TYPHOID  FEVER. 

complications.  Pure  Siberian  musk  is  a  powerful  stimulant  in  condi- 
tions of  nervous  depression.  Administered  in  pill  or  suppository  in 
single  doses  of  from  5  to  10  grains  (0.32-0.65),  it  sometimes  produces 
decided  effects.  The  difficulty  of  obtaining  it,  its  great  cost,  and  the 
uncertainty  of  its  eifects  preclude  its  general  employment.  Hyoscine 
hydrobromate,  codeine,  and  asafoetida  are  also  useful  in  the  treatment 
of  active  delirium,  while  delirium  suggestive  of  hysteria  is  often 
favorably  influenced  by  full  doses  of  valerian,  alone  or  in  combination 
with  the  bromides. 

Such  external  antipyretics  as  the  ice-cap  or  the  cold  douche  are 
indicated  where  delirium  is  marked  and  persistent  or  there  is  stupor 
tending  to  coma.  Applications  of  cold  must  be  transient  and  not  too 
frequently  repeated,  lest  they  be  followed  by  depression  and  collapse. 
It  is  a  good  practice  to  accompany  them  by  warm  applications  to  the 
feet  and  legs  and  sinapisms  to  the  prsecordium  and  epigastrium.  The 
tepid  or  warm  bath  or  the  warm  bath  gradually  lowered  exerts  a  favor- 
able influence  upon  this  group  of  nervous  symptoms.  The  delirium  of 
enteric  fever  is,  as  a  rule,  manageable.  Physical  restraint  is  rarely 
required,  though  it  occasionally  happens,  especially  in  hospitals  where 
the  nurses  have  a  number  of  cases  to  look  after,  that  it  is  necessary  to 
confine  the  patient  by  a  sheet  passed  over  the  lower  part  of  his  chest 
and  fastened  under  the  bed. 

Good  nursing  is  indispensable.  The  enteric  fever  patient  who  has 
become  delirious  should  never  for  an  instant  be  left  alone. 

Tremor,  out  of  proportion  to  the  other  signs  of  nervous  prostration, 
has  been  regarded  by  Sir  William  Jenner  as  a  sign  of  deep  ulceration 
of  the  intestine.  In  any  case  supervention  of  tremor  is  to  be  regarded 
as  an  indication  for  the  administration  of  alcohol  in  full  doses.  Other 
nervous  symptoms  occurring  during  enteric  fever  do  not  call  for  special 
treatment.  Those  that  persist  after  the  subsidence  of  the  febrile  move- 
ment are  to  be  treated  in  accordance  with  general  rules. 

Dryness  of  the  tongue  and  the  accumulation  of  sordes  upon  the  teeth 
and  gums  demand  the  frequent  administration  of  water  in  small 
amounts,  washing  of  the  mouth  with  pure  water  or  water  containing 
borax,  claret,  or  small  amounts  of  tincture  of  myrrh,  or  the  use  of  a 
cotton  mop  wet  with  a  saturated  solution  of  boric  acid. 

Fissures  at  the  nostrils  or  at  the  angle  of  the  mouth  or  upon  the  lips 
may  be  treated  by  the  occasional  application  of  a  soft  ointment  contain- 
ing 20  grains  (1.3)  of  boric  acid  to  the  ounce  (31.). 

Vomiting  is  not  a  common  symptom  in  enteric  fever.  Occurring  at 
the  onset  of  the  disease,  it  is  usually  an  indication  of  profound  infection 
or  of  extreme  gastric  irritability.  Under  these  circumstances  nourish- 
ment by  the  mouth  should  be  temporarily  withheld,  while  fractional 
doses  of  calomel  at  short  intervals  or  full  doses  of  chemically  pure 
cerium  oxalate  or  of  dilute  hydrochloric  acid  or  cocaine  hydrochlorate, 
gr.  ^  (0.01),  may  be  given.  At  the  same  time  sinapisms  may  be  applied 
to  the  epigastrium  and  iced  dry  champagne  administered  in  small 
amounts.  In  some  instances  vomiting  is  due  to  antecedent  lesions  of 
the  stomach.  When  vomiting  occurs  late  in  the  course  of  the  attack  it 
is  very  often  due  to  uraemia,  and  is  then  associated  with  other  evidences 
of  nephritis. 


TREATMENT.  217 

In  all  cast's  the  in-inc  sliouhl  he,  IVoiii  the  hcjrinniii^  of  the  attack, 
systematically  cxamiiuHl  at  intervals  <>i'  two  or  three  days.  A  ti'ace  of 
albnniin  witliont  casts  or  with  a  cast  here  and  there — febrile  albuminuria 
— is  not  in  itself  of  great  clinical  importance,  but  a  large  percentage  of 
albumin  M'ith  many  casts,  and  es]x>cially  epithelial  or  blood  casts,  indi- 
cates the  develoj)ment  of  an  intercurrent  acute  nepin-itis. 

(hnxiipdfion  late  in  the  course  of  the  attack  may  be  due  to  the  con- 
tinued use  of  a  diet  that  is  at  once  concentrated  and  leaves  a  minimum 
of  unabsorbed  residuum.  It  may,  however,  result  from  torpidity  of 
the  large  intestine.  In  the  latter  case  the  fecal  matter  accumulates  in 
the  form  of  scybalae.  This  condition  may  set  up  a  sort  of  secondary 
diarrhoea,  due  to  the  irritation  of  the  lower  boAvel  and  attended  with  a 
feeling  of  tenesmus  and  local  distress  promptly  relieved  by  the'  removal 
of  the  cause.  Prolonged  constipation  is  not  necessarily  a  sign  of  mild 
intestinal  lesions.  On  the  contrary,  deep  ulceration  of  a  single  Peyer's 
patch  may  arrest  peristalsis  and  thus  produce  constipation.  It  is  there- 
fore important  to  avoid  the  administration  of  laxative  drugs  after  the 
middle  of  the  second  week.  Nor  are  large  enemata,  especially  if 
administered  with  some  energy,  without  danger.  Diarrhoea  requires  no 
especial  treatment  so  long  as  the  stools  are  of  moderate  amount  and  do 
not  exceed  three  or  four  in  the  course  of  twenty-four  hours.  This 
symptom  is  frequently  due  to  the  use  of  improper  food  or  excessive 
amounts  of  food,  particularly  milk,  the  strong  animal  broths,  or  beef- 
tea.  The  substitution  of  a  suitable  diet  is  followed  by  relief.  In  other 
cases  the  prejiarations  of  bismuth,  as  the  subcarbonate,  subnitrate, 
salicylate,  or  subgallate,  administered  by  the  mouth  in  full  doses,  con- 
-stitute  an  efficient  medication.  When  necessary  small  doses  of  opium 
may  be  employed  in  addition.  The  so-called  intestinal  antiseptics,  such 
as  naphtalin,  thymol,  resorcin,  and  the  like,  are  less  useful.  The 
administration  of  astringents,  such  as  alum,  plumbic  acetate,  silver 
nitrate,  tannic  acid,  catechu,  and  kino,  in  the  present  state  of  knowledge 
lacks  the  support  alike  of  theoretical  basis  and  empirical  result.  If  the 
stools  be  highly  fetid  or  ammoniacal,  creasote,  salol,  or  salophen  may 
be  given  or  animal  charcoal  may  be  administered  in  broth. 

Tympanites  is  a  very  common  symptom.  When  excessive  it  consti- 
tutes an  urgent  indication  for  the  administration  of  alcoholic  stimulants 
or  for  their  increase  if  already  employed.  Turpentine  or  camphor  in 
addition  to  guarded  doses  of  opium  must  be  added  to  the  treatment,  and 
active  preparations  of  pepsin  or  peptenzyme,  alone  or  together  with 
hydrochloric  acid,  should  be  administered  with  the  food.  Compresses 
wrung  out  of  iced  water  or  turpentine  stupes  should  be  applied,  and 
very  cautious  light  massage  of  the  abdomen  may  be  useful.  Small 
enemata  of  iced  w  ater  and  enemata  of  cold  water  containing  turpentine 
in  emulsion  are  sometimes  followed  by  good  results.  The  careful  intro- 
duction of  a  long  intestinal  tube  will  sometimes  relieve  the  distention 
of  the  loAver  bowel.  The  puncture  of  the  distended  gut  with  a  hypo- 
dermic needle  through  the  bowel  'svall  is  an  unwarrantable  procedure. 
The  systematic  administration  of  laxative  doses  of  calomel  or  castor 
oil  every  third  or  fourth  day  during  the  first  week  or  ten  days  tends  to 
obviate  to  a  great  extent  excessive  intestinal  disturbance,  whether  con- 
stipation, diarrhoea,  or  tympanites. 


218  ENTERIC  OB   TYPHOID  FEVER. 

Intestinal  hemorrhage  is  to  be  treated  by  the  temporary  diminution,  or 
even  the  complete  withdrawal,  of  food  for  a  time,  and  by  the  adminis- 
tration of  opium,  either  by  the  mouth  or  by  suppository.  For  the  time 
being  even  water  is  to  be  administered  in  small  amounts.  To  relieve 
thirst  it  is  better  to  permit  small  pieces  of  ice  to  be  dissolved  in  the 
mouth.  The  action  of  the  bowels  is  to  be  controlled  by  the  further 
administration  of  full  doses  of  bismuth.  If  the  loss  of  blood  be  exces- 
sive, there  is  imminent  danger  to  life  and  more  active  measures  are 
required.  An  ice-bag  should  be  applied  to  the  abdomen  in  the  region 
of  the  right  iliac  fossa.  Opium  is  to  be  gradually  increased  until  drow- 
siness and  contraction  of  the  pupils  follow.  Ergotin  may  be  adminis- 
tered hypodermically  at  short  intervals.  Enemata  of  iced  water,  not 
exceeding  4  ounces  (120)  at  a  time,  may  be  repeated  at  short  intervals. 
The  astringent  preparations  of  iron  either  by  the  mouth  or  by  the  rec- 
tum, and  the  employment  of  gallic  acid,  turpentine,  alum,  or  lead  ace- 
tate, are  not  likely  to  be  followed  by  direct  results.  The  pillows  are  ta 
be  removed  and  the  foot  of  the  bed  elevated  upon  blocks.  Sterilized 
normal  salt  solution  in  amounts  of  from  4  to  6  ounces  (120-180)  should 
in  grave  cases  be  introduced  by  hypodermoclysis  at  from  two  to  four 
diflPerent  points  and  repeated  as  required.  Fluid  restored  to  the  body 
in  this  manner  is  both  safer  and  more  effective  than  intravenous  injec- 
tions. The  transfusion  of  blood  is  attended  with  serious  risk,  and  is 
scarcely  to  be  considered  under  these  circumstances.  The  fall  of  tem- 
perature and  improvement  in  the  mental  condition  of  the  patient  which 
follow  intestinal  hemorrhage  are  usually  transitory  ;  exceptionally,  how- 
ever, they  mark  the  beginning  of  convalescence.  An  abrupt  fall  of  tem- 
perature of  several  degrees  to  the  normal  or  below  it,  occurring  in  the 
mid-course  of  the  attack,  will  justify  the  suspicion  that  hemorrhage  has 
taken  place,  even  though  no  blood  may  have  yet  appeared  in  the  stools. 
This  suspicion  will  be  confirmed  by  the  discovery  of  local  dulness  upon 
percussion  in  the  abdomen,  usually  tympanitic.  After  intestinal  hemor- 
rhage the  diet  must  for  a  time  be  restricted  to  a  minimum,  and  no  effort 
should  be  made  to  move  the  bowels  for  a  period  of  at  least  ten  days. 
Spontaneous  evacuations  are  apt,  however,  to  occur  in  the  course  of  six, 
or  eight  days. 

Peritomtis  calls  for  the  free  administration  of  opium.  This  drug  is 
to  be  given  in  the  form  of  the  deodorized  tincture  in  doses  of  10  minims 
(0.62)  at  intervals  of  an  hour  until  evidences  of  its  physiological  effects 
show  themselves.  If  opium  be  not  well  borne  by  the  stomach,  morphia 
is  to  be  administered  hypodermically.  No  nourishment  is  to  be  given 
except  concentrated  meat  juice,  a  teaspoonful  at  a  time,  together  with 
equal  parts  of  brandy  and  water  in  the  same  amounts.  Ice-bags  should 
be  applied  to  the  abdomen.  Should  the  patient  rally,  it  is  of  the  utmost 
importance  that  the  bowels  be  confined  as  long  as  possible.  An  action 
will  usually  occur  at  the  end  of  several  days,  even  under  the  continued 
use  of  opium.  If  not,  at  the  end  of  a  week  or  ten  days  small  lukewarm 
enemata  of  water  containing  glycerin  or  glycerin  suppositories  may  be 
cautiously  employed.  Peritonitis  in  a  small  proportion  of  the  cases 
arises  in  consequence  of  infection  through  the  base  of  an  ulcer  without 
perforation ;  in  other  instances  the  sloughing  out  of  the  base  of  an  ulcer 
that  causes  perforation  is  preceded  by  local  adhesive  peritonitis  forming 


TREATMENT.  210 

attai'hnuMits  with  an  adjacent  visciis  or  coil  of  intestines,  thus  pi'eventin<;- 
general  peritoneal  infection.  Under  these  eircnnistances  in  exce})tional 
cases  rccovcrv  may  occur.  As  a  rule,  suddenly  developing  peritonitis  is 
due  to  perforation  of  the  gut,  permitting  the  intestinal  contents  to  escape 
into  the  general  cavity  of  the  peritoneum.  The  occurrence  of  this  acci- 
dent at  the  close  of  defervescence  or  (hiring  convalescence,  when  ai)pctite 
is  retiuMiini",  the  nutrition  improving,  and  the  strength  of  the  })atient 
augmenting,  raises  the  question  as  to  the  propriety  of  cadiotomy  in  order 
to  suture  the  lesion,  resect  the  bowel  at  the  point  of  perforation,  establish 
an  anastomosis  between  uninvolved  portions  of  the  intestine,  or  form 
an  artificial  anus,  and  to  carry  into  effect  the  proper  treatment  of  the 
infected  peritoneum.  In  selected  cases  the  hopelessness  of  ordinary 
methods  of  treatment  justifies  surgical  procedure,  and  this  opinion  finds 
support  in  the  fact  that  a  small  proportion  of  favorable  results  have 
been  reported. 

Ferf oration  of  the  intestine  is  usually  single.  Murchison's  record 
showed  one  perforation  in  28,  two  in  5,  and  three  in  4  cases.  R.  H.  Fitz 
found  in  167  eases  of  intestinal  perforation  collected  from  various 
sources  138  single  perforations  and  29  multiple  perforations. 

During  the  course  of  enteric  fever  palpation  of  the  abdomen  is  to  be 
practised  with  great  caution  by  reason  of  the  danger  of  exciting  peri- 
tonitis, causing  perforations  or  rupturing  the  spleen. 

Collapse  attending  intestinal  hemorrhage  or  perforation  or  sudden 
heart  failure  is  to  be  treated  by  absolute  quiet,  elevating  the  foot  of  the 
bed,  the  application  of  external  heat,  hypodermic  injection  of  suitable 
doses  of  strychnia,  atropine,  ether,  or  solutions  of  camphor  in  ether. 

Epistaxis  occurring  early  in  the  course  of  the  disease  is  usually  slight, 
often  a  mere  stain  upon  the  handkerchief,  and  of  diagnostic  significance 
only.  Later  in  the  course  of  the  attack  it  is  frequently  abundant,  but 
rarely  attended  w^ith  danger.  The  application  of  ice  to  the  brow  or  the 
instillation  of  very  hot  water  into  the  nostril  is  useful.  Persistent 
epistaxis  may  render  plugging  of  the  nostrils  necessary.  The  adminis- 
tration of  ergot,  turpentine,  and  the  preparations  of  iron  is  frequently 
employed. 

Retention  of  urine  is  liable  to  occur  in  severe  cases.  A  routine 
examination  of  the  suprapubic  region  is  important.  When  necessary 
the  catheter  is  to  be  employed  :  a  soft-rubber  instrument  in  the  case  of 
the  male,  a  glass  catheter  in  the  case  of  the  female,  is  preferable.  The 
instrument  should  be  thoroughly  sterilized ;  immediately  before  its 
introduction  the  parts  about  the  meatus  should  be  invariably  bathed 
with  corrosive  sublimate  solution,   1  :  2000. 

The  chest  complications  of  enteric  fever  are  frequently  attended  with 
insignificant  subjective  symptoms.  For  this  reason  systematic  exam- 
ination by  means  of  the  methods  of  physical  diagnosis  is  necessary  at 
short  intervals. 

Dicrotism  diminishes,  or  in  some  cases  wholly  ceases,  upon  the 
administration  of  proper  doses  of  alcohol. 

Cardiac  asthenia  demands  alcohol  and  strychnia.  Caffeine  citrate  is 
also  useful.  When  the  fiiilure  of  the  circulation  is  extreme  the  pillows 
are  to  be  removed,  the  foot  of  the  bed  elevated  by  blocks,  and  absolute 
rest  in  the  recumbent  posture  maintained.     Cases  of  sudden  death  have 


220  ENTERIC  OB   TYPHOID  FEVER. 

occurred  as  a  result  of  the  patient's  abruptly  assuming  the  erect  posture. 
In  the  feeble  heart  of  enteric  fever  digitalis  in  small  doses  is  of  ques- 
tionable advantage ;  in  larger  doses  harmful.  The  nitrites,  and  espe- 
cially amyl  nitrite  and  nitroglycerin,  are  of  service.  The  hypodermic 
administration  of  ether  or  camphor  in  ether  in  10  per  cent,  solution  is 
useful.  So  also  is  the  application  of  sinapisms  or  turpentine  stupes  to 
the  prsecordia  and  epigastrium. 

Hypostatic  congestion  may  be  to  some  extent  prevented  by  the  sys- 
tematic employment  of  measures  to  maintain  the  forces  of  the  circula- 
tion. The  patient's  position  must  from  time  to  time  be  changed  from 
the  dorsal  to  the  lateral  decubitus. 

Bronchitis  when  slight  requires  no  special  treatment.  AVhen  severe 
it  must  be  managed  in  accordance  with  general  principles.  Dry  cups, 
oxygen  inhalations,  the  administration  of  ammonium  carbonate  and 
increased  doses  of  alcohol,  are  indicated  in  the  graver  forms.  The 
dangers  of  inhalation  bronchitis  and  secondary  broncho-pneumonia  may 
be  to  some  extent  reduced  by  thoroughly  rousing  the  patient  before  the 
administration  of  nourishment. 

The  formation  of  heel-sores  may  be  anticipated,  and  to  a  great  extent 
prevented,  by  proper  nursing.  Frequent  change  of  posture,  the  removal 
of  pressure  by  means  of  Avater-bags  or  air-cushions,  scrupulous  cleanli- 
ness, and  attention  to  the  bed  must  be  practised  in  all  cases.  Erosions 
are  to  be  immediately  treated  upon  general  surgical  jjrincijDles.  The 
water-bed  may  become  necessary. 

The  fever  requires  when  moderate  no  special  treatment.  This  is 
especially  the  case  when  the  morning  remissions  are  considerable, 
amounting  to  1.5°-2°  F.  (.8°-l.l°  C).  Higher  temperatures  and 
slight  morning  remissions  call  for  the  use  of  external  antipyretics.  In 
a  fever  of  so  prolonged  duration  as  enteric  fever  a  very  high  and 
unbroken  temperature  must  be  regarded  as  a  grave  symptom,  and  yet 
cases  marked  by  such  temperatures  frequently  terminate  in  recovery. 
On  the  other  hand,  cases  in  which  the  temperature  at  no  time  rises 
above  103°  F.  (39°  C.)  occasionally  prove  fatal.  The  height  of  the 
fever  is  not  so  much  an  absolute  gauge  of  the  intensity  of  the  infection 
as  it  is  a  manifestation  of  the  reaction  on  the  part  of  the  organism  to 
the  toxaemia. 

The  rapid  and  extensive  depression  of  temperature  following  the 
administration  of  full  doses  of  antipyrine,  acetanilid,  phenacetin,  and 
similar  pharmaceutical  preparations  is  transient  and  associated  with 
unfavorable  symptoms,  such  as  excessive  sweating,  cardiac  depression, 
and  a  tendency  to  collapse.  Furthermore,  the  eifect  of  these  drugs 
upon  the  general  course  of  the  disease  is  far  from  favorable.  Their  use 
as  antipyretics  is  to  be  emphatically  discountenanced  in  the  treatment 
of  enteric  fever.  The  same  is  to  be  said  of  the  internal  and  external 
application  of  guaiacol.  External  antipyretic  treatment  by  means  of 
cold  sponging,  cold  compresses,  the  application  of  ice,  the  cold  pack, 
cold  or  gradually  cooled  baths,  cold  aifusidn,  iced-water  enemata,  and 
the  use  of  Leiter's  coils  is  equally  efficient  in  reducing  temperature  and 
unattended  by  the  hazardous  perturbations  of  the  functions  of  the  body 
that  follow  the  use  of  the  so-called  internal  antipyretics.  Such  applica- 
tions produce  an  effect  in  children  greater  than  in  adults  in  proportion 


TREATMENT.  221 

as  the  extent  of  surface  to  whicli  the  application  is  made  is  rehitivelv 
greater  as  compared  with  tlie  vohinie  to  he  (-(Kdcd.  The  effect  is  more 
prompt  and  decided,  tlie  disturbances  of  circuhition  are  greater,  and 
reaction  is  more  tardy.  Tlie  employment  of  cold  in  the  treatment  <»f 
enteric  fever  in  childhood  demands,  therefore,  a  degree  of  caution. 

Convalescence  is  slow.  In  many  cases  months  elapse  before  the 
patient  regains  his  previous  bodily  and  mental  vigor.  Exce[>tionally  the 
patient  never  regains  his  full  strength  and  powers  (»f  endurance.  Dur- 
ing the  week  following  defervescence  the  temperature  is  labile  and 
affected  by  slight  causes.  Recrudescences  of  fever  occurring  during  this 
period  are  abrupt  and  transient.  Constipation  may  cause  a  slight  rise 
of  temperature,  which  immediately  falls  upon  movement  of  the  bowels. 
Similar  rises  of  temperature  occasionally  occur  after  the  first  taking  of 
solid  food,  upon  undue  exertion,  after  the  visits  of  friends,  or  conversa- 
tions upon  matters  of  business.  Patients,  therefore,  should  be  assidu- 
ously cared  for  several  days  after  the  temperature  has  reached  the 
normal.  During  this  period  temperature  observations  should  be  taken 
in  the  morning  and  evening,  and  the  diet  should  be  for  at  least  a  week 
restricted  to  milk,  eggs,  custards,  light  farinaceous  foods,  animal  broths, 
and  jellies.  If  the  case  progress  favorably,  at  the  end  of  a  week 
ordinary  light  diet  may  be  gradually  resumed,  but  the  seedy  fruits  and 
other  hard  substances  liable  to  pass  through  the  intestines  unchanged 
are  to  be  avoided.  Durino:  the  earlv  convalescence  the  cravino-  for  food 
is  often  such  that  patients  complain  bitterly  both  of  the  quantit}'  and 
qualit}^  of  their  sick-room  fare.  If  during  convalescence  diarrhrea  per- 
sist, the  diet  is  to  be  carefully  regulated,  and  the  preparations  of  bismuth, 
together  with  small  doses  of  opium,  may  be  administered.  Xot  rarely 
there  is  a  tendency  to  constipation  which  yields  to  simple  salt-and-water 
enemata  or  glycerin  suppositories. 

General  asthenia  is  often  marked  and  persistent.  Under  these  cir- 
cumstances the  patient's  activities  must  be  kept  well  ^nthin  the  limit  of 
fatigue.  If  cardiac  asthenia  be  pronounced,  as  shown  by  feeble,  rapid, 
or  irregular  pulse  and  faintness,  and  dyspnoea  upon  exertion,  carefully 
regulated  rest,  alternating  with  gentle,  systematic  exercise  supervised 
with  equal  care,  an  abundant,  nutritious  dietary,  together  with  strychnia, 
arsenic,  and  iron,  prove  useful.  Alcohol  is  also  indicated.  These 
measures  constitute  also  the  proper  treatment  of  the  associated  antTemia. 
Early  change  of  surroundings  and  climate  is  of  advantage. 

ThefalUng  of  the  hair  that  takes  place  during  couvalescence  is  in  the 
majority  of  instances  followed  by  a  new  growth.  Experience  has  shown 
that  it  is  undesirable  to  subject  the  patient  to  the  annoyance  of  shaving 
the  head,  though  the  hair  shoidd  be  cropped  close  to  the  scalp. 

Under  favorable  conditions  the  convalescent  from  enteric  fever 
rapidly  gains  in  weight ;  he  gains  strength  more  slowly. 

The  furunculosis  of  convalescence  is  to  be  treated  by  the  prompt 
evacuation  of  the  pus,  the  application  of  antiseptic  dressings,  and  in 
persistent  cases  the  internal  administration  of  calcium  sulphide. 

Periostitis  occasionally  occurs.  Exceptionally  the  inflammation 
undergoes  resolution  without  the  formation  of  pus  ;  more  commonly 
suppuration  occurs  and  extensive  necrosis  may  take  place.  Early  sur- 
gical treatment  is  indicated. 


222  ENTERIC  OR   TYPHOID  FEVER. 

Peripheral  neuritis,  which  affects  more  frequently  the  lower  extrem- 
ities, is  to  be  treated  by  rest,  massage,  and  electricity,  together  with  the 
use  of  cod-liver  oil,  iron,  and  minute  doses  of  arsenic. 

Persistent  rhachialgia  and  other  spinal  symptoms  are  best  treated  by 
rest,  massage,  and  the  occasional  application  of  the  Paquelin  cautery. 
In  some  of  the  reported  cases  suggestion  appears  to  have  played  an  im- 
portant part  in  the  rapid  amelioration  of  the  symptoms. 

Thrombosis  of  the  femoral  vein  should  be  treated  by  the  application 
of  a  flannel  bandage  from  the  toes  to  the  groin,  the  elevation  of  the  foot 
and  leg  upon  a  pillow,  and  the  control  of  the  early  pain  by  h}^odermic 
injections  of  morphia.  After  a  sufficient  time  for  the  complete  organ- 
ization of  the  thrombus  has  elapsed  the  establishment  of  a  collateral 
circulation  may  be  favored  by  daily  massage.  When  pain  and  tender- 
ness have  disappeared  and  the  patient  is  sufficiently  convalescent  to 
leave  his  bed,  an  elastic  stocking  should  be  worn. 

(e)  Specific  or  Etiolog-ical  Plans  of  Treatment. — Quinine,  calomel, 
iodine,  carbolic  acid,  sulphurous  acid,  chlorine,  salol,  boric  acid,  turpen- 
tine, oil  of  eucalyptus,  thymol,  camphor,  the  naphtols  and  naphtalin, 
bismuth  salicylate,  guaiacol,  and  many  other  drugs  have  been  adminis- 
tered on  theoretical  grounds  to  patients  suffering  from  enteric  fever. 
The  temporary  administration  of  certain  drugs  of  this  class  may  have 
in  some  instances  exerted  a  favorable  symptomatic  influence  upon  the 
gastro-intestinal  derangements  of  the  disease.  There  is,  however,  no 
adequate  evidence  to  show  that  any  of  them  or  any  combination  of 
them,  persistently  administered  throughout  the  course  of  the  attack,  is 
capable  of  any  definite  favorable  modification  of  the  toxaemia  or  of  uni- 
formly abridging  the  duration  of  the  attack  or  notably  reducing  the 
death-rate  in  large  series  of  cases.  None  of  these  drugs  can  be  said  to 
have  stood  the  test  of  time  in  the  treatment  of  enteric  fever  or  to  have 
been  generally  adopted  by  the  profession. 

Intestinal  antisepsis,  in  so  far  as  the  pathogenic  organisms  of  enteric 
fever  are  concerned,  is  directed  against  specific  germs  not  present  in  the 
bowel  prior  to  the  breaking  down  of  the  intestinal  lymph  elements,  and 
is  therefore  largely  inoperative ;  general  antisepsis,  if  by  that  we  are  to 
understand  a  germicidal  influence  upon  bacteriological  forms  diffusely 
implanted  in  the  lymph  tissues  throughout  the  organism,  is  a  vain 
fancy,  wholly  unsupported  by  facts.  The  parasite  is  more  resistant  to 
such  influences  than  the  host.  Clinical  and  pathological  considerations 
are  alike  opposed  to  the  whole  subject  of  the  antiseptic  treatment  of 
enteric  fever. 

(/)  The  Method  of  Hydrotherapy . — Curry  at  Liverpool,  at  the  close 
of  the  last  century,  and  Nathan  Smith  of  Yale  College,  about  the  same 
time,  advocated  the  use  of  cold  water  in  the  treatment  of  the  more 
serious  symptoms  of  the  fevers.  The  methods  consisted  principally  in 
cold  affusion,  though  sponging  was  also  employed.  The  teachings  of 
these  physicians  were  not  generally  accepted.  It  is  true  that  during 
the  past  century  hydrotherapeutic  methods  have  been  employed  in  the 
treatment  of  the  fevers,  and  especially  in  combating  high  temperature. 
Nevertheless,  it  remained  for  Ernst  Brand  of  Stettin  to  formulate  a 
definite  procedure  for  the  treatment  of  enteric  fever  by  systematic  cold 
bathing.     Brand's  first  publication  upon  this  subject  appeared  in  1861. 


TREATMENT.  223 

The  lUL'tliod  attracted  little  attention,  however,  until  ahont  the  time  of 
the  close  of  the  Franco-Prussian  War  in  1871.  It  was  subseciuently 
practised  in  the  hospitals  at  Lyons  by  the  French  military  surgeons, 
who  as  prisoners  of  war  had  had  the  opportunity  of  observing  its  eifects 
at  Stettin.  Its  ])raetice  has  slowly  but  steadily  extended,  until  it  is  now 
extensively  employed  in  hospitals  and  to  some  extent  also  in  families. 
The  method  of  ]>rand  has  been  eontinucnisly  used  in  the  (jrerman  Hos- 
pital of  Philadelphia  since  I  introduced  it  in  my  service  there  on  the 
1st  of  February,  1890.  All  patients  suffering  from  this  disease  have 
been  submitted  to  it  except  very  rare  cases  in  which  the  axillary  tem- 
perature has  not  reached  101.5°  F.  (38.6°  C),  some  of  those  admitted 
late  in  the  course  of  the  attack — that  is,  during  or  after  the  third  week — 
and  those  brought  in  moribund. 

The  details  of  the  method,  which  except  in  some  minor  particulars 
is  that  formulated  by  Brand,  are  as  follows  : 

The  patient  receives  a  full  bath  at  about  the  temperature  of  the  ward 
every  three  hours  when  the  thermometer  placed  in  the  rectum  registers 
102.2°  F.  (39°  C.)  or  over.  When  axillary  temperatures  are  taken  the 
bath  is  administered  at  the  end  of  the  third  hour  if  the  temperature 
exceed  101.5°  F.  (38.6°  C).  The  temperature  of  the  bath  standing  in 
the  ward  varies  between  65°  and  70°  F.  (18.3°-21.1°  C.) ;  if  in  very 
warm  weather  it  be  found  higher  than  70°  F.  (21.1°  C),  it  is  cooled  to 
that  point  by  ice  or  the  addition  of  freshly  drawn  water.  Shortly  after 
the  patient  has  fully  reacted,  usually  in  half  or  three  quarters  of  an  hour, 
his  temperature  is  frequently  taken  again  in  order  to  determine  the  effect 
of  the  individual  bath.  This  is  not,  however,  necessary,  and  is  very 
often  omitted,  especially  if  the  patient  be  already  asleep.  The  patient 
remains  in  the  bath,  as  a  rule,  fifteen  minutes,  during  which  time  he  is 
systematically  rubbed  by  the  attendants  and  encouraged  to  rub  himself. 
For  this  purpose  the  nurses  use  their  bare  hands  or  bath-gloves.  These 
frictions  stimulate  the  peripheral  circulation,  constantly  change  the  water 
in  contact  with  particular  points  of  the  surface,  moderate  the  sensation 
of  cold,  and,  as  Glenard  has  remarked,  help  to  pass  the  time.  If  the 
pyrexia  be  high,  the  temperature  before  the  bath  exceeding  104°  F. 
(40°  C.)  or  rising  very  rapidly  after  the  bath,  or  if  it  be  but  little  in- 
fluenced by  the  bath,  the  immersion  is  prolonged  to  twenty  or,  in 
unusual  cases,  to  twenty-one  or  twenty-two  minutes. 

The  tub,  which  is  upon  wheels,  is  placed  at  the  side  of  the  bed  and 
parallel  to  it  at  the  distance  of  about  a  yard.  Both  are  surrounded  by 
ward  screens  of  white  muslin  upon  iron  frames,  leaving  sufficient  room 
for  the  attendants.  The  patient's  night-dress  is  removed  under  the  bed- 
covering,  his  body  is  covered  with  a  sheet  or  a  large  folded  napkin  is 
placed  about  the  loins,  and  he  is  lifted  from  the  bed  into  the  bath. 
Many  of  the  patients  in  whom  the  treatment  is  instituted  early  in  the 
attack,  or  in  whom  for  other  reasons  the  symptoms  are  comparatively 
mild,  prefer  to  rise  and  step  into  the  tub  with  the  assistance  of  the 
attendants,  and  no  harm  has  ever  been  observed  to  result  from  per- 
mitting them  to  do  so.  If  the  patient  be  asleep,  he  is  not  immediately 
bathed,  but  fifteen  or  twenty  minutes  are  permitted  to  elapse  after  he  is 
aroused.  If  he  be  sweating,  his  skin  is  thoroughly  dried  before  the 
bath.     The  tub  is  lined  with  planished  copper,  perfectly  smooth.    There 


224  ENTERIC  OB   TYPHOID  FEVER. 

is  a  sloping  support  for  the  shoulders  and  head  of  the  patient,  which, 
however,  rest  upon  a  rubber  air-cushion.  The  water,  usually  about 
thirty  gallons  for  the  adult,  is  sufficient  to  cover  the  patient  to  the  neck. 
Upon  entering  the  bath  he  receives  an  ounce  of  spirit  well  diluted  or 
half  a  glass  of  red  wine,  or  either  of  these  may  be  administered  in 
divided  amounts  during  the  bath.  His  head  and  face  are  immediately 
and  repeatedly  bathed  with  cold  water,  and  a  compress  wet  with  the  same 
is  applied  to  his  forehead  ;  a  basin  and  pitcher  of  cold  water  are  at  hand 
for  this  purpose.  In  cases  with  high  temperature  or  marked  nervous 
symptoms  the  cold  water  is  very  often  from  time  to  time  poured  over 
the  head  and  face  from  the  height  of  a  few  inches. 

Upon  entering  the  bath  the  respirations  are  suddenly  deepened. 
After  the  first  shock  the  sensations  for  a  time  are  not  disagreeable,  but 
in  five  or  six  minutes  the  patient  begins  to  be  restless  and  complains  of 
cold.  In  ten  or  twelve  minutes  shivering  takes  place.  About  the  same 
time  the  extremities  and  face  become  slightly  cyanotic.  While  the 
patient  is  in  the  bath  his  bed  is  covered  with  a  rubber  sheet,  this  with 
a  blanket,  and  over  both  is  laid  an  ordinary  ward  sheet.  The  patient 
is  lifted  out,  laid  upon  the  bed  thus  arranged,  closely  tucked  in  the 
sheet,  and  covered  with  the  blanket.  In  the  course  of  ten  or  fifteen 
minutes  he  is  thoroughly  dried  and  his  night-dress  is  replaced.  About 
this  time  reaction  is  usually  established,  the  patient  receives  nourish- 
ment in  the  form  of  milk  or  broth,  and  quickly  falls  into  a  gentle  sleep. 
When  there  is  marked  cardiac  asthenia  or  if  for  any  other  cause  reac- 
tion is  retarded,  the  patient  should  be  at  once  dried  beneath  the  blanket, 
receive  a  hot  toddy,  and  have  a  hot  water  bag  placed  in  contact  with 
his  feet.  The  condition  of  the  patient  is  carefully  watched  during  the 
bath,  and  its  duration  is  shortened  if  its  immediate  effects,  as  manifested 
by  shivering,  cyanosis,  and  restlessness,  are  too  pronounced. 

The  German  Hospital  has  a  wheeled  tub  for  each  of  the  small  wards 
set  apart  for  the  enteric  fever  cases.  Several  forms  of  portable  tubs  are 
supplied  by  dealers.  An  ordinary  tub  may  be  placed  upon  a  low  truck 
or  platform  upon  wheels.  In  private  practice  the  portable  tub  of  Dr. 
Batt  is  convenient  for  immediate  use.^  There  is  no  difficulty,  however, 
in  procuring  an  ordinary  tub  from  a  plumber,  which  may  remain  per- 
manently by  the  bedside  of  the  patient,  being  noiselessly  and  with  but 
little  trouble  filled  by  means  of  rubber  tubing  from  the  faucet  in  the 
neighboring  bath-room,  and  emptied  by  the  same  tube  used  as  a  siphon 
out  at  the  window  or  into  a  basin  connecting  with  the  drainage  system 
of  the  house  upon  the  floor  below. 

In  the  fever  wards  of  the  German  Hospital  the  tubs  are  filled  directly 
from  a  tap  of  sufficient  length  extending  from  the  wall  at  a  proper  height, 
and  they  are  emptied  at  the  same  point  directly  into  a  waste-way  in  the 
floor,  the  wall  and  floor  being  lined  with  slate  or  tiling. 

^  Dimensions  of  tub  when  ready  for  use :  length,  6  feet  3  inches  ;  width,  22  inches ; 
depth,  IS  inches.  Dimensions  of  tub  when  folded  for  carrying:  length,  2  feet  9  inches  ; 
thickness,  9  inches.  Dimensions  of  box  containing  frame :  length,  3  feet  3  inches  ;  width, 
8  inches  ;  depth,  3  inches. 

The  tub  part  is  composed  of  heavy  canvas  covered  with  rubber,  is  seamless,  and  has  a 
tensile  strength  of  350  pounds.  The  tub  is  supported  by  hooks  inserted  through  the 
canvas  before  the  rubber  is  applied.  The  frame  is  composed  of  brass  pipe  nickel  plated. 
Both  tub  and  frame  can  be  rendered  aseptic  by  boiling. 


TREATMENT. 


225 


For  a  single  ])ationt,  as  occurs  usually  in  private  practice,  the  water 
should  1)0  chanoi'd  once  in  twenty-four  hours.  In  hospital  ])ractice, 
especially  when  a  number  of  cases  are  being  treated,  it  bec-onies  neces- 
sary to  bathe  several  patients  in  the  same  water.  After  the  sixth  bath 
the  water  should  be  changed.  The  patients  void  urine  always  immedi- 
ately before  the  bath,  and  I  have  never  known  an  instance  in  which 
fecal  incontinence  occurred  during  the  bath.  It  is  desiral)le  to  have  two 
attendants  for  the  administration  of  the  bath,  though  under  ordinary 
circumstances,  when  the  patients  are  in  a  condition  to  assist  themselves, 
the  bath  may  be  administered  by  a  single  attendant.  AVhen  there  are  a 
large  number  of  cases  in  hospital  wards,  as  frequently  occurs  at  the 
time  of  the  epidemic  prevalence  of  the  disease,  the  administration  of 
the  baths  becomes  very  laborious  and  a  correspondingly  large  staff  of 
nurses  is  required.  During  the  bath  the  temperature  of  the  water  is 
slightly  raised,  the  change  amounting  to  from  2°  to  3°  F.  (1.1°  to 

Fig.  24. 


106°' 
105= 
104' 

103' 
102' 
101' 
100' 

99 

NORMAL 
98^ 

97' 

MlE 

M 

E 

M    E 

M 

E 

M 

E 

rwT  E 

M 

E 

M    E 

M 

E 

M 

E 

M    E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

^ 

^ 

r 

1 

i 

^ 

^: 

^ 

-  + 

= 

= 

E 

i 

-=_ 

E 

E 

E 

E 

E 

E 

E 

1 

1 

1 

i 

1 

= 

= 



\  J^ 

M 

1 

S 

^ 

w 

j 

5 

E 

1 

1 

1 

1 

E 

E 

1 

1 

— 

=: 

E 

= 

= 

E 

= 

1 

1 

= 

1 

g 

= 

1 
1 

E 

S 
^ 

t 

1 

E 

1 

i 

=: 

1 

1 

1 

1 

i 

'M 

^;e 

- 

^ 

= 

i 

1 

1 

1 

^ 

i 

^ 

E 

= 

E 

E 

E 

1 

E 

i 

1 

1 

1 

E 

1 

H 

M 

1 

1 

s 

s 

s 

i 

— 1 — 

-^ — 

= 

t=: 

=^ 

=r 

^ 

= 

^ 

— 

=: 

=: 

= 

^ 

= 

=. 

= 

=: 

= 

rH 

= 

= 

— 

= 

OAV  OF 
DISEASE 

8 

0 

1 

0 

1 

1 

12 

13 

11 

1 

5 

16 

1 

7 

1 

8 

19 

2 

0 

21 

2 

2 

23 

21 

25 

20 

27 

28    1 

PULSE 

55 

= 

5 

2    2 

§ 

£ 

5  = 

2    = 

sis 

'^ 

?, 

?i   a 

2 

s 

R 

2 

2 

s 

S 

S 

1 

s 

a 

g 

?! 

s 

g 

S 

S 

? 

n  \v, 

S    f 

f! 

s 

STOOL 

1 

=  1— 

— 

1 

— 

— 

T 

1 

— 

1 

II 

1 

II 

1 

\\ 

II 

_J 

DATE 

3 

i 

5 

G 

7 

8 

9 

10 

11 

12 

13 

14 

15 

IB 

17 

18 

19 

20 

21 

22 

231 

Case  bathed  from  ninth  day.    The  black  line  shows  a.  m.  and  p.  m.  temperatures  ;  the  red  line  the 
third  hour  temperature  taken  immediately  before  the  baths  (German  Hospital). 


1.6°  C).  The  frequency  of  the  bath  is  determined  by  the  eifect  upon 
the  patient's  temperature.  If  at  the  end  of  three  hours  the  temperature 
remains  below  101.5°  F.  (38.6°  C.)  in  the  axilla  or  102.2°  F.  (39°  C.) 
in  the  rectum,  the  patient  is  not  disturbed  until  his  temperature  is  again 
taken  at  the  end  of  another  period  of  three  hours.  If,  however,  during 
the  second  period  of  three  hours  nervous  symptoms  arise  or  manifest 
increase  of  fever  is  present,  the  temperature  is  taken  sooner  and  the 
bath  administered  at  once  according  to  rule.  Milder  cases  and  those 
with  declining  temperature  may  require  only  two  or  three  baths  in  the 
course  of  the  twenty-four  hours.  Early  cases  and  those  Avith  high  tem- 
perature are  subjected  to  the  bath  every  third  hour,  alike  during  the 
day  and  night,  and  it  sometimes  happens  that  these  frequent  baths  are 
necessary  for  several  days  in  succession. 

Patients  admitted  prior  to  the  tenth  day  of  the  attack  receive  one  or 
more  laxative  doses  of  calomel.     Other  drug's  are  ordinarilv  not  admiu- 


VoL.  I.— 15 


226 


ENTERIC  OR   TYPHOID  FEVER. 


istered,  and  a  majority  of  the  patients  reach  convalescence  without  a 
single  further  dose  of  medicine.  The  maxim  that  the  patient  rather 
than  the  disease  is  to  be  treated  is,  however,  constantly  borne  in  mind, 
and  when  the  indications  have  arisen  I  have  not  hesitated  to  administer 
increased  doses  of  alcohol  and  aromatic  spirit  of  ammonia,  strychnine, 
opium,  etc.  in  full  doses.  The  necessity  for  medication  has,  however, 
in  my  own  service  been  very  infrequent. 

The  diet  has  been  already  detailed.  It  has  not  only  been  possible 
to  give  it  in  larger  amounts  than  under  the  ordinary  expectant  method 
of  treatment,  but  patients  frequently  crave  and  demand  food  throughout 
the  attack.  In  such  cases  two  or  more  raw  eggs  are  added  to  the  milk 
and  broth  ordinarily  administered.    During  convalescence  red  wine  and 

Fig.  25. 


aoWELS.   NUH8ER 
OF  MOVEMENTS 

1 

1 

F  „ 
106 

7j- 

sjs- 

s- 

s  s 

s 

s- 

s- 

s-s 

s-s 

s- 

2- 

s 

s- 

s- 

s- 

s 

^-^ 

s 

s 

5- 

s- 

s- 

s- 

s 

s 

s 

s 

s 

5 

2 

J 

s- 

s- 

< 

s 

2- 
< 

2- 

s- 

2i2^ 

1^- 

n' 

Q. 

□. 

< 

< 

0- 

f.-^'S.- 

n- 

2  - 

s- 

^- 

i?- 

i?" 

i?" 

:?" 

0" 

J^ 

O' 

° 

S 

"1 

Stgj^ 

0- 

.n 

*+■  '  ^    -i- 

CO 

o>_ 

o_ 

«■- 

oJ.- 

-m. 

m- 

-*- 

«-r^ 

co-'d-l 

0, 

'^- 

^ 

cl- 

^ 

r^ 

0- 

^ 

0: 

CO- 

^ 

^- 

^■ 

■°- 

-^- 

oj-l 

* 

^ 

— 

*- 

m+d-;f- 

104° 
103° 
102' 
101° 

100° 

1- 

5     99° 

1- 
< 

tt     93° 
H 

O 

m     97: 

< 

h-      > 

DAY  OF 
DISEASE 

PULSE 
RESP. 

^ 

1 

A 

/^ 

fl 

f 

V 

^ 

T 

T 

-^s 

' 

. 

'\ 

' 

1 

1 

t 

>v 

/ 

/ 

*^, 

/ 

^^^'    \ ' / 

i                          '            1 

f 

1 

j 

;    ^      V7' 

'                 «l 

' 

T 

/ 

' 

/ 

\ 

^-^n 

■ 

r 

/'    1 

^ 

t 

f 

f 

1 

^ 

1     i 

1 

I 

/ 

1 

1 

U 

f 

H — r 

[      1 

I 

1  1/ 

1 

/ 

/ 

1     1/ 

f 

11  / 

I      J_ 

III 

— 

U 



ly-^h 

L--— :- 

— 

— 

— 

— 

— 

— 

^— 

— 

— 

l— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

^- 

^ 

_ 

_ 

c 

-j 

- 

^— 

^ 

-U 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

V~ 

- 

— 

■■ 

u 

J 

u 

... 

1 

7" 

* 

— 

— 

' 

— 

— 

^ 

„ 

i.. 

^ 

rr 

n- 

fy. 

^ 

rr 

fr 

-\-- 

^ 

'}--- 

- 

"H 

~^ 

j- 

- 

- 

f- 

- 

- 

h" 

- 

- 

[^ 

" 

], 

- 

[7 

- 

f7 

" 

< 

< 

n 

< 

< 

_< 

? 

~ 

-^ 

"ij- 

"i 

-f- 

c'  \- 

-d 

~x 

^S 

'ifr 

^ 

^ 

^ 

-d 

'X 

- 

fr 

•f- 

-s- 

"X 

-^ 

;S 

Ix 

z 

- 

- 

lu 

i 

'^ 

IS 

t 

o_ 

-li 

'n 

o_ 

1 

1 

— 

:!_ 

= 

.m 

24 

--.m. 

s.  = 

^ri- 

= 

- 

= 

- 

- 

= 

= 

25 

= 

- 

= 

- 

- 

- 

= 

- 

- 

- 

-m^ 

26 

- 

-co 

- 

- 

i 

¥ 

3 

?, 

g 

I    = 

1 

g 

s  S 

3    1 

2 

1 

= 

1 

E 

= 

§ 

§ 

" 

^ 

S 

s 

a 

g 

s 

= 

1 

= 

a 

s 

1 

5 

2 

s 

a 

% 

s 

g 

s 

1 

1 

s 

1 

s 

s 

s 

SS 

S 

5  s 

s 

7, 

s  s 

§    § 

s 

s 

s 

s 

?3 

^ 

S 

s 

^ 

?. 

S 

a 

S 

g 

g 

s 

i 

s 

S 

g 

s 

§ 

S 

s 

£ 

s 

i 

s 

s 

i 

i 

1 

s 

Cold  baths  :  15  minutes.  Cold  sponging. 

Enteric  fever,  showing  immediate  effects  of  individual  baths  upon  the  temperature,  and  rapid  rise 
to  the  fastigium;  also  slight  effects  of  cold  sponging  (Pennsylvania  Hospital). 

preparations  of  iron,  especially  Basham's  mixture  of  iron  and  ammonium 
acetate,  are  administered.  No  solid  food  is  given  until  the  evening  tem- 
perature has  been  normal  for  a  week. 

Brand  has  shown  that  the  mortality  is  reduced  to  a  minimum  where 
the  treatment  is  instituted  prior  to  the  fifth  day.  A  diagnosis  of  enteric 
fever  can  rarely  be  made  in  civil  practice  so  early  as  this.  The  regular 
daily  system  of  personal  inspection  and  reports  in  military  practice  ren- 
der a  probable  diagnosis  practicable  thus  early.  In  hospital  practice  a 
small  proportion  only  of  the  cases  are  admitted  during  the  first  week. 
In  the  service  of  the  German  Hospital  a  provisional  diagnosis  of  enteric 
fever  is  regarded  as  an  indication  for  the  employment  of  the  baths  upon 
admission.     Under  this  practice  occasional  errors  have  led  us  to  bathe 


TREATMKXT.  227 

patients  mIio  have  suhsiMjtU'iitly  proved  to  bo  .sutl'cring  iVom  iiiHiienza  or 
other  acute  febrile  disease. 

As  a  rule,  the  bej^inninp;  of  the  attack  can  only  be  approximately 
fixed.  The  clerks  are  instructed  in  taking  the  histories  to  date  the 
bi'tiinninii'  of  the  attack  from  the  day  on  wliieh  the  patient  re<rai"ded 
himself  as  having-  fever  or  on  which  he  was  obliged  to  i::ive  \\\)  work. 
The  eruption  and  enlargement  of  the  si)leen  are  events  that  aid  in  fixing; 
the  period  of  onset. 

In  a  series  of  128  consecutive  cases  in  wliieh  the  date  of  the  first  day 
of  the  disease  could  be  approximately  fixed  we  found  that  of  32  cases 
admitted  not  later  than  the  fifth  day,  1,  or  about  3.4  per  cent.,  terminated 
fatally  ;  of  78  cases  admitted  prior  to  the  tenth  day,  6  died — a  death- 
rate  of  7.7  per  cent.  ;  and  in  18  cases  admitted  after  the  tenth  day,  4 
died,  giving  a  mortality  of  22  per  cent. 

AVhen  the  diagno  ns  of  enteric  fever  is  clear,  neither  age,  sex,  men- 
struation, pregnancy,  nor  the  free  sweating  that  attends  many  cases  is 
regarded  as  a  contraindication  for  the  systematic  treatment  by  cold  baths 
or  as  calling  for  any  modification  of  this  treatment.  I  have  administered 
the  baths  at  once  to  patients  admitted  with  broncho-pneumonia  or 
croupous  pneumonia  as  complications,  and  have  continued  the  treatment 
when  these  complications  have  subsequently  developed.  The  occurrence 
of  intestinal  hemorrhage  renders  the  immediate  discontinuance  of  the 
bath  necessary,  and  in  some  instances  the  baths  have  not  been  resumed. 
The  signs  of  peritonitis  preclude  the  administration  of  further  baths. 
Under  this  method  of  treatment  diarrhoea  is  rarely  a  troublesome  symp- 
tom :  if  the  stools  number  more  than  three  or  four  in  the  course  of 
twenty-four  hours,  large  cold  water  compresses  or  ice-bags  are  applied 
to  the  surface  of  the  abdomen  in  the  intervals  between  the  baths.  Con- 
stipation has  been  usually  readily  relieved  by  -enemata. 

AVhen  the  temjjerature  no  longer  rises  above  101.5°  F.  (38.6°  C.)  no 
further  baths  are  administered  and  the  patient  is  regarded  as  entering 
upon  convalescence.  He  is  kept  in  bed  and  upon  a  liquid  diet  until  the 
evening  temperature  has  been  normal  for  a  Aveek.  He  is  then  allowed 
to  spend  a  portion  of  the  day  in  a  chair,  and  after  a  time  is  allowed  to 
walk  about,  and  in  suitable  weather  to  go  into  the  open  air.  In  uncom- 
plicated cases  the  convalescence  is  usually  more  rapid  than  after  other 
methods  of  treatment,  and  most  of  our  patients  in  the  German  Hospital 
have  returned  to  their  homes  within  a  fortnight  of  the  completion  of  the 
defervescence. 

The  treatment  of  enteric  fever  by  systematic  cold  bathing  constitutes 
a  definite  procedure  not  to  be  confounded  with  other  hydrotherapeutic 
measures,  such  as  the  cold  pack,  cold  aifusions,  spraying,  or  continuous 
immersion.  It  is  to  be  looked  upon  as  a  method  entirely  distinct  and 
difierent  from  any  form  of  merely  antipyretic  treatment.  The  reduction 
in  temperature  by  the  individual  bath  constitutes  one  only  of  several 
important  effects  of  the  routine,  systematic,  rhythmical  use  of  the  bath 
at  regular  intervals.  In  a  majority  of  the  cases  after  six  or  eight  baths 
have  been  administered  a  striking  modification  of  the  clinical  picture 
takes  place.  Headache,  delirium,  and  stupor  cease ;  the  patient  falls 
into  natural  sleep,  from  which  he  is  easily  aroused,  often  with  a  bright 
expression  and  clear  mind  ;  tremor  and  subsnltus  are  not  often  seen ; 


228  ENTERIC  OR   TYPHOID  FEVER. 

the  tongue  cleans  oif  and  becomes  moist ;  anorexia  becomes  less  marked, 
and  it  is  not  uncommon  even  in  the  midst  of  the  attack  for  the  j)atient 
to  take  his  food  with  avidity ;  tympanites  is  rarely  seen,  and  excessive 
or  troublesome  diarrhoea  is  exceptional.  In  a  series  of  140  of  our  cases 
at  the  German  Hospital  intestinal  hemorrhage  occurred  in  10  instances, 
or  7  per  cent. 

The  effect  upon  the  circulatory  system  is  distinctly  favorable.  The 
deep  inspirations  immediately  following  the  immersion  of  the  patient, 
and  from  time  to  time  excited  by  the  application  of  cold  water  to  his 
face,  neck,  and  the  upper  part  of  his  chest  during  the  bath,  tend  to 
diminish  the  danger  of  pulmonary  complications,  to  fully  expand  the 
peripheral  vesicles,  and   to  prevent  hypostasis. 

The  influence  upon  the  circulatory  system  is  immediate  and  marked. 
Shortly  after  immersion  the  pulse  becomes  smaller,  its  tension  is  in- 
creased, its  frequency  reduced — dicrotism  ceases.  These  effects  upon  the. 
respiration  and  circulation  are  maintained  for  some  time  after  the 
patient  has  been  taken  out  of  the  bath  and  put  to  bed.  In  severe  cases, 
and  in  particular  in  those  in  which  the  treatment  has  been  instituted 
comparatively  late  in  the  course  of  the  attack,  symptoms  of  collapse 
may  occur.  Under  these  circumstances  the  duration  of  the  bath  must 
be  reduced  to  five  or  even  three  minutes,  and  in  rare  instances  it  be- 
comes necessary  to  abandon  the  treatment  altogether. 

The  secretion  of  urine  is  increased.  Slight  transient  albuminuria 
without  casts  is  occasionally  observed.  Nephritis  does  not  appear  to  be 
more  common  as  a  complication  than  under  other  methods  of  treatment. 

The  effect  of  the  individual  bath  upon  the  fever  is  decided,  the  fall 
of  the  temperature,  as  taken  in  the  rectum  fifteen  minutes  after  the 
bath,  ranging  from  1°  to  4°  F.  (.55°-2.2°  C).  In  some  instances  the 
reduction  is  even  greater  than  this.  This  abrupt  fall  is  usually  followed 
by  a  gradual  rise,  the  fastigium  being  regained  at  the  expiration  of  two 
or  three  hours.  The  effect  of  the  single  bath  upon  the  temperature  is 
much  less  and  the  succeeding  rise  is  more  rapid  in  the  early  than  in  the 
later  course  of  the  attack.  In  some  instances  the  effect  of  the  bath 
upon  the  temperature  remains  for  several  days  slight ;  more  frequently 
decided  falls  and  more  gradual  rises  are  observed  after  a  series  of  six  to 
ten  baths  have  been  administered.  In  children  the  reduction  of  temper- 
ature is  greater  and  more  rapid  than  in  adults.  A  striking  modification 
of  the  general  temperature  curve  is  shown  in  the  form  of  the  lysis, 
which  is  usually  prolonged  and  gradual,  covering  a  period  of  eight  or 
ten  days  from  the  end  of  the  second  week,  and  contrasting  strongly  with 
the  remittent  fever  curve  of  this  period  of  the  attack  under  ordinary 
methods  of  treatment.  In  the  milder  cases  the  course  of  the  attack  is 
shortened ;  in  those  of  average  intensity  and  severe  cases  it  does  not 
appear  to  be  abridged.  Convalescence,  however,  is  shortened  and 
sequels  are  comparatively  infrequent.  In  408  cases  treated  in  the 
German  Hospital  according  to  this  plan  up  to  October  1,  1894,  relapses 
occurred  in  46  instances — 11.3  per  cent. — and  more  than  one  relapse  in 
2  instances.  The  general  statistics  of  the  bath  treatment  show  a  higher 
proportion  of  relapses  than  those  of  other  methods.  It  has  been 
suggested  that  the  increased  frequency  of  relapse  may  be  related  to  the 
diminished  death  rate. 


TREATMENT.  229 

The  iuflnonco  of  this  method  of  troatnvcnt  upon  the  death  rate  is 
deeided,  and  there  is  a  remarkable  correspondenee  in  the  statisties  of 
ditf'erent  observers.  Thus,  the  mortality  in  the  Jled  Cross  Hospital  at 
Lyons,  aeeordino'  to  Tripier  and  J^oiiveret,  amounted  to  7.3  ])er  eent.  ; 
that  of  F.  E.  Hare  in  the  Brisbane  Hospital,  (Queensland,  7.84  jier 
cent. ;  that  of  Osier  in  the  Johns  Hopkins  Hospital,  7.1  per  eent. ;  that 
at  the  German  Hospital  in  Philadelphia  to  7.8  per  cent.'  These  results 
demonstrate  that  the  method  of  Brand,  systematically  carried  out  and 
applied  to  successive  cases  as  they  present  themselves,  effects  a  reduc- 
tion in  the  death  rate  of  more  than  7  per  cent.  The  fatal  cases  under 
this  method  of  treatment  have,  as  a  rule,  been  grave  from  the  beginning, 
though  death  has  very  often  not  occurred  nntil  after  prolonged  illness. 
In  some  of  them  the  evidences  of  an  intense  local  or  systemic  infec- 
tion, such  as  intestinal  hemorrhage,  perforation,  and  very  high  tempera- 
tures, have  been  present.  In  others  grave  complications,  such  as  pneu- 
monia, acute  nephritis,  and  meningitis,  have  occurred.  Finally,  a  small 
proportion  have  died  in  relapse. 

Much  has  been  written  concerning  the  harshness  of  the  Brand  method 
of  treating  enteric  fever.  It  has  been  criticised  as  "  brutal "  and  "  bar- 
barous." Our  experience  at  the  German  Hospital  does  not  justify  these 
criticisms.  It  is  true  that  the  patients  very  often  complain  of  the  dis- 
agreeable sensations  attending  the  earlier  baths.  After  a  day  or  two 
they  become  accustomed  to  them,  and  it  has  happened  in  more  than  one 
instance  that  the  patient  has  stepped  into  the  tub  at  his  bedside  without 
waiting  for  the  nurse.  Occasionally  the  patients  have  complained  of  the 
baths  throughout  the  whole  treatment.  In  private  practice  I  have 
sometimes  found  very  great  difficulty  in  overcoming  the  objections  of 
the  patient,  but  in  no  instance  have  I  been  forced  to  abandon  the  treat- 
ment on  this  account.  The  treatment  involves  discomfort  and  occasion- 
ally some  suffering  upon  the  part  of  the  patient,  and  entails  upon  the 
nurses  and  attendants  a  vastly  increased  amount  of  labor,  especially  in 
hospital  practice,  where  there  are  at  times  a  large  number  of  cases  to  be 
cared  for.  These  facts  cannot  be  disregarded,  but  they  are  without 
weight  as  objections  to  a  method  of  treatment  which  diminishes  the  suf- 
ferings of  the  individual  and  reduces  the  general  mortality  at  least  one 
half. 

[g)  Prophylactic  and  Curative  Inoculations. — The  investigations 
of  Stern,  Brieger,  Kitasato,  and  Wassermann  led  Friinkel  and  Manchot 
to  employ  in  the  treatment  of  cases  of  enteric  fever  a  sterilized  liquid 

^  Further  statistics  of  the  German  Hospital  to  January  1,  1896,  are  as  follows  : 

From  October  1,  1894,  to  January  1,  1895,  27  cases  "with  5  deaths  ;  mortality,  18.5 
per  cent. 

January  1,  1895,  to  January  1,  1896,  90  cases,  89  treated  by  baths,  with  a  single 
death  ;  a  mortality  of  1.1  per  cent.     The  fatal  case  among  the  bathed  cases  in  this  series 

was  that  of  M.  H ,  female,  single,  aged  twenty-five,  a  native  of  Germany.     Death 

occurred  during  the  third  week  of  the  disease  from  peritonitis  following  perforation  of  the 
intestine.  The  fatal  case  not  bathed  was  that  of  H.  S ,  male,  white,  aged  twenty- 
seven,  unmarried,  a  carpenter.  This  patient  was  admitted  to  the  hospital  in  the  after- 
noon of  October  14,  1895,  having  been  sick  only  a  few  days.  He  was  sutiering  from  con- 
vulsions ;  temperature,  102.7°  F^  (39.3°  C).  Died  the  following  morning.  The  anatom- 
ical diagnosis,  based  upon  the  intestinal  lesions,  together  with  enlargement  of  the  spleen 
and  of  the  mesenteric  glands,  was  enteric  fever. 

The  total  number  of  cases  treated  by  systematic  cold  bathing  to  January  1,  1896,  is 
524,  with  38  deaths;  a  mortality  of  7.25  per  cent. 


230  ENTERIO  OR   TYPHOID   FEVER. 

obtained  from  the  culture  of  typhoid  bacilli  in  bouillon  made  from  the 
thymus  of  the  calf  and  heated  to  60°  C.  Their  report  is  based  upon 
the  employment  of  this  procedure  in  57  cases.  Injections  were  made 
deeply  into  the  muscles  of  the  buttock,  and  were  without  unfavorable 
local  effects.  The  first  injection  consisted  of  0.5  c.c.  of  the  sterilized 
fluid,  and  was  not  followed  by  reaction  even  in  the  case  of  children. 
On  the  following  day  1  c.c.  was  injected  into  the  opposite  buttock. 
The  second  injection  was  followed  in  the  majority  of  cases  by  rise  of 
temperature  with  chilly  sensations.  In  the  course  of  some  hours  the 
temperature  usually  showed  a  decided  fall,  but  rose  again  in  those  cases 
in  which  the  injections  were  discontinued.  Frankel  administered  the 
injections  every  second  day,  increasing  the  dose  1  c.c.  each  day.  The 
temperature  range  ceased  to  be  subcontinuous  and  showed  marked 
remissions.  Constitutional  symptoms  were  less  intense,  and  complete 
absence  of  fever  resulted  in  the  course  of  a  few  days.  The  early  defer- 
vescence was  followed  by  diuresis  with  cessation  of  diarrhoea.  The 
spleen  remained  enlarged  and  rose  spots  persisted. 

Rumpf  about  the  same  time  published  the  results  of  the  treatment 
of  30  cases  of  enteric  fever  with  sterilized  cultures  of  the  bacillus 
pyocyaneus.  The  fluid  employed  was  obtained  by  the  culture  of  the 
bacillus  pyocyaneus  in  thymus  bouillon.  Its  action  was  very  much  like 
that  observed  in  the  cases  treated  by  Frankel  with  typhoid  bouillon. 
The  temperature  curve  shortly  assumed  the  remittent  type  ;  diuresis 
occurred,  together  with  rapid  subsidence  of  nervous  symptoms. 

Hammerschlag  has  reported  5  cases  of  enteric  fever  treated  by  the 
transfusion  of  blood  from  convalescent  cases.  The  results,  however, 
are  inconclusive.  Hughes  and  Carter  treated  several  cases  with  blood 
serum  obtained  from  convalescents.  In  some  instances  the  injections 
were  followed  by  a  decided  fall  of  temperature.  Otherwise  there  was 
no  important  modification  of  the  symptoms. 

Beumer  and  Peiper  employed  1  per  cent,  peptone  bouillon  as  a 
culture  medium,  and  destroyed  the  bacilli  by  exposure  to  a  temperature 
between  55°  and  60°  C.  for  one  hour.  Longer  exposure  or  a  higher 
temperature  decidedly  decreased  the  virulence  of  the  culture.  Sheep 
were  inoculated  with  these  cultures  at  intervals  varying  from  three 
days  to  two  weeks,  the  amount  injected  being  gradually  increased  from 
1  c.c.  to  100  c.c.  The  animals  were  then  bled,  the  serum  treated  with 
0.5  per  cent,  solution  of  carbolic  acid,  and  preserved  in  a  cold,  dark 
place.  Serum  obtained  from  iniinoculated  sheep  was  found  to  be  un- 
favorable to  the  development  of  bacilli  typhi  abdominalis,  but  the 
serum  from  inoculated  sheep  was  far  more  unfavorable  to  their  devel- 
opment. This  serum  was  found  to  possess  both  immunizing  and  cura- 
tive properties.  No  dangerous  efl^ects  followed  its  injection  in  healthy 
men,  but  further  experimentation  is  necessary  to  establish  its  immuniz- 
ing and  curative  effects  in  the  human  being. 

Klemperer  and  Levy  by  treating  dogs  with  gradually  increasing 
amounts  of  bouillon  cultures  of  typhoid  bacilli  obtained  a  blood  serum 
capable  of  immunizing  susceptible  animals,  such  as  mice  and  guinea- 
pigs,  against  the  action  of  virulent  typhoicl  bacilli,  and  of  effecting  a 
cure  by  this  treatment  some  time  after  infection  had  been  produced. 
They  established  the  fact  that  the  administration  of  the  serum  in  small 


TREATMENT.  231 

(lUiiiititics  to  luiinaii  hcin^s  was  without  daiiii^er.  The  treatment  was 
thereupon  instituted  in  5  patients  sulTerin<i'  from  enterie  fever.  Three 
injeetions  were  administered  upon  sueeessive  evenings.  No  loeal  dis- 
comfort or  constitutional  disturVwnce  resulted.  Neither  cutaneous  rashes 
nor  albuminuria  followed.  The  patients  were  selected  cases  in  the  first 
week  of  the  attack,  the  snbsequent  course  of  which  was  mild. 


TYPHUS    FEVER. 

By  ALVAH  H.  doty,  M.  D. 


Definition. — Typhus  fever  is  an  acute,  characteristic,  infectious  and 
essential  fever.  It  prevails  in  this  country  only  in  an  epidemic  form. 
No  affection  runs  a  more  defined  and  limited  course ;  an  abrupt  change 
(crisis)  takes  place  on  or  about  the  fourteenth  day.  Eruption  is  almost 
always  present,  and  constitutes  the  sign  by  which  the  disease  can  usu- 
ally be  recognized  ;  without  it  a  positive  diagnosis  cannot  be  made. 

History. — Typhus  fever  is  unquestionably  a  disease  of  antiquity ; 
excellent  descriptions  of  it  are  given  in  the  works  of  the  earliest  medi- 
cal writers.  It  seems  strange  that  a  malady  wdiich  in  times  past  has 
decimated  not  only  armies,  but  countries,  should  not  have  been  better 
understood  and  its  identity  sooner  established.  It  had  long  been  re- 
garded, however,  as  a  variety  of  continued  fever  which  at  times  appeared 
in  an  epidemic  form,  and  apparently  but  little  eifort  was  made  to  se^ja- 
rate  it  from  other  diseases  wdth  which  it  was  confounded.  It  is  certain 
that  little  attention  was  paid  to  its  infectious  character.  During  the 
epidemic  of  typhus  fever  which  occurred  in  Philadelphia  in  the  year 
1836,  Drs.  Gerald  and  Pennock  of  that  city,  after  careful  and  exhaustive 
study,  were  convinced  of  the  non-identity  of  typhus  and  typhoid  fevers. 
Their  conclusions  were  afterward  confirmed  (1849-51)  by  the  very  valu- 
able clinical  and  pathological  investigations  of  Sir  AVilliam  Jenner  in  the 
London  Fever  Hospital.  The  devastation  caused  by  this  disease  in  early 
times  was  in  a  great  measure  due  to  the  non-recognition  of  its  infectious 
character  and  the  want  of  proper  precautions  to  prevent  its  propagation. 

Synonyms. — During  the  long  period  in  which  confusion  reigned  con- 
cerning the  nature  of  typhus  fever  it  received  innumerable  names,  sug- 
gested by  different  symptoms  and  signs  which  are  more  or  less  constant 
in  this  disease,  or  by  its  occurrence  in  certain  localities  or  under  certain 
circumstances.  Among  the  more  common  designations  found  are  ship, 
jail,  camp,  malignant,  spotted,  pestilential,  and  pyogenic  fever,  Irish 
ague,  and  the  plague.  These  various  names,  although  still  used  by 
some,  are  manifestly  improper  and  should  be  discarded.  The  doubt 
and  uncertainty  existing  in  the  medical  profession  before  1840  regard- 
ing typhus  fever  are  well  indicated  by  +he  above  array  of  names. 

The  term  typhus  was  probably  suggested  by  Boissier  de  Sauvages  in 
1760.  It  is  not  a  fortunate  one,  as  it  refers  simply  to  the  clouded  con- 
dition of  the  mind  which  is  so  marked  in  this  disease  ;  nevertheless,  custom 
has  confirmed  its  use,  and  it  will  probably  b'"  retained. 

Etiology. — Typhus  Bacillus. — Whatever  may  have  been  the  former 
opinion  as  to  the  origin  of  typhus  fever,  it  may  be  regarded  as  settled  that 
it  is  caused  by  a  specific  living  micro-organism.  The  fact  that  the  sj)e- 
cific  organism  has  not  yet  been  identified  should  not  militate  against  this 

233 


234  TYPHUS  FEVER. 

conclusion.  Clinical  observation  in  this  disease,  in  conjunction  with  our 
present  knowledge  of  the  germ  origin  of  the  infectious  diseases,  leaves  no 
reasonable  doubt  as  to  the  manner  by  which  typhus  fever  is  propagated. 
The  statement  that  the  specific  organism  of  typhus  fever  has  not  thus 
far  been  discovered  is  not  meant  to  imply  that  numerous  and  careful 
investigations  have  not  been  made.  Hlava  states  that  during  an  epi- 
demic at  Prague  in  the  year  1888  he  found  in  the  blood  of  20  out  of 
23  cases  of  typhus  fever  where  post-mortem  examinations  were  held, 
and  in  2  out  of  10  cases  examined  during  life,  a  well  defined  bacterium 
to  which  he  has  given  the  name  of  Streptohacillus.  He  believes  this  to 
be  the  cause  of  typhus  fever.  It  was  found  only  in  the  blood.  Injec- 
tions of  cultures  of  this  organism  into  mice,  rabbits,  cats,  and  pigeons 
were  followed  by  negative  results ;  some  febrile  reaction  was  produced 
in  young  pigs.  Hallier,  Zuelzer,  Thoinot,  Calmette,  Mott,  Lewaschen, 
Cheeseman,  and  others  during  the  past  twenty-five  years  have  reported 
the  discovery  in  the  blood  of  various  germs  which  they  believe  to  be 
the  cause  of  typhus  fever.  There  is  still  a  want  of  concert  in  the 
results  of  these  investigations,  and  sufficient  evidence  has  not  yet  been 
presented  to  decide  this  important  question,  although  there-  is  little 
doubt  that  the  discovery  of  the  true  organism  is  only  a  question  of  time. 
]S[otwithstanding  the  now  generally  accepted  belief  as  to  the  infec- 
tious origin  of  typhus  fever,  there  are  those  who  decline  to  accept 
this  conclusion  and  follow  the  teaching  of  Murchison,  who  died  in 
the  conviction  that  it  was  possible  and  probable  that  the  disease 
could  be  generated  de  novo  by  the  crowding  together  of  many  per- 
sons in  badly  ventilated  apartments,  combined  with  filth  and  insuf- 
ficient food.  The  disease  thus  produced  he  believed  was  capable  of 
transmission  to  others.  Although  this  theory  cannot  be  entertained,  it 
should  receive  the  most  respectful  consideration,  coming  as  it  does  from 
one  to  whom  the  world  is  indebted  for  valuable  observations  and  statis- 
tics regarding  this  disease.  It  must  be  remembered  that  Dr.  Murchison 
died  in  1879,  when  comparatively  little  was  known  regarding  micro- 
organisms in  relation  to  disease,  and  that  his  study  of  the  subject  w^as 
limited,  his  deductions  being  based  solely  on  the  results  of  his  clinical 
observations.  It  may  be  stated  that  Dr.  Cayley,  editor  of  the  third 
edition  of  Murchison's  work  on  continued  fever,  endorses  the  present 
belief  regarding  the  origin  of  typhus  fever.  Murchison  was  unduly 
impressed  with  the  fact  that  typhus  fever  frequently  appeared  abruptly 
in  imperfectly  constructed  camps  and  in  jails  and  other  institutions  which 
were  overcrowded  and  badly  ventilated,  and  in  which  the  inmates  were 
supplied  with  poor  food,  and  where  no  apparent  source  of  infection  save 
that  due  to  the  unsanitary  conditions  existed.  That  this  renders  the 
soil  favorable  for  the  propagation  of  typhus  fever  is  beyond  dispute,  and 
we  are  oftentimes  baffled  in  our  attempts  to  ascertain  the  manner  by 
which  the  contagium  has  been  introduced  into  an  institution  or  commu- 
nity. Failing  in  this,  however,  we  should  not  infer  that  the  disease  is 
generated  de  novo.  Numerous  cases  have  occurred  in  my  own  experi- 
ence where  the  contagium  has  been  received  in  a  most  peculiar  and  unex- 
pected manner,  and  the  source  has  only  been  discovered  after  long  and 
careful  investigation.  If  the  typhus  contagium  were  generated  de  novo 
when  overcrowding,  poor  ventilation,  and  poverty  are  present,  we  should 


rnEDisposiyci  causes.  235 

expect  to  Hiul  it  more  or  less  constantly  whei'e  these  conditions  exist. 
Statistics  and  facts  do  not  show  this.  Inniuucrahlc  instances  could  be 
cited  where  all  of  these  f  ictors  were  present — notably  the  inilitaiy  prisons 
diiriiii;'  the  late  war,  where  ])ersonal  hygiene,  etc.  were  at  their  lowest  ebb 
— still,  typhus  fever  did  not  apj)ear. 

PiiEDisi'osiNG  Causes. — Accepting,  as  we  must,  the  present  belief 
as  to  the  exciting  cause  of  typhus  fever,  it  will  be  necessary  to  study  the 
})redisj)osing  causes.  Foremost  among  them  arc  orercroirfJuu/,  jxxn- 
rciifi/dfioii,  and  jjorcrfi/.  As  these  conditions  are  mainly  confined  to 
the  poonn-  class,  we  should  conse([uently  expect  to  find  the  disease  |)rin- 
cipally  among  these  peo])le.  This  is  clearly  and  strikingly  verified. 
Out  of  439  cases  of  typhus  fever  Avhich  occurred  in  the  city  of  New 
York  during  1892  and  1893,  434  were  removed  from  the  poorer  tene- 
ment and  lodging  houses,  principally  the  latter.  Of  a  group  of  48 
cases  removed  to  the  Rece])ti()n  Hosj)ital  during  the  winter  of  1881-82, 
all  were  from  the  poorer  class  of  tenement  and  lodging  houses  or  were 
inmates  of  workhouses  or  hospitals.  Of  the  18,268  typhus  patients 
admitted  to  the  London  Fever  Hospital  during  a  period  of  twenty- 
three  years,  95.76  per  cent,  belonged  to  the  lowest  classes,  and  were, 
as  a  rule,  inmates  of  workhouses,  etc.  (Murchison). 

Fdinhie  and  scarcitij  of  food  have  commonly  been  followed  by 
typhus  fever.  The  horrors  of  the  Irish  famine  which  occurred  between 
1813  and  1818,  and  which  aifected  the  lower  classes,  can  hardly  be  ex- 
aggerated. The  intensely  cold  weather  during  these  years  had  almost 
completely  destroyed  the  potato  and  other  crops.  For  the  want  of 
Avork  thousands  were  rendered  homeless  and  obliged  to  wander  about  in 
quest  of  food.  Innumerable  cases  of  starvation  occurred,  and,  as  might 
be  expected,  these  people  were  ripe  for  the  reception  of  typhus  fever. 
The  few  cases  which  were  constantly  occurring  in  Ireland  during  the 
latter  part  of  1816  rapidly  increased,  until  a  terrible  epidemic  re- 
sulted. It  is  estimated  that  during  this  period  there  were  800,000  cases 
in  Ireland,  which  represented  about  one  eighth  of  the  entire  population. 
In  Dublin  alone  there  were  70,000  cases,  representing  one  third  of  the 
whole  population  of  the  city.  The  epidemic  disappeared  during  the 
latter  part  of  1819.  It  is  a  significant  fact  that  the  disappearance  fol- 
hjwed  the  abundant  harvest  of  1818. 

Intemperance. — The  influence  of  intemperance  on  the  propagation  of 
typhus  fever  is  marked,  and  has  been  recognized  by  all  who  have  had  to 
do  with  this  disease.  More  than  one  half  the  patients  suffering  from 
typhus  fever  removed  to  the  Reception  Hospital  in  New  York  City 
during  the  epidemics  of  1881-82  and  1892-93  were  addicted  to  the 
immoderate  use  of  alcohol.  The  statistics  of  the  Glasgow  and  Edin- 
burgh infirmaries,  as  cited  by  Craigie  and  Davidson,  also  show  that  over 
50  per  cent,  of  the  typhus  fever  patients  admitted  to  those  institutions 
were  intemperate.  It  will  be  seen  that  poverty,  intemperance,  over- 
crowding, etc.,  by  interfering  with  the  proper  nourishment  of  the  body 
and  with  the  functions  of  the  different  organs,  reduce  the  vital  resist- 
ance and  render  a  person  more  susceptible  to  the  typhus  contagium, 
and  after  receiving  it  less  able  to  combat  it ;  whereas  those  who  are 
well  nourished,  of  regular  habits,  temperate  in  regard  to  the  use  of 
alcohol,  and    who    live  in    clean   and  well    ventilated   and   not   over- 


236 


TYPHUS  FEVER 


crowded  apartments,  are  far  less  susceptible  than  those  in  the  group 
above  referred  to,  and  oiFer  better  prognosis. 

Temperature  and  Season. — Although  typhus  fever  seems  to  be  more 
readily  propagated  during  the  winter  months,  it  cannot  be  said  that 
temperature  or  the  season  of  the  year  has  any  special  influence  as  a  pre- 
disposing agent.  It  is  true  that  epidemics  are  more  apt  to  occur  during 
the  cold  weather,  particularly  during  the  winter  months,  but  this  is  un- 
questionably due  to  the  fact  that  at  these  periods  the  people  are  kept 
closer  together,  ventilation  is  made  imperfect  in  order  to  retain  as  much 
heat  as  possible  in  living  apartments,  and  more  poverty  exists.  As  a 
result  of  these  influences  the  disease  is  more  readily  contracted.  There 
are  some  countries,  such  as  Ireland  and  Russia,  where  the  disease  is 
always  present.  This  is  undoubtedly  due  to  the  manner  in  which  the 
people  live  while  in  their  own  country,  as  investigation  does  not  show 
that  they  are  more  susceptible  to  the  disease  during  the  epidemics  that 
have  occurred  in  the  United  States.  Typhus  may  occur  in  any  country 
excepting  those  within  the  tropics. 

Sex  and  Age. — Sex  has  very  little  influence  in  the  propagation  of 
typhus.  Of  the  18,268  cases  reported  by  Murchison  above  referred 
to,  8946  were  males,  and  9322  were  females.  This  may  be  regarded  as 
representing  about  the  usual  percentage  of  each  sex  when  both  are 
equally  exposed  to  the  infection.  Of  741  cases  occurring  in  New  York 
City  during  the  epidemic  of  1881-82,  there  were  632  males  and  109 
females ;  during  the  epidemic  of  1892-93,  out  of  663  cases  there  were 
535  males  and  128  females.  During  both  of  these  epidemics  the 
jDatients  were  mainly  removed  from  cheap  male  lodging  houses,  while 
the  patients  figuring  in  Murchison's  statistics  were  taken  mainly  from 
residences,  institutions,  etc.  where  both  males  and  females  were  inmates. 

The  following  tables,  taken  from  the  records  of  the  Riverside  and 
Reception  Hospitals,  IN^ew  York  City,  show  the  relative  frequency  of 
the  disease  between  infancy  and  old  age : 


Table  showing  the  Influence  of  Age. 


1881. 


Age. 
5  years  and  under, 
5     "      to     10, 

No. 

3 

20 

10  " 

to     20, 

51 

20  " 

to     30, 

156 

30  " 

to     40, 

152 

40  " 

to     50, 

83 

50  " 

to     60, 

41 

60  " 

to     70, 

20 

70  " 

to     80, 

3 

1892. 

Age. 
5  years  and  under, 
5     "      to     10, 

No. 
15 
23 

10  " 

to     20, 

62 

20  " 

to    30, 

61 

30  " 

to    40, 

33 

40  " 

to     50, 

22 

50  " 

to     60, 

8 

Per  cent. 

0.57 

3.78 

9.64 

29.49 

28.73 

15.69 

7.75 

3.78 

0.57 


Per  cent. 

6.69 

10.27 

27.68 

27.23 

14.73 

9.82 

3.58 


1882. 


Age. 

No. 

Per  cent 

5  years  anc 

under, 

1 

0.49 

5     ' 

to 

10, 

5 

2.42 

10  ' 

to 

20, 

24 

11.65 

20  ' 

to 

30, 

49 

23.79 

30  ' 

to 

40, 

63 

30.58 

40  ' 

to 

50, 

37 

17.96 

50  ' 

to 

60, 

21 

10.19 

60  ' 

to 

70, 

5 

2.43 

70  ' 

to 

80, 

1 

0.49 

1893 

Age. 

No. 

Per  cent. 

5  years  anc 

under, 

1 

0.23 

5     ' 

to 

10, 

4 

0.91 

10  ' 

to 

20, 

22 

5.01 

20  ' 

to 

30, 

120 

27.33 

30  ' 

to 

40, 

136 

30.98 

40  ' 

to 

50, 

92 

20.96 

50  ' 

to 

60, 

39 

8.S8 

60  ' 

to 

70, 

23 

5.24 

70  ' 

to 

80, 

2 

0.46 

rREDTSPOSINa   CAUSES.  237 

Murchisoii  found  the  iiicjui  ajic  of  o4"j()  cases  under  observutioii  iit 
the  Loudon  Fever  irosi)ital  from  1848  to  18;>7  to  be  *2J)..'>-'i  years, 
"  wliicli  is  about  tlii'ee  years  above  tlie  mean  a^c  of  the  total  ])o|)ulation." 
Oi'  18,1.')8  eases  rej)orted  l)y  the  same  autiior,  1(1.10  per  cent,  of  the 
eases  were  between  fifteen  and  nineteen  years  of  af^o  ;  12.()  per  (;ent. 
were  between  ten  and  fourteen  years  of  age ;  13.25  per  cent,  of  tlie  cases 
were  between  twenty  and  twenty-four :  these  are  the  three  largest 
])ereentages  of  tliis  table.  A  study  of  the  tables  taken  from  the 
Kiverside  and  Reception  Ilospitals  will  show  a  marked  diilerence  in 
the  trecpieney  of  ty[)hus  fever  at  different  ages.  These,  liowev(!r, 
will  be  more  in  harmony  with  each  other  when  it  is  understood  that 
during  the  epidemics  of  1881-82  and  1892-93  in  the  city  of  New 
York  the  disease  very  early  in  the  epidemic  invaded  the  cheap  lodging 
houses  of  this  city.  As  these  are  filled  entirely  by  males,  and  chiefly 
by  men  of  ages  ranging  between  twenty  and  sixty  years,  with  very  few 
l)oys,  it  will  l)e  apjireeiatcd  that  the  cases  taken  from  these  places  must 
necessarily  be  drawn  from  persons  over  twenty  years  of  age  ;  whereas 
in  the  statistics  given  from  the  London  Fever  Hospital  the  patients 
were  removed  from  the  cheaper  class  of  tenement  houses  and  residences, 
where  every  member  of  the  family  was  subjected  to  the  same  infection. 
It  will  be  seen,  however,  that  under  ten  and  over  sixty-five  years  of  age 
the  disease  is  infrequent.  As  already  stated,  typhus  fever  is  usually 
mild  and  rarely  fatal  under  ten  years  of  age. 

Other  Influences. — Pursuits  which  involve  confinement  in  close  and 
badly  ventilated  apartments,  or  those  which  entail  continued  mental  ex- 
citement or  nervous  depression,  are  predisposing  agents.  Fear  is  regarded 
l)y  the  laity  as  a  potent  predisposing  cause.  The  importance  of  this  is 
exaggerated,  and  it  probably  acts  as  a  predisposing  cause  only  when  it 
impairs  the  appetite  and  general  health  and  renders  the  person  extremely 
nervous.  I  have  met  with  one  well  marked  instance  where  fear  might 
be  regarded  as  playing  an  important  part  in  the  production  of  the  disease. 
It  is  as  follows  :  An  engineer  employed  on  one  of  the  islands  under  the 
jurisdiction  of  the  Commissioners  of  Charities  and  Correction  in  New 
York  City  became  very  much  frightened  when  it  was  announced  that 
typhus  fever  had  appeared  in  an  adjoining  building  Math  which  he  offici- 
ally had  no  communication.  The  man  kept  religiously  away  from  every 
one  who  was  in  communication  with  the  case,  and  practically  remained 
in  his  own  apartment  when  not  at  work.  On  the  third  or  fourth  day  of 
the  outbreak  he  completely  broke  down,  became  violently  agitated,  and 
remained  in  bed,  declaring  that  he  knew  that  he  had  the  fever.  The 
liberal  use  of  bromide,  with  the  assurance  that  he  would  not  have  the 
disease,  put  him  on  his  feet  again.  His  work  was  resumed,  but  he  con- 
tinued to  worry,  though  physically  in  good  health.  During  the  follow- 
ing week  he  Avas  taken  abruptly  ill  with  typhus  fever,  and  died.  While 
I  do  not  believe  that  fear  can  be  regarded  as  an  important  predisposing 
cause,  I  am  sure  that  it  militates  against  recovery  if  it  is  well  marked, 
and  tends  to  make  a  very  unfavorable  prognosis. 

It  has  been  claimed  that  the  typhus  germ  is  lighter  than  the  air  :  this, 
however,  cannot  be  accepted  as  true,  and  should  not  be  taken  into  con- 
sideration in  selecting  the  apartment  for  confinement  of  patients  affected 
with  this  disease. 


238  TYPHUS  FEVER. 

Direct  contact  is  not  necessary  to  cause  typhus  fever.  The  germ  is 
transmitted  by  emanations  from  the  body,  air-passages,  and  possibly  by 
discharges  from  the  intestinal  tract.  Air  and  fomites  act  as  media  in 
communicating  the  contagium.  Walls  and  ceilings  of  apartments  be- 
come infected.  (See  Ventilation,  page  235.)  It  cannot  be  estimated 
how  long  the  contagium  remains  active  under  various  conditions,  and 
therefore  the  fact  that  a  long  period  of  time  has  elapsed  since  the 
occurrence  of  a  case  cannot,  as  far  as  the  clothing,  bedding,  etc.  is 
concerned,  be  taken  in  lieu  of  proper  and  careful  disinfection.  It  is 
generally  regarded  as  a  fact  that  the  poison  must  be  highly  concen- 
trated to  be  transmitted  by  fomites.  This  may  be  true  in  the  main,  but 
there  has  been  sufficient  evidence  presented  from  time  to  time  to  prove 
that  a  person  visiting  a  t^^hus  case  may  be  the  medium  by  which  the 
disease  is  carried  to  other  individuals.  Sailors  have  been  known  to 
carry  the  disease  to  their  own  ship  by  having  visited  infected  vessels.  A 
case  under  my  observation  in  1893  well  illustrates  this  point :  A  man  liv- 
ing on street  had  died  of  what  afterward  proved  to  be  typhus  fever. 

He  had  before  death  been  removed  to  the  hospital.  His  apartment  in 
one  of  the  poorer  tenement  houses  had  not  been  disinfected ;  his  wife, 
desiring  to  comply  with  the  ordinary  custom  in  these  cases,  although  the 
body  was  not  present,  invited  some  friends  to  visit  her  ;  among  them 

was  a  woman,  Mrs.  M ,  living  on  the  Boulevard,  who  brought  with 

her  a  friend  who  lived  out  of  town  ;  the  husband  of  Mrs.  M  was 

unable  to  accompany  them.  After  having  made  a  protracted  call  at  the 
residence  of  the  deceased,  they  returned  home.    Within  two  weeks  Mrs. 

M and  her  husband  were  removed  to  the  Reception  Hospital  with 

typhus  fever.  The  latter,  as  stated  above,  did  not  visit  the  infected 
apartment ;  the  germ,  it  is  fair  to  suppose,  was  conveyed  to  the  husband 
by  Mrs.  M and  her  friend.    The  latter  did  not  contract  the  disease. 

Attempts  have  been  made  to  estimate  the  distance  to  which  the  germ 
may  be  transmitted ;  it  has  been  given  in  feet :  this,  of  course,  cannot 
be  entitled  to  any  very  serious  consideration,  as  such  estimates  cannot 
safely  be  used  in  a  practical  way,  since  the  danger  of  infection  is  not 
dependent  alone  on  the  close  proximity  of  the  patient.  The  mixture  of 
plenty  of  fresh  air,  which  neutralizes  the  poison  by  dilution,  is  an  ele- 
ment which  is  far  more  important  to  consider.  It  is  fair  to  assume 
that  a  case  of  typhus  fever  in  a  large  and  well  ventilated  apartment 
will  not,  as  a  rule,  propagate  the  disease  if  a  reasonable  amount  of  care 
is  exercised.  It  is  a  well  known  fact  that  a  nurse  caring  for  a  case  of 
typhus  fever  in  a  private  apartment  where  there  is  sufficient  ventilation 
runs  but  little  risk  of  contracting  the  disease,  compared  with  a  nurse 
who  is  caring  for  cases  of  this  kind  in  the  wards  of  a  hospital. 

Murchison  and  Levy  believed  that  tj^phus  is  not  infectious  during 
the  very  early  period  of  the  disease,  probably  not  until  the  end  of  the 
first  week.  This  belief  appears  to  be  rather  generally  accepted,  and  I 
can  add  that  as  the  result  of  my  personal  observation  during  the  epi- 
demics which  during  the  last  fifteen  years  have  occurred  in  New  York 
City  I  am  inclined  to  endorse  this  statement.  Where  patients  were  re- 
moved during  the  first  three  or  four  days  of  the  disease  and  the  apart- 
ment was  properly  disinfected,  secondary  cases  did  not,  as  a  rule,  occur. 
Where  subsequent  cases  did  occur  it  is  possible  and  probable  that  the 


/ '. I  THO 1. 0 ( ! ICA L  A NA  TOM Y.  2-\\) 

iiit"r('ti(»ii  CMMU'  IVoiu  sonu'  t)tlicr  sourt-c.  Cases  arc  cited,  howcxci',  wliciv 
it  is  (|Mitt'  clear  that  the  disease  may  iuive  been  contracted  during;  tlie  first 
davs  of  the  disease,  and  it  would  be  manifestly  unsafe  to  re<2:ard  this  point 
as  in  any  way  settled,  as  it  would  necessarily  tend  to  relax  our  efforts 
in  the  j)ronii)t  I'enioval  of  cases  from  tenement  houses  to  other  a|)art- 
ments  prejKired  for  their  reception.  It  would  also  interfere  with  disin- 
fection, the  value  of  which  cannot  be  overestimated.  Dr.  Mooi'e  I'efers 
to  the  opinion  of  the  late  Dr.  Perry  of  Glasgow,  who  believed  that  the 
most  infectious  period  of  typhus  fever  is  during  convalescence.  Al- 
thouiih  this  belief  is  shared  by  others,  I  reoard  its  accejitance  as  dan- 
oerous  and  opposed  to  the  proper  ])rotecti()n  of  the  ])ublic. 

It  has  not  as  yet  been  satisfactorily  determined  whether  or  not  the 
dead  body  is  capable  of  propagathig  typhus  :  thus  far,  there  seem  to  be 
no  well  authenticated  cases  ^vhere  infection  has  taken  place  from  this 
source.  Murchison  believed  that  he  contracted  the  disease  in  the  dis- 
secting-room. This,  however,  could  not  be  substantiated,  as  an  ei)i- 
demic  of  typhus  fever  existed  in  Edinburgh  at  the  time,  and  it  is  but 
fair  to  assume  that  he  was  brought  more  or  less  directly  in  contact  with 
the  disease,  and  that  he  was  infected  in  this  manner ;  besides,  the  cloth- 
ing which  envelops  the  dead  body  may  be  the  source  of  infection.  How- 
ever, as  no  sufficient  reason  has  been  presented  why  this  should  not  occur, 
it  W'Ould  be  unwnse  to  regard  this  point  as  settled. 

The  question  of  idiosyncrasy  is  somewdiat  obscure,  and  has  about  the 
same  relation  to  this  disease  as  to  others.  There  are  some  wdio  seem 
immune  to  typhus  fever  and  are  proof  against  infection,  W' hile  others  are 
readily  susceptible  and  may  have  the  disease  twice  or  three  times.  Dr. 
Murchison  was  an  example  of  the  latter  class,  he  having  had  typhus 
fever  twice.  What  this  peculiar  susceptibility  or  immunity  consists  of 
is  unknown,  and  cannot  be  anticipated  by  an  examination  of  a  person. 

Does  one  wdio  is  constantly  dealing  with  infectious  diseases  become 
immune  is  a  question  which  is  of  peculiar  interest,  but  w^hich  is  seldom 
referred  to.  There  are  those  who  believe  that  this  is  actual,  and  refer 
to  the  small  number  of  cases  occurring  among  health  department  officials 
and  quarantine  officers,  wdio  are  constantly  dealing  w'ith  this  class  of 
disease.  It  ^vould  at  least  appear  to  be  more  than  a  coincidence.  One 
attack  of  typhus  fever,  as  a  rule,  confers  immunity  against  a  subsequent 
one.     Ho w^ ever,  a  second  or  third  attack  sometimes  occurs. 

Pathological  Anatomy. — The  anatomical  changes  found  after 
death  from  typhus  fever  are  not  specifically  characteristic,  but  are  similar 
to  those  present  in  other  acute  infectious  diseases.  The  organs  present 
lesions  that  often  occur  in  various  conditions  attended  Avith  fever,  and 
the  most  noticeable  feature  at  the  autojjsy  table  is  the  presence  of  the 
changes  unaccompanied  by  well  marked  and  specific  alterations.  The 
findings  at  the  post-mortem  examination,  if  taken  by  themselves,  apart 
from  a  clinical  history  or  a  probable  exposure  to  typhus  fever,  are 
usually  not  sufficient  to  establish  the  diagnosis. 

The  skin  frequently  retains  traces  of  the  petechial  rash.  The  blood 
is  generally  dark  and  fluid,  and  the  body  tends  to  early  decomposition. 
The  muscles  are  dark  red  in  color,  and  may  be  the  seat  of  granular  or 
waxy  changes,  and  occasionally  of  hemorrhages.  The  heart  is  soft  and 
flabby.     The  liver  is  large  and  soft.     The  spleen  is  almost  always  much 


240  TYPHUS  FEVER. 

enlarged  and  soft.  The  kidneys  are  usually  swollen  and  congested, 
and  the  parenchymatous  degeneration  is  more  advanced  in  them  than  in 
the  other  viscera. 

The  intestines  are  often  normal,  but  have  a  rosy  color.  The  Peyer's 
patches  not  infrequently  present  the  "  shaven  beard "  appearance,  but 
are  never  ulcerated  as  in  typhoid  fever. 

Apart  froru  the  parenchymatous  degenerations  of  the  organs  already 
mentioned,  the  most  constant  complicating  lesions  are  found  in  the 
respiratory  tract.  Acute  bronchitis,  and  pulmonary  hypostatic  con- 
gestion, and  oedema  are  common.  Laryngitis  and  lobular  or  lobar 
pneumonia  and  gangrene  of  the  lungs  are  sometimes  met  with. 

Inflammations  of  the  serous  membranes  are  very  unusual. 

IncubatiojST. — This  period  generally  ranges  from  eight  to  twelve 
days,  usually  the  latter.  There  is  some  diversity  of  opinion  among 
writers  regarding  this  stage.  Hutchison  refers  to  a  case  where  the  incu- 
bation was  thirty-one  days.  Huss  at  Stockholm  speaks  of  this  stage  as 
one,  two,  or  three  days,  sometimes  ten,  or  in  some  cases  only  a  few  hours. 
Lebut  in  his  article  on  typhus  in  Von  Ziemssen's  Encyclopedia  places  it 
at  five  to  seven  days.  Where  a  clear  history  could  be  obtained  in  the 
cases  of  typhus  fever  occurring  in  the  city  of  New  York  during  1881- 
82  and  1892-93  the  period  of  incubation  was  found  to  be  about  twelve 
days.  This,  I  believe,  w^ill  prove  to  be  about  the  duration  in  most  cases 
if  the  histories  are  carefully  investigated.  I  can  account  for  the  state- 
ments that  the  usual  period  of  incubation  is  from  three  to  seven  days 
only  on  the  assumption  that  the  histories  of  the  individual  cases  were 
not  carefully  and  fully  obtained.  While  there  are  very  few  instances  in 
which  the  period  of  incubation  exceeds  twelv^e  days,  there  are  some 
Avhere  the  time  is  much  shorter.  Well  authenticated  cases  are  even 
cited  in  which  the  period  of  incubation  was  hardly  appreciated,  the 
stage  of  invasion  occurring  almost  immediately  after  the  exposure. 
This  may  be  attributed  to  a  peculiar  susceptibility  of  the  individual  or 
to  concentration  of  the  poison  to  such  an  extent  that  its  effect  upon  the 
system  was  almost  immediate.  After  examining  a  number  of  cases  of 
typhus  fever  I  have  frequently  experienced  a  headache  w^hich  has  lasted 
for  a  portion  of  the  day.  This  experience  has  been  shared  by  my  col- 
leagues. 

Symptoms. — Invasion. — One  of  the  marked  characteristic  signs  of 
typhus  fever  is  the  abruptness  of  its  invasion.  This  can  be  relied  upon 
as  one  of  the  most  valuable  aids  in  making  an  early  diagnosis,  and  is  in 
marked  contrast  with  the  slow  invasion  of  typhoid  fever. 

The  period  of  invasion  usually  lasts  from  one  to  three  days,  during 
which  the  patient  suffers  from  a  slight  chill  or  chilly  sensations  (a 
decided  or  well  marked  chill  is  unusual)  :  this  symptom  is  accom- 
panied by  general  malaise,  which  soon  amounts  to  great  and  indescrib- 
able prostration,  accompanied  by  headache,  vertigo,  loss  of  appetite,  and 
soreness  about  the  body  ;  pains  in  back  and  limbs,  particularly  the  thighs 
and  calves  of  the  legs.  The  tongue  has  a  white  coating  at  first,  and  is 
usually  large  and  pale.  The  coating  subsequently  becomes  darker  in 
color.  The  uniform  and  well  marked  congestion  of  the  conjunctivae 
peculiar  to  this  disease  may  be  very  early  recognized,  and  is  a  strong 
diagnostic  point  in  favor  of  typhus.     The  dusky  appearance  of  the  face 


SYMI'TOMS.  241 

is  vorv  iioticcahlc.  Considerable  tremor  in  the  hands  is  nsnally  present. 
The  urine  is  iuLili  colored,  scanty,  and  may  have  a  siK-citic  oravity  as 
high  as  lO.'jO.  There  are  no  special  abdominal  sym])toms  ;  the  bowels 
are  usually  constipated.  There  is  sometimes  nausea,  but  seldom  vom- 
iting. The  mental  condition  becomes  rapidly  blunted  and  confused,  and 
the  patient  is  listless  and  suffers  from  insomnia.  The  prostration  be- 
comes more  marked  as  the  disease  i)asses  into  the  eruptive  stage.  Dur- 
ing the  stage  of  invasion  the  pulse  is  increased  in  frequency  and  is  com- 
pressible, and  the  temperature  usually  reaches  102°  or  lO;]"^  F.,  or 
sometimes   even  higher. 

Eruption. — Usually  on  the  fourth  day,  rarely  after  the  sixth,  the 
eruption  peculiar  to  typhus  fever  appears.  At  first  it  does  not  show  its 
true  characteristics,  but  develops  as  a  rash  which  frequently  resembles 
that  of  measles  and  is  often  mistaken  for  it.  The  spots  are  irregular  in 
form  and  slightly  raised,  varying  in  size  from  that  of  a  large  pea  to  the 
point  of  a  pencil.  The  spots  may  be  isolated  or  grouped  in  patches 
similar  to  those  of  measles  ;  they  do  not  at  this  time  present  the  dusky 
appearance  which  is  subsequently  shown,  but  have  a  dark  pink  color 
and  disappear  on  pressure.  The  eruption  appears  at  first  on  the  chest, 
abdomen,  and  then  on  the  arms  and  thighs.  The  upper  and  anterior 
part  of  the  shoulder  and  the  anterior  aspect  of  the  forearm  have  always 
appeared  to  me  to  offer  the  best  aspect  for  study.  At  these  sites  the 
skin  is  cleaner  and  whiter,  and  the  eruption  is  usually  well  marked. 
Some  writers  lay  great  stress  on  the  appearance  of  the  eruption  on  the 
back  of  the  hand  :  I  do  not  regard  this  site  as  so  favorable  for  study, 
as  this  part  of  the  hand,  particularly  in  the  subjects  who  are  affected 
with  typhus,  is  usually  hardened  and  discolored  by  work  and  exposure 
to  the  weather,  and  the  eruption  is  not  always  easily  distinguished. 

The  eruption  is  not  often  apparent  on  the  face  and  neck.  Dr. 
Moore  believes  this  to  be  due  to  two  reasons  :  first,  because  these  parts 
are  very  vascular  and  the  hyperemia  due  to  the  fever  conceals  the  spots  ; 
second,  because  the  rash  develops  less  thoroughly  in  parts  exposed  to  the 
air.  This  explanation  appears  to  be  reasonably  consistent  with  the  facts 
as  far  as  it  is  ascribed  to  hypersemia,  which  in  this  disease  is  usually  in- 
tense. The  second  reason  can  hardly  be  accepted,  as  in  other  eruptive 
diseases,  such  as  measles  and  smallpox,  the  eruption  on  the  face  is  more 
intense  than  elsewhere.  In  addition  to  the  early  measly  rash  referred 
to,  there  is  often  a  mottled  condition  of  the  skin  which  is  due  to  a  sub- 
cuticular eruption.  This  has  the  appearance  of  being  deep  seated,  and, 
although  it  can  be  recognized,  it  is  paler  and  not  as  distinct  as  the 
former.  The  "  mulberry  rash  "  of  Sir  William  Jenner  represents  the 
combination  of  the  two  eruptions  just  described.  The  mottling  is  per- 
haps best  seen  when  standing  three  or  four  feet  away  from  the  patient. 
If  possible  a  suspected  case  of  typhus  should  always  be  examined  in 
the  daylight. 

The  measly  or  morbilliform  eruption  gradually  changes  its  charac- 
ter :  the  slight  elevation  disappears,  and  the  dusky  pink  color  becomes 
much  darker,  and  does  not  disappear  on  pressure.  This  change  is  con- 
stant, and  is  a  very  important  point  in  the  diagnosis.  It  is  due  to 
capillary  hemorrhage  followed  by  the  formation  of  pigment,  which 
takes  the  place  of  the  very  early  hypersemia :  this  change  is  fully 
Vol.  I.— 16 


242  TYPHUS  FEVER. 

apparent  on  the  fifth  or  sixth  day,  and  may  be  considered  the 
typical  and  permanent  eruption  of  typhus  fever.  Another  element 
is  to  be  added  to  this  eruption  before  its  description  is  complete  :  I 
refer  to  the  appearance  of  true  petechise,  which  may  be  found  on  the 
eighth  or  tenth  day  in  the  centre  of  the  dusky  spots,  constituting  the 
permanent  eruption  already  referred  to  ;  they  are  of  a  bluish  tint  and 
their  borders  are  not  abrupt,  but  grade  into  the  dusky  color  of  the 
typhus  rash ;  they  may  invoh^e  but  a  minute  portion  of  the  typhus  spot 
or  they  may  almost  entirely  obscure  it.  These  petechial  points  repre- 
sent subcutaneous  ecchymoses.  The  petechise  alone  frequently  occur  in 
other  diseases  ;  they  constitute  an  extremely  important  diagnostic  sign 
only  when  they  occur  in  combination  with  the  dusky  rash  just  described. 
Credit  is  given  by  Murchison  to  Staberoh,  Stewart,  and  Jenner  for  the 
description  of  the  conversion  of  the  permanent  typhus  eruption  into 
petechise.  The  petechise  of  typhus  are,  as  a  rule,  confined  to  adult 
patients.  About  the  time  that  the  rash  is  fully  formed  the  subcutaneous 
eruption  or  mottling  commonly  disappears.  As  might  be  expected  from 
the  description  just  given  of  the  permanent  eruption,  it  can  be  recog- 
nized after  death,  provided  dissolution  does  not  occur  late  in  the  course 
of  the  disease  from  some  sequelse.  The  eruption  generally  disappears 
when  about  eight  or  ten  days  old. 

The  rash  would  probably  not  be  present  if  death  occurred  on  the 
first  or  second  day  of  the  eruption,  while  it  is  due  to  simple  hypersemia. 
I  know  of  no  statistics  regarding  this  point,  as  a  fatal  result  rarely 
occurs  at  this  stage. 

As  already  stated,  the  typhus  eruption  never  appears  in  successive 
crops,  as  in  typhoid  fever ;  a  day  or  two  may  elapse  before  the  entire 
eruption  presents  itself,  but  when  fully  out  it  remains  until  it  all  grad- 
ually disappears.     This  is  in  marked  contrast  with  t^-phoid  fever. 

In  some  cases  where  the  measly  or  early  eruption  has  been  quite 
prominent  a  slight  desquamation  may  subsequently  take  place.  This, 
however,  is  not  very  common. 

The  eruption  is  almost  always  present  in  typhus  fever,  and  without 
it  a  diagnosis  of  this  disease  can  rarely  be  made.  It  certainly  cannot 
be  made  in  isolated  cases.  I  have  seen  but  one  case  where  the  diao;nosis 
of  t^^Dhus  fever  without  an  eruption  was  in  a  measure  justified.  During 
the  last  epidemic  in  Xew  York  City  (1892-93)  a  suspicious  case  was  re- 
ported at  Mt.  Sinai  Hospital.  The  patient,  a  man,  had  been  removed 
from  a  vicinity  where  t\^3hus  fever  was  prevalent ;  his  temperature  and 
general  symptoms  were  characteristic,  but  there  was  an  entke  absence 
of  an  eruption  or  mottling,  the  skin  presenting  a  particularly  clear  and 
wliite  appearance.  The  temperature  dropped  about  the  end  of  the 
second  week,  convalescence  ensued,  and  the  patient  was  discharged.  I 
saw  the  case  in  consultation  with  Drs.  Janeway  and  Jacobi.  The 
general  symptoms,  particularly  those  referable  to  the  nervous  system, 
were  characteristic  of  typhus,  and,  as  there  was  nothing  to  account 
for  them,  the  case  was  regarded  as  probable  t}^hus  without  an  erup- 
tion. I  regard  this  as  justifiable  when  well  marked  cases  of  typhus 
fever  exist  in  the  same  place  or  vicinity.  JMurchison's  statistics  of  ad- 
missions into  the  London  Fever  Hospital,  which  cover  a  period  of 
twenty-three  years,  show  that  out  of  18,268  cases  of  typhus  fever  the 


SYMPTOMS.  243 

eruption  was  present  in  17,02.'>,  or  Do. 2  per  cent.  He  admits  that  in 
some  eases  the  eruption  may  have  been  overlooked,  and  states  that  in 
1864  unusual  eare  was  taken  at  the  London  Fever  Hospital  to  ascertain 
if  the  eruption  was  present :  during  tliis  time  it  was  found  in  97.77  per 
cent,  of  the  eases.  The  class  of  people  usually  affected  with  typhus  are 
those  who  pay  absolutely  no  attention  to  personal  hygiene  or  cleanliness, 
and  a  slight  eruption  is  easily  overlooked,  particularly  as  the  examina- 
tion of  the  eases  is  often  superficial,  the  task  l)eing  as  a  rule  an  unsavory 
one.     The  eruption  is  more  often  absent  in  children  than  in  adults. 

The  eruption  does  not  ahvays  follow  the  course  above  described ;  it 
may  not  pass  beyond  the  first  or  second  stage.  In  children  it  usually  does 
not  become  petechial,  and  the  disease  is  frequently  mistaken  for  measles. 
In  mild  cases  the  eruption  may  begin  to  fade  on  the  third  or  fourth  day. 

In  some  few  cases  the  true  typhus  eruption  may  be  preceded  by  a 
preliminary  eru])tion  or  roseola,  "which  may  cover  considerable  portions 
of  the  body  and  may  be  confounded  with  scarlatina.  This  roseola  is 
transient  and  gradually  fades  as  the  regular  eruption  appears.  It  is 
well  to  bear  this  in  mind,  as  a  diagnosis  of  scarlet  fever  might  cause 
considerable  embarrassment  and  dangerous  infection.  Dr.  Wilks  refers 
to  a  case  where  a  preliminary  eruption  covered  the  whole  body,  and  was 
undoubtedly  promptly  diagnosticated  as  scarlet  fever.  The  appearance 
of  the  eruption  is  not  followed  by  a  fall  in  the  temperature,  as  in  the 
case  of  smallpox. 

Temperature. — There  appears  to  be  a  uniformity  of  opinion  re- 
garding the  character  of  the  temperature  in  typhus  fever.  The  disease 
is  ushered  in  with  a  comparatively  sudden  rise,  which  reaches  the  maxi- 
mum during  the  first  week  or  possibly  later.  It  may  reach  103°  F.  on 
the  evening  of  the  first  day,  rarely  rising  higher.  Murchison  had  the 
record  of  a  case  which  reached  104.9°  F.  on  the  first  day,  as  cited  by 
Griesinger.  The  maximum  when  reached  is  generally  no  higher  than 
105°  F.  and  a  fraction.  In  children  it  may  reach  or  exceed  the  maxi- 
mum just  given  without  indicating  a  grave  prognosis.  A  remission 
usually  occurs  during  the  early  part  of  the  second  week,  and  in  uncom- 
plicated cases  a  gradual  decline  takes  place  until  about  the  fourteenth 
day,  when  there  is  usually  a  sudden  descent  of  from  three  to  five  degrees, 
to  or  below  normal,  commonly  the  latter.  This  rapid  decline  may  be 
immediately  preceded  by  an  exacerbation.  The  sudden  decline  which 
occurs  on  or  about  the  fourteenth  day  may  be  looked  upon  as  peculiar 
to  typhus  fever  :  it  represents  the  crisis,  and  is  an  exceedingly  important 
diagnostic  point.  An  absence  of  the  remission  during  the  early  j^art 
of  the  second  week  renders  the  prognosis  unfavorable.  An  increase  in 
the  temperature  during  the  second  week  usually  indicates  the  presence 
of  some  complication  which  is  generally  referable  to  the  lungs.  A  low 
temperature  should  not  afford  one  a  sense  of  security,  as  in  many  fatal 
cases  the  temperature  does  not  exceed  103°  F.  This  condition  is  found 
where  there  is  a  great  depression  of  the  vital  powders. 

The  peculiar  manifestation  of  the  temperature  of  typhus  fever  which 
is  in  marked  contrast  with  that  of  typhoid  fever  is  the  slight  variation 
in  the  daily  range.  This  may  be  looked  upon  as  the  rule,  and  is  ex- 
ceedingly important  in  the  differential  diagnosis.  A  slight  increase  in 
temperature  usually  occurs  in  the  evening,  although  in  some  cases  it 


244 


TYPHUS  FEVER. 


may  be  highest  in  the  morning.  During  the  early  part  of  convalescence 
it  frequently  remains  subnormal.  During  this  period  (convalescence)  a 
temporary  rise  of  temperature  may  occur  without  apparent  cause  and 
without  special  significance. 

The  following  temperature  charts,  taken  from  the  records  of  the 
Riverside  Hospital,  illustrate  the  range  of  temperature  in  what  may 
be  regarded  as  typical  cases  : 

Fig.  26. 


105° 
104° 
103° 
102° 
101° 
100° 
99' 
98' 


3     4     5 


i 


m 


7      8     0    10   11    12    13   14    15    Ki    17    18 


I 


i 


i 


S5 


i 


m 


i? 


Case  I. — Temperature  chart. 


Case  I.  (recovery). — H.  M ,  male,  aged  thirty-two  years,  was  an 

orderly  in  the  typhus  ward  of  the  hospital  during  the  epidemic  in  New 
York  City  in  1881.  The  chart  therefore  records  the  range  of  temper- 
ature from  the  beginning  of  the  disease. 

Fig.  27. 


106° 
105° 
104° 
103° 
102° 
101° 
100' 
99' 
98' 
97' 


■ 


I 


i 


8     9    10    11   12    13    14    15   10    17    18    19 


i 


B 


i: 


2i 


«; 


i^i? 


30 


Case  II.— Temperature  chart. 


SiMJ'TOMS. 


24/5 


Case  I  J.  (recoverv).— J.  D ,  male,  :i<ic(l  clcvon  years,  iniuato  in 

an  institution  in  >sew  Y(>ri<  City  wlu-rc  an  outbreak  of  typhus  occurred 
in  Noveniher,  ISSI.  The  j)atieiit  was  at  once  removed  to  the  Riverside 
Hospital. 

Case  J  J  J.  (recovery). — G.  S ,  male  aged  twenty-six  years,  River- 
side Hospital,  February,  l«9;j.    The  temperature  chart  in  this  case  indi- 


Fm.  28. 

o'isEWE      4     5     c,     r     8     '.)     ]0    11    i-.>    ]:;    11    ].-,    It; 

;        ;        ;               ■        ■               ,.-.--     — 

106' 

i-m.       t- 

1-^-1           M     "A 

1  j't             -1     M 

□ 

J 

~^    \-    -       -     -A 

1 — i— w.^-- J         ] 

1 —  Y ■"  L'      \ 

inn'                                                           ^r^ 

lUU                                                                       1  /     1 

t       t 

yj                                                                     ; 

Case  III. — Temperature  chart. 

cates  the  range  from  the  fourth  day  of  the  disease.  A  record  of  the 
preceding  days  was  unfortunately  not  kept,  the  patient  not  being  under 
observation. 

It  will  be  seen  by  the  al)ove  charts  that   the  crisis  in  these  cases 
occurred  about  the  fourteenth  dav. 


Fig.  29. 


106 
105' 
104' 
103' 
102' 
101' 
100' 


5     6     7      8      0     lu    11    12    1.3 


11 


g 


ffl 


Case  IV.— Temperature  chart. 


246  TYPHUS  FEVER. 

Case  IV.  (death). — J,  C ,  male,  aged  forty-eight  years,  Riverside 

Hospital,  April,  1893.  This  patient  was  an  orderly  at  the  Reception 
Hospital  and  was  addicted  to  the  use  of  liquor.  His  death  occurred 
about  the  fourteenth  day  of  the  disease. 

Pulse. — The  pulse  of  typhus  has  certain  peculiarities  which  are  gen- 
erally present  in  severe  and  well  marked  adult  cases.  In  the  begin- 
ning of  the  disease  it  ranges  from  100  to  120  or  130.  The  latter  is 
usually  reached  on  the  second  or  third  day.  Of  90  cases  cited  by 
Murchison,  in  only  15  did  the  pulse  go  above  120.  Of  13  cases  re- 
ported by  this  author  as  occurring  in  the  service  of  Dr.  Henderson 
where  the  pulse  exceeded  134,  5  died.  In  a  group  of  26  cases  at  the 
Riverside  Hosjjital  during  1892-93  between  the  ages  of  twenty-one 
and  sixty-five  (mean  age  thirty-seven),  there  were  10  deaths,  in  8  of 
which  the  pulse  went  above  120 ;  of  the  16  which  recovered,  the  pulse 
was  above  120  in  6  cases.  These  patients  were  inmates  of  lodging 
houses,  and  among  them  the  mortality  was  high.  Dr.  Murchison  un- 
doubtedly refers  to  adult  cases  in  speaking  of  pulse  frequency,  as  it  is 
common  to  find  the  pulse  above  this  point  (134)  in  children.  In 
Xovember,  1881,  an  outbreak  of  typhus  fever  occurred  among  the  chil- 
dren who  were  inmates  of  an  institution  in  New  York  City ;  there  were 
19  children  affected,  all  under  twelve  years  of  age.  The  records  of 
these  cases  show  that  in  10  the  pulse  was  above  130,  in  6  it  was  above 
140,  and  in  3  it  was  above  150;  all  of  these  cases  recovered.  In  the 
class  of  severe  cases  the  pulse  becomes  progressively  weaker  and  the 
cardiac  impulse  is  finally  lost.  Subsequently  the  first  sound  of  the  heart 
becomes  weaker  and  may  disappear.  The  second  sound  may  also  be 
affected  in  a  similar  manner.  It  is  very  unusual  for  the  pulse  to  remain 
firm  and  strong  throughout  the  first  week  of  the  disease.  In  90  young 
and  robust  patients  Murchison  found  but  4  cases  where  the  heart 
remained  in  this  condition.  During  the  second  week  the  pulse  is  usually 
dicrotic,  irregular,  or  intermittent.  During  the  early  part  of  the  disease 
the  pulse  rate  may  be  very  low,  with  a  subsequent  rise.  In  a  case 
reported  by  Barallier  (Murchison)  of  a  man  fifty  years  of  age  the  pulse 
remained  at  28  for  three  days.  A  very  low  pulse  generally  denotes 
extreme  prostration. 

A  stethoscope  should  be  used  in  ascertaining  the  condition  of  the 
heart  and  circulation.  The  radial  pulse  cannot  be  depended  upon  to 
indicate  the  number  of  cardiac  contractions,  as  the  heart  may  beat  twice 
to  one  wave  of  the  radial  pulse.  This  difference  is  not  only  due  to 
feebleness  of  the  circulation,  but  to  a  want  of  muscular  tone.  In  favor- 
able cases  the  heart  becomes  somewhat  stronger  about  the  tenth  or 
eleventh  day.  The  silence  of  the  heart,  as  the  name  implies,  means 
that  the  pulsations  cannot  be  detected,  and  almost  invariably  indicates 
approaching  death.  During  this  period  of  weakness  and  rapidity  of  the 
heart  the  daily  variation  in  the  number  of  pulsations  is  small,  a  slight 
increase  usually  occurring  at  night.  After  the  first  day  of  the  disease 
there  is  very  little  relationship  between  the  temperature  and  pulse ;  that 
is,  the  temperature  may  be  high  when  the  pulse  is  slow,  and  vice  versa. 
During  the  early  part  of  convalescence  the  pulse  may  be  slower  than 
normal. 

Respiraiory  System. — The  increase  in  the  respiratory  action  is  de- 


SYMPTOMS.  247 

pendent  in  a  great  measure  on  pulmonary  complications  ;  nujre  or  less 
hypostatic  conocstion  is  present  in  nearly  all  cases.  During  the  first 
week  the  respirations  do  not,  as  a  rule,  exceed  25  ;  however,  with  a  high 
pulse  and  temperature  they  may  become  more  rapid.  On  admission  to 
the  hospital  of  the  grou])  of  20  cases  above  referred  to,  the  nnm])er  of 
respirations   exceeded   25  in   all  but  2  cases. 

The  following  table  indicates  the  highest  and  lowest  respiratory  range 
in  the  10  fatal  cases  belonging  to  this  group  : 

Age.  On  admission.  at      ■  at-    • 

V-  ^  ry       ■     ,•  Maximum.  Mmimum. 

1  eare.  Kespiration. 

21 32 48 28 

54 32 56 30 

25 44 44 20 

42 36 38 22 

33 28 34 28 

65 30 48 20 

35 32 44 26 

38 30 54 28 

39 26 30 24 

55 28 32 18 

In  the  fatal  class  the  mean  number  of  respirations  was  43 ;  in  the 
cases  which  recovered  the  mean  number  was  36.  The  pulmonary  con- 
gestion usually  present  may  end  in  oedema  of  the  lungs,  which  is  denoted 
by  hurried  and  embarrassed  respiration  ;  coarse  rales  at  first,  then  fine 
crackling  rales,  and  frothy  expectoration  tinged  with  blood.  This  con- 
dition usually  ends  fatally.  In  cases  of  great  prostration  the  respira- 
tions may  be  subnormal  in  frequency  and  not  exceed  8  or  10.  In  this 
class  of  cases  the  temperature  is  usually  low.  In  severe  cases  the  respi- 
ration may  be  sighing  or  irregular.  Where  great  cerebral  irrital^ility 
exists  the  respirations  are  jerky  and  spasmodic.  This  is  regarded  by 
Murchison  as  an  unfavorable  sign.  The  nervous  or  cerebral  breathing 
of  Sir  Dominic  Corrigan,  which  is  of  a  blowing  or  hissing  character,  and 
Cheyne-Stokes  respiration,  are  sometimes  present. 

Epistaxis  does  not  usually  occur.  In  7000  uncomplicated  cases 
Murchison  found  it  but  12  times.  The  records  of  the  Riverside  Hos- 
pital also  show  that  epistaxis  is  uncommon. 

Dic/estive  Trad. — During  the  first  week  the  tongue  becomes  very 
dry  and  rough.  This  constitutes  a  strong  diagnostic  point  in  favor  of 
typhus  fever,  and  is  present  in  three  fourths  of  the  cases.  The  whitish 
fur  that  is  first  noticeable  changes  to  a  dark  brown  color,  and  is  gener- 
ally confined  to  the  centre  of  the  tongue,  while  the  edges  and  point  are 
pale.  This  condition  continues  until  convalescence  approaches,  when 
the  coating  gradually  disappears  and  the  tongue  becomes  moist.  There 
is  a  loss  of  appetite,  and  sometimes  nausea,  but  vomiting  is  uncommon. 
The  iliac  meteorism  and  gurgling  which  are  so  often  present  in  ts^phoid 
fever  are  wanting  in  typhus.  Pain  or  tenderness  may  be  found  in  the 
hepatic  region,  or  sometimes  in  other  parts  of  the  abdomen,  but  it  has 
no  particular  significance.  Constipation  is  usually  present.  Diarrhoea 
sometimes  appears  at  about  the  time  of  the  crisis. 

Urine. — In  the  early  part  of  the  disease  the  urine  is  high  colored, 
and  may  continue  so  until  convalescence  is  established.  It  then  be- 
comes lighter  in  color.     At  first  the  specific  gravity  may  reach  1030 ; 


248  TYPHUS  FEVER. 

this  afterward  becomes  diminished,  and  is  apt  to  be  subnormal  after 
the  crisis.  The  amount  of  urine  at  first  is  notably  diminished,  even 
when  a  large  amount  of  fluid  is  taken.  At  this  time  it  usually  has  an 
acid  reaction.  During  convalescence  the  amount  is  generally  equal  to 
or  above  the  normal.  Suppression  sometimes  occurs  as  the  result  of  an 
acute  nephritis.  The  chlorides  in  the  urine  are  markedly  diminished, 
and  may  disappear  as  in  pneumonia.  Investigations  by  Parke,  Mur- 
chison,  Buchannan,  and  others  show  that  the  urea  is  at  first  increased. 
In  a  case  cited  by  Buchannan  the  quantity  of  urea  passed  on  the  fifth 
day  was  851  grains;  that  passed  on  the  twelfth  day  was  1011  grains. 
As  a  rule,  however,  the  quantity  diminishes  during  the  second  week, 
and  may  fall  below  the  normal  register.  An  increase  is  also  shown  in 
the  amount  of  uric  acid.  Albumin  is  probably  found  in  one  half  or 
more  of  the  cases.  This  does  not  usually  indicate  previous  organic 
disease  of  the  kidneys,  but  generally  is  due  to  simple  hypersemia  or  some 
acute  affection  of  these  organs  induced  by  typhus  fever.  The  presence 
of  albumin  is  frequently  accompanied  by  mucus,  epithelium,  and  casts 
of  the  uriniferous  tubes.  Organic  disease  of  the  kidneys  renders  the 
prognosis  very  unfavorable,  inasmuch  as  it  favors  the  occurrence  of 
uraemia  and  ursemic  convulsions. 

Nervous  System. — Pain  in  the  back  and  limbs  and  frontal  headache, 
particularly  over  the  temples,  are  constant  symptoms  and  are  well 
marked  during  the  first  week.  The  headache  was  present  in  almost 
every  case  received  at  the  Riverside  Hospital  during  1881—82  and 
1892-93.  In  251  cases  observed  by  Murchison  and  Henderson  head- 
ache was  present  in  236.  The  pain  in  the  different  parts  referred  to 
varies  in  intensity,  and  usually  subsides  about  the  seventh  or  eighth  day. 
At  this  period  deafness,  which  occurs  in  a  large  percentage  of  the  cases, 
is  noticed.  This,  as  a  rule,  disappears  during  convalescence  or  soon 
afterward,  although  in  a  few  cases  it  remains  permanent. 

Typhus  fever  is  associated  with  early  and  great  impairment  of  the 
mental  faculties.  Well  marked  delirium  generally  occurs  during  the 
latter  part  of  the  first  week,  although  from  the  first  there  is  obstinate 
wakefulness  associated  with  general  dulness,  the  patient  being  unable  to 
converse  intelligently.  The  delirium  occurs  at  first  during  the  night, 
but  later  there  is  no  interval  of  lucidity.  The  delirium  ranges  from  a 
low  muttering  form,  which  is  so  commonly  found  in  older  subjects,  to 
that  of  acute  mania,  where  the  patient  can  only  be  controlled  by  force. 
In  alcoholic  cases  it  very  frequently  assumes  the  character  of  delirium 
tremens.  This  I  have  repeatedly  noticed  in  patients  removed  from 
lodging  houses,  these  people,  as  a  rule,  being  alcoholic  subjects.  A 
suicidal  tendency  is  not  infrequent.  The  prognosis  is  in  a  great  measure 
governed  by  the  degree  of  delirium  ;  when  the  latter  is  profound  the 
prognosis  is  correspondingly  unfavorable. 

The  pupils  are  usually  contracted,  sometimes  to  an  intense  degree, 
producing  what  is  known  as  the  pinhole  pupil.  The  latter  condition 
constitutes  a  very  unfavorable  sign. 

Complications  and  Sequelae. — Although  numerous  complications 
and  sequelae  may  occur  in  typhus  fever,  it  is  necessary  to  refer  to  but  a 
few  of  them.  Of  these  bronchitis  stands  at  the  head.  This  is  so  con- 
stant and  prominent  that  it  may  be  regarded  rather  as  a  symptom  than 


COMPLICATIONS  AND  SEQUELJE— DIAGNOSIS.  249 

a  complic-ation.  It  may  (generally  be  expected  to  occur.  Among  those 
complications  which  are  infrequent  may  be  mentioned  lobar  pneumonia, 
larvnii'itis,  iicncnil  convulsions,  pytemia,  plilco:masia  dolens,  thrombosis, 
embolism,  mcnini;itis,  and  intestinal  hemorrhage.  General  convulsions 
which  are  ura?mic  in  origin  constitute  an  exceedingly  dangerous  com- 
plication ;  they  occur  late  in  the  disease,  during  the  latter  i)art  of  the 
second  week.  The  attack  is  generally  preceded  by  a  greatly  diminished 
amount  of  urine,  at  times  amounting  to  suppression.  The  mental  con- 
dition is  also  notably  atfected  at  this  time,  the  stupor  or  delirium  being 
intensified.  The  convulsions  are  usually  followed  by  coma  and  death, 
the  latter  occurring  within  twenty-four  hours. 

Diagnosis. — Typhoid  fever  is  frequently  mistaken  for  typhus,  even 
by  those  having  wide  experience.  Some  of  the  essential  points  to  be 
borne  in  mind  in  deciding  between  these  diseases  are  as  follows  :  Typhus 
fever  has  a  very  short  and  rather  abrupt  period  of  invasion.  It  usually 
commences  with  a  slight  chill  or  chilly  sensation  and  a  rapid  rise  of 
temperature,  pronounced  headache,  and  pain  in  the  back  and  limbs. 
On  the  third  or  fourth  day,  rarely  after  the  fifth  or  sixth,  the  character- 
istic eruption  appears.  In  typhoid  fever  there  is  notably  a  long  period 
of  incubation  and  invasion.  The  patient  has  been  suffering  for  days 
with  general  malaise  (which  is  frequently  regarded  as  due  to  malaria  or 
general  debility),  and  it  is  only  after  ten  or  fifteen  days,  when  the  symp- 
toms have  gradually  become  more  pronounced,  that  he  is  obliged  to  go  to 
bed  and  remain  there.  I  regard  this  as  one  of  the  most  important  points 
in  the  differential  diagnosis,  and  it  can  almost  always  be  relied  upon. 
This  cannot  l^e  said  of  the  diarrhcea  and  epistaxis,  which  are  erroneously 
believed  by  some  to  be  present  in  all  cases  of  typhoid  fever.  When 
epistaxis  is  present  it  suggests  at  once  t^-phoid  fever.  Murchison  found 
it  in  but  12  out  of  7000  cases  of  uncomplicated  cases  of  t}73hus  fever. 
Diarrhoea  is  likewise  a  very  uncommon  symptom  of  t^-phus  fever,  par- 
ticularly before  the  crisis.  Abdominal  pain,  tenderness,  and  tympanites, 
which  are  so  constant  in  typhoid  fever,  are,  as  a  rule,  absent  or  only 
feebly  marked  in  t}^3hus.  The  characteristic  eruptions  of  these  diseases 
are  markedly  different.  When  t^-pical,  that  of  typhus  appears  on  or 
before  the  fifth  day  and  is  found  over  the  greater  jjart  of  the  body. 
When  it  is  fully  formed  it  is  dusky  in  color,  does  not  disappear  on  pres- 
sure, and  there  are  no  successive  crops,  as  in  typhoid.  The  eruption  in 
this  disease  is  not  short  lived,  as  in  typhoid,  but  remains  distinct  for 
several  davs,  and  is  usually  present  when  death  occurs  in  uncomplicated 
cases.  In  typhoid  the  eruption  does  not  appear  until  the  beginning  of 
the  second  week.  It  is  confined  principally  to  the  abdomen,  back,  and 
chest,  and  consists  of  small  rose  colored  papules  which  disappear  on 
pressure.  Successive  crops  occur.  It  is  in  those  cases  in  which  the 
typhus  eruption  is  slight  or  the  typhoid  eruption  is  profuse  that  errors 
are  apt  to  occur.  I  cannot  speak  too  strongly  on  this  point.  Numer- 
ous cases  of  tvphoid  have  come  under  my  observation  which  have  been 
positively  declared  to  be  typhus  fever  on  account  of  the  accompanying 
general  eruption.  In  some  cases  it  was  a  profuse  typhoid  eruption  ;  in 
others  it  was  a  septic  eruption  or  an  accidental  one.  It  must  be  borne 
in  mind  that  a  profuse  typhoid  exanthem  follows  the  ordinary  course  of 
the  eruption  in  that  disease  ;  that  is,  in  two  or  three  days  the  first  crop 


250  TYPHUS  FEVER. 

disappears  and  is  succeeded  by  a  second,  or  the  first  crop  disappears  and 
a  much  smaller  crop  follows.  In  other  words,  there  are  successive 
crops  instead  of  a  permanent  eruption. 

Accidental  eruptions  Avhich  sometimes  accompany  typhoid  are,  as  a 
rule,  short  lived,  and  disappear  on  pressure  or  become  indistinct  in  two 
or  three  days.  A  general  eruption  sometimes  follows  a  high  tempera- 
ture. I  have  seen  numerous  cases  where  the  history  of  the  invasion  and 
the  early  symptoms  w^ere  clearly  indicative  of  a  typical  case  of  typhoid 
fever ;  still,  on  account  of  a  profuse  eruption,  either  typhoid  or  foreign 
to  the  disease,  the  diagnosis  of  typhoid  fever  would  not  be  accepted  until 
corroborated  by  the  autopsy.  Even  if  the  history  of  the  eruption  alone 
were  carefully  studied,  it  would,  as  a  rule,  help  to  clear  up  whatever 
doubt  might  exist  as  to  the  diagnosis,  I  wish  to  repeat  that  the  early 
history  of  the  case,  particularly  the  period  of  invasion,  should  always 
be  carefully  taken  into   consideration  before  a   decision  is  made. 

In  considering  the  diiferential  diagnosis  between  measles  and  typhus 
fever,  it  should  be  remembered  that  measles  is  essentially  a  disease  of 
children,  while  typhus  affects  adult  life.  The  high  temperature  and 
pulse  and  early  acute  catarrhal  symptoms  affecting  the  eyes  as  well  as 
the  respiratory  tract  point  toward  measles.  The  bronchial  or  catarrhal 
svmptoms  accompanying  typhus  are  not  as  acute  or  as  early.  The  erup- 
tion of  measles,  although  it  may  in  a  w^ay  be  confounded  with  the  early 
eruption  of  typhus,  is  particularly  prominent  on  the  face,  where  the 
eruption  of  typhus  is  absent.  If  measles  occurs  in  an  adult,  the 
mental  dulness  and  subsequent  delirium  which  are  marked  in  typhus 
are  wanting.  Special  care  should  be  taken  to  ascertain  if  there  have 
been  other  cases  of  measles  in  the  family  or  vicinity.  It  is  Avell  to 
remember  that  the  eruption  of  two  distinct  diseases  may  be  present  at 
the  same  time.  I  have  the  notes  of  a  well  marked  case  of  typhoid  fever 
in  the  beginning  of  the  second  week  which  I  saw  in  consultation  at  the 
New  York  Hospital  in  1893.  The  typical  eruption  of  typhoid  fever 
was  present  on  the  abdomen.  At  this  stage  the  temperature  suddenly 
became  higher  and  pronounced  coryza  and  other  catarrhal  symptoms 
appeared.  In  two  or  three  days  the  characteristic  eruption  of  measles 
appeared  on  the  face  and  chest.  An  investigation  disclosed  the  fact  that 
the  patient,  a  young  man,  had  attended  his  sister's  children  who  were 
suffering  from  measles,  shortly  before  he  was  removed  to  the  hospital. 

If  the  patient  is  closely  observed  and  the  present  and  previous  his- 
tory is  carefully  studied,  malarial  fevers  can  hardly  be  confounded 
with  typhus.  The  periodicity  which  is  usually  prominent  in  malarial 
fevers,  the  controlling  effect  of  quinine  and  other  remedies,  the  history 
of  the  patient  being  at  the  tune  present  in  a  malarial  district  or  having 
previously  lived  in  one,  the  absence  of  an  eruption,  the  evidence  of  an 
enlarged  firm  spleen,  etc.,  should  exclude  typhus  fever. 

A  differential  diagnosis  between  cerebral  meningitis  and  typhus  fever 
is  not  always  easy  at  first.  As  a  rule,  however,  in  meningitis  the 
cerebral  symptoms  occur  earlier  and  are  more  marked,  the  headache  is 
more  intense,  and  the  hearing  is  abnormally  acute ;  there  are  also 
present  photophobia  and  acute  delirium.  In  meningitis  symptoms  of 
irritation  or  compression  are  very  early  noticeable,  such  as  vomiting, 
ptosis,    strabismus,    unequal    or    contracted    pupils,   muscular   rigidity, 


rno(.;yosis.  251 

tremor  or  paralysis,  etc.,  whicli  arc  uncommon  in  typhus.  Vomiting, 
wliich  is  a  very  common  and  constant  sym})tom  in  meningitis,  is  very 
nirelv  seen  in  uncomplicated  cases  ot"tyj)hus  lever.  (Jf  course  the  pres- 
ence of  a  well  marked  typhus  eruption  would  decide  between  the 
diseases  referred  to.  This,  however,  may  not  appear  for  two  or  three 
days. 

Epidemic  cerebro-spinal  meningitis  may  be  mistaken  for  typhus 
fever,  but  only  in  exceptional  cases.  Although  the  invasion  of  typhus 
is  rapid,  that  of  cerebro-spinal  meningitis  is  luarkedly  abrupt,  and 
almost  always  occurs  during  the  night  with  really  no  premonitory  stage. 
Cerebro-spinal  meningitis  usually  affects  children  before  the  tenth  year, 
while  typhus  is  a  disease  of  adult  life.  In  the  latter  the  critical  period 
occurs  late  in  the  disease.  In  cerebro-spinal  meningitis  death  may 
take  place  within  twenty  four  or  forty  eight  hours,  and  the  cerebral 
symptoms,  such  as  intense  headache,  photophobia,  phonopholjia,  and 
delirium,  become  at  once  prominent.  In  this  disease,  also,  vomiting  is 
almost  always  present,  while  it  is  rare  in  typhus.  In  cerebro-spinal 
meningitis  the  pain  is  marked  over  the  nape  of  the  neck  and  down  the 
back  over  the  region  of  the  spine.  On  the  third  or  fourth  day  contrac- 
tions of  the  muscles  of  the  neck  and  back  are  present.  Retraction  of 
the  head  and  opisthotonos  are  more  or  less  pronounced.  The  retraction 
of  the  head  is  a  sign  which  is  generally  understood  by  the  family,  and 
constitutes  a  very  important  point  in  the  diagnosis.  The  s^nnptoms  just 
referred  to  belong  to  cerebro-spinal  meningitis,  and  are  not  found  in 
tvphus  fever.  An  herpetic  eruption  is  very  commonly  found  about  the 
lips,  ears,  and  cheeks  in  cerebro-spinal  meningitis,  and  only  occasionally 
presents  itself  in  typhus.  The  eruption  of  cerebro-spinal  meningitis  is 
irregular,  has  no  definite  form,  and  does  not  by  any  means  always 
appear.  It  is  usually  found  in  certain  parts  where  the  temperature  is 
supposed  to  be  reduced,  and  is  not  spread  uniformly  over  the  body,  as 
in  typhus.  I  can  hardly  believe  that  a  case  of  cerebro-spinal  meningitis 
could  exist  where  the  diagnosis  could  not  be  made  if  the  history  and 
symptoms  were  carefully  studied  without  the  question  of  the  eruption 
being  taken  into  consideration,  particularly  after  the  lapse  of  tsvo  or 
three  days. 

Pneumonia  is  sometimes  mistaken  for  typhus  fever,  and  vice  versa. 
However,  a  thorough  physical  examination  of  the  chest,  with  a  careftil 
investigation  as  to  the  history  of  the  case,  ought  after  a  day  or  so  to  clear 
up  whatever  doubt  may  exist.  Acute  yellow  atrophy  of  the  liver  and 
malignant  endocarditis  have  also  been  mistaken  for  tx'jDhus  fever. 

Peogxosis. — Among  the  more  important  signs  and  symptoms  which 
indicate  an  unfavorable  prognosis  are — advanced  age,  intemperate  habits, 
a  pulse  in  an  adult  of  over  120,  marked  and  persistent  nervous  symptoms, 
such  as  delirium,  a  dark  and  abundant  eruption,  great  mental  depres- 
sion, disease  of  the  kidneys  or  other  organs,  rapid  respiration,  insom- 
nia which  cannot  be  relieved,  Ursemic  convulsions  and  pronounced 
coma  vigil  almost  always  indicate  a  fatal  termination.  A  pinhole  pupil 
is  also  regarded  as  an  extremely  unfavorable  sign ;  early  relaxation  of 
the  sphincters,  continued  high  temperature,  particularly  in  adults,  and 
also  the  advent  of  the  different  complications,  tend  to  make  an  unfavor- 
able diagnosis.     It  must  be  remembered,  however,  that  although  some 


252  TYPHUS  FEVER. 

of  the  signs  above  enumerated  are  almost  invariably  followed  by  a  fatal 
termination,  recoveries  have  taken  place  after  their  appearance  ;  and 
every  effort  should  be  made  to  sustain  life  as  long  as  possible. 

Prophylaxis. — Well  directed  and  practical  efforts  toward  the  pre- 
vention of  typhus  fever  in  a  community  are  far  more  important  than  the 
treatment  of  this  disease  ;  this  fact,  unfortunately,  is  too  often  over- 
looked. It  can  confidently  be  said  that  if  the  proper  preventive  means 
are  employed  an  outbreak  of  typhus  will  soon  be  under  control.  It  is 
of  the  utmost  importance  that  cases  of  typhus  fever  should  be  early 
recognized,  and  that  suspected  cases  should  receive  the  most  careful 
attention  and  care  until  they  are  proven  not  to  be  typhus.  If  in  a 
private  residence  or  small  house,  the  patient  should  be  placed  in  a  well 
ventilated  room  on  the  top  floor,  everything  in  the  apartment  having 
been  previously  removed  which  is  not  absolutely  needed  for  the  patient, 
particularly  upholstered  articles.  After  removal,  the  clothing,  bedding, 
etc.  and  the  room  previously  occupied  by  the  patient  should  be  sub- 
mitted to  a  rigid  disinfection,  as  will  be  hereafter  described.  No  one 
should  enter  the  infected  room  except  the  nurses  and  physicians.  This 
regulation  should  be  particularly  enforced,  and  food  should  be  carried 
to  the  floor  by  an  attendant  and  taken  to  the  room  by  the  nurse.  The 
dishes  should  be  placed  in  boiling  water  or  a  solution  of  bichloride  of 
mercury,  1  :  2000,  before  being  returned.  Nurses  leaving  the  apart- 
ment should  remove  all  the  clothing  worn  in  the  infected  chamber  be- 
fore going  outside,  should  have  a  bath  and  have  the  hair  thoroughly 
washed  ;  all  linen,  etc.  when  soiled  should  be  put  in  tubs  of  boiling 
water,  and  afterward  placed  in  a  solution  of  bichloride  of  mercury, 
1  :  2000.  Worthless  articles  should  be  destroyed  at  once,  preferably  by 
burning.  When  the  patient  is  able  to  leave  the  room  he  should  be  care- 
fully and  thoroughly  bathed,  rubbed,  and  dressed  in  fresh  clean  clothes, 
and  removed  to  another  room.  The  windows,  doors,  and  all  openings 
into  the  infected  apartment  should  be  sealed  by  pasting  Avith  strips  of 
paper.  The  apartment  should  then  be  disinfected  by  sulphur  dioxide, 
at  least  four  pounds  of  sulphur  to  each  1000  cubic  feet  of  air  space  ;  at 
the  same  time  the  air  of  the  room  should  be  rendered  moist.  The  doors 
and  windows  and  other  openings  should  be  kept  closed  for  at  least  eight 
or  ten  hours,  and  longer  if  possible. 

The  most  effective  means  of  all  for  disinfection  is  heat.  If  a  disin- 
fection apparatus  where  a  high  degree  of  heat  can  be  secured,  such  as 
is  used  by  the  Health  Departments  of  different  cities,  is  available,  the 
clothing,  mattresses,  pillows,  comfortables,  and  other  material  of  this 
character  which  have  already  been  subjected  to  the  above  fumigation 
and  which  cannot  be  washed,  should  by  all  means  be  heated  in  this 
manner  or  otherwise  should  be  burned.  Sulphur  dioxide  cannot  be  de- 
pended upon  as  a  safe  disinfectant  in  this  instance,  as  it  has  very  little 
penetrative  power,  and  is  only  effective  where  bare  surfaces  are  exposed. 
After  fumigation  the  woodwork  and  wooden  parts  of  furniture,  beds, 
etc.  should  be  carefully  wiped  with  a  solution  of  bichloride  of  mercury, 
1  :  2000.  I  have  referred  above  to  a  case  occurring  in  a  private  resi- 
dence. Cases  originating  in  tenement  or  apartment  houses  and  hotels 
should  always  be  removed  to  a  hospital  or  place  prepared  for  the  recep- 
tion of  such  cases.     Neither  should  cases  of  typhus  fever  be  cared  for  in 


TREAT^rKST.  253 

institutions  unless  a  scpanitt'  or  distinct  l)uil(lin<r  be  assijjnwl  for  this 
purpose  under  the  care  ot"  tliose  who  have  absohitely  nothing-  to  do  with 
the  main  buikling. 

The  aihnission  of  plenty  of  fresh  air  to  the  apartment  <rreatly  dimin- 
ishes the  dauiier  of  infection.  Fresh  air  not  only  dilutes  and  jrreatly 
lessens  tiic  amount  of  infection,  but  is  a  very  effective  o;ermicide,  and  is 
of  inestimal)le  value  to  the  i)atient.  As  a  matter  of  precaution  in 
exaniinini>-  the  body  of  typhus  patients  the  bedelothin<»-  or  clothin<r  of 
the  patient  should  be  removed  beforehand  in  order  that  the  infected 
stratum  of  air  be  displaced. 

I  know  of  no  circumstance  which  so  strikingly  illustrates  the  value 
of  proper  disinfection  as  a  preventive  agent  as  that  which  followed 
the  disinfection  of  the  infected  Bowery  lodging  houses  in  Xew  York 
City  during  the  simimer  of  1893.  It  was  found  after  a  careful  and 
extended  investigation  that  the  sources  of  infection  in  the  cases  of 
typhus  fever  received  at  the  Reception  Hospital  during  the  spring 
of  1893  were  almost  all  traceable  to  the  lodging  houses  above  re- 
ferred  to,  aljout  thirty  in  number,  consisting  of  large  four-  or  five-story 
buildings  accommodating  from  fiftv  to  two  hundred  lodgers.  The 
Health  Department  at  once  ordered  the  thorough  disinfection  of  these 
places.  The  walls,  ceilings,  floors,  bedsteads,  chairs,  etc.  were  washed 
with  a  solution  of  bichloride  of  mercury,  1  :  1000,  and  then,  while 
the  walls  and  contents  were  still  wet,  each  room  was  fumigated  with 
sulphur  dioxide.  A  large  number  of  the  mattresses  which  were  old 
and  worn  out  were  destroyed.  The  others  with  the  bedding  were 
removed  to  the  disinfecting  plant  of  the  Health  Department  and  dis- 
infected by  heat.  As  a  result  of  this  procedure  the  number  of  cases  of 
typhus  fever  occurring  in  Xew  York  was  rapidly  reduced.  The  follow- 
ing table  will  be  more  eloquent  than  Avords  : 

Xumber   of    cases   of  typhus 
1893.  fever  removed  to  Eeception 

Hospital. 

First  quarter  (January,  February,  and  March) 210 

Second  quarter  (April,  May,  and  June) 116 

Third  quarter  (July,  August,  and  September) 12 

It  may  be  added  that  the  12  cases  occurring  in  the  third  quarter  were 
received  at  the  hospital  during  the  early  part  of  July.  There  have  been 
no  reported  cases  of  typhus  fever  in  Xew  York  City  since  the  period 
referred  to  above,  July,  1893'. 

Teeatmext. — Little  can  be  said  in  the  way  of  therapeutics.  There 
is  no  specific  for  the  treatment  of  t^^j^hus  fever.  The  most  rational  and 
successful  line  of  treatment  consists  in  combating  the  different  symp- 
toms as  they  appear  by  proper  nourishment,  the  judicious  use  of  stimu- 
lants, agents  which  reduce  the  temperature,  and  narcotics  and  anodynes 
to  allay  pain  and  restlessness  and  produce  sleep.  Pnre  milk  constitutes 
the  most  effective  means  of  administering  nourishment.  If  in  its 
natural  state  it  disagrees  with  the  patient,  Vichy  or  lime-water  may  be 
added  or  it  may  be  peptonized.  I  cannot  leave  the  subject  of  food 
without  speaking  strongly  in  favor  of  kumyss  as  a  nourishing  agent,  for 
not  ojily  in  typhus,  but  in  all  continued  fevers,  I  know  of  no  form  of 
nourishment  that  equals  this  when  it  is  properly  made  and  administered. 


254  TYPHUS  FEVER. 

It  is  made  in  this  country  from  cow's  milk  fermented  with  yeast  in 
tightly  closed  bottles.  The  coagulation  which  follows  is  essentially  the 
same  as  that  which  is  found  in  the  stomach.  The  breaking  up  of  this 
coagulum  in  the  stomach  requires  considerable  effort  on  the  part  of  the 
muscular  walls  of  this  organ,  which  is  frequently  incapable  of  properly 
performing  the  task,  and  the  milk  is  ejected.  This  commonly  takes 
place  in  weak  and  badly  nourished  children  and  in  those  suffering  from 
almost  any  severe  form  of  disease.  The  coagulated  milk  constituting 
kumyss  is  shaken  from  time  to  time  by  the  maker  until  it  becomes  fluid, 
and  is  then  ready  for  use.  It  will  thus  be  seen  that  kumyss  is  milk 
practically  ready  for  assimilation  when  it  reaches  the  stomach.  The 
carbonic  acid  contained  in  this  beverage  is  usually  very  grateful  to  the 
patient,  but  if  this  gas  is  contraindicated  the  bottle  may  be  left  uncorked 
for  a  short  time  in  the  refrigerator.  Kumyss  also  contains  2  or  3  per 
cent,  of  alcohol,  resulting  from  fermentation,  which  is  of  great  value 
in  typhus  fever.  The  acidity  is  also  generally  acceptable  to  the 
patient.  The  value  of  kumyss  is  frequently  impaired  by  age,  hot 
weather,  etc. ;  it  then  becomes  very  acid  and  disagreeable,  and  per- 
haps irritates  the  stomach.  My  experience  with  beef  extract  in  fever 
is  unsatisfactory.  There  are  numerous  other  forms  of  nourishment 
which  have  more  or  less  value  according  to  the  experience  of  differ- 
ent physicians. 

Cold  baths  and  cold  sponging  are  the  agents  which  have  been  mainly 
depended  upon  at  Riverside  Hospital  for  the  reduction  of  the  tempera- 
ture. This  method  appears  to  be  universally  endorsed  by  those  Avho 
have  had  large  experience  in  the  treatment  of  this  disease,  particularly 
by  Combemale,  Petruso,  and  others.  Petruso  employed  cold  baths  in 
two  epidemics  with  very  satisfactory  results.  The  wet  pack  has  been 
emploved  bv  some,  and  sponging  may  be  used  instead  of  the  bath  when 
deemed  advisable.  An  objection  to  the  plunge  bath  as  ordinarily  used 
is  the  necessity  for  transferring  the  patient  to  a  tub,  which  requires  some 
exertion  on  his  part.  This  can  be  avoided  by  improvising  a  tub  in  the 
bed  in  the  following  manner  :  A  large  rubber  sheet  is  passed  underneath 
the  patient,  the  upper  end  of  which  is  carried  over  the  pillow ;  on  the 
sides  and  foot  of  the  bed  are  placed  tightly  rolled  blankets,  the  sides 
and  lower  end  of  the  rubber  sheet,  already  placed  in  position,  are  carried 
up  and  over  the  rolled  blankets,  making  a  receptacle  in  which  the 
patient  lies  ;  water  of  the  temperature  of  about  85°  F.  is  now  poured 
into  the  bath,  and  the  temperature  is  further  reduced  to  75°  F.  by  the  ad- 
dition of  cold  water  or  ice.  The  patient  should  be  well  rubbed  while  in 
the  bath  and  carefully  watched.  As  a  rule,  patients  can  remain  in  a 
bath  of  this  temperature  for  fifteen  minutes.  The  rolled  blanket  at  the 
lower  end  or  side  can  now  be  partly  removed,  and  the  rubber  blanket 
so  arranged  that  the  contents  of  the  tub  can  flow  into  a  receptacle  on 
the  floor.  The  patient  should  now  be  thoroughly  dried  and  rubbed  and 
the  rubber  blanket  removed.  He  should  be  carefully  covered  up  and  a 
stimulant  administered.  The  cold  plunge  or  bed  bath  is  almost  ahvays 
followed  by  a  marked  reduction  in  the  temperature  ;  the  pulse  becomes 
stronger,  a"  diminution  in  the  delirium  and  restlessness  takes  place,  and 
sleep  often  follows.  The  frequency  with  which  these  baths  may  be 
employed  depends  of  course  on  the  "temperature  ;  if  this  remains  above 


TRKATMKSr.  255 

102°  F.,  the  baths  arc  pailicularly  indicated  and  -lionld  l)e  used  every 
three  hours. 

(iuiniue  uiay  he  employed  as  an  antipyretic  when  the  teiuperature  is 
hi<>h  and  the  hath  is  contrainchcated  ;  it  is  at  least  a  sale  remedy.  This, 
however,  cannot  he  said  oi"  antipyrine,  phenaeetin,  and  remedies  ol"  this 
class.  AVhile  they  rechice  the  tenn)eratiire,  they  are  a})t  to  cause  con- 
siderable depression,  which  should  be  avoided.  I  believe  this  to  Ik*  tlie 
feeling  of  the  majority  of  those  who  have  had  experience  in  tlie  treat- 
ment of  tyj^hns  fever. 

Stimuhmts  are  particularly  indicated  in  this  disease;  their  vahie  is 
conspicuously  apparent  in  the  later  stage,  particularly  in  alcoholic  sub- 
jects. Digitalis  is  used  as  a  heart  tonic  and  diuretic.  Nitroglycerin 
and  strychnine  particularly  may  be  also  recommended  as  heart  stimu- 
lants. Morjihine,  although  objected  to  by  some,  is  unquestionably 
valuable  in  the  insomnia  accompanying  the  disease  when  judiciously  ad- 
ministered, and  in  comparatively  small  doses  is  certainly  a  cardiac 
stimulant.  Innumerable  remedies,  such  as  sulphonal,  trional,  bromide, 
chloral,  etc.,  have  been  used  to  relieve  the  insomnia  Avith  varying  suc- 
cess, and  may  be  given  a  trial.  The  fluid  extract  of  guarana  was  a 
favorite  remedy  at  Riverside  Hospital,  New  York,  during  the  epidemic 
of  1881-82  for  the  headache  which  is  present  in  typhus  fever.  It  is 
strongly  recommended  by  Dr.  Frank  Chapin,  who  was  in  charge  of  the 
above  hospital  during  the  epidemic  above  referred  to.  One  or  two 
drachms  of  the  fluid  extract  should  be  occasionally  given.  Sinakoski 
says  that  for  over  two  years  he  treated  typhus  by  every  known  method, 
and  as  a  result  he  feels  satisfied  that  the  calomel  treatment  is  superior 
to  all  others,  and  if  begun  early  greatly  diminishes  the  severity  or  aborts 
the  disease.  I  cannot  but  feel  that  this  writer  is  over  confident  regard- 
ing this  form  of  treatment.  I  certainly  do  not  believe  that  the  disease 
can  be  aborted.  Mr.  H.  T.  Webster  regards  Echinacea  am/usftfolia  as 
a  valuable  antizymotic,  and  reports  that  he  has  used  it  with  success  in 
typhus  fever.  Schleschumizen  reports  good  results  from  the  internal 
use  of  creolin  in  doses  of  f  grain  in  distilled  w^ater  four  or  six  times 
daily.  Under  this  treatment  the  disease  w^as  more  submissive  and  pur- 
sued a  milder  course  with  a  lower  temperature.  Dr.  A^ance  of  Sonoma, 
California,  recommends  that  leeches  be  applied  to  the  temple  in  young 
and  robust  patients.  It  will  thus  be  seen  that  innumerable  remedies  and 
plans  of  treatment  have  from  time  to  time  been  suggested,  but  I  believe 
the  method  which  I  have  already  recommended,  of  treating  the  difier- 
ent  symptoms  and  complications  as  they  present  themselves,  is  the  most 
practical  and  valuable. 


RELAPSING  FEVER 

By  warren  COLEMAN,  M.  D. 


Definition. — Relapsing  fever  is  an  acute  infectious  disease  caused 
by  a  spirillum,  the  Spirochoita  Obermeierl,  and  characterized  by  a  febrile 
paroxysm,  by  a  period  of  intermission,  and  by  one  or  more  relapses. 

Etiology. — The  discovery  of  the  spirochseta  of  relapsing  fever 
by  Obermeier  was  made  known  in  1873,  though  the  organism  had 
been  seen  by  this  observer  as  early  as  1868.  It  is  a  delicate  spirally 
twisted  filament  of  homogeneous  ^  appearance,  varying  in  length  from 
16-40  //,  or,  approximately,  from  two  to  six  times  the  diameter  of  a  red 
blood  cell,  and  is  always  in  active  motion  when  seen  in  fresh  cover-glass 
preparations.  Its  movements  are  a  combined  rotation  on  its  long  axis, 
propelling  the  organism  backward 
and  forward,  and  a  shortening  or 
lengthening  of  its  spirals,  a  portion 
of  the  organism  straightening  out 
at  times  and  thrashing  around 
among  the  corpuscles  in  whip- 
like   fashion. 

The  spirochseta  should  be  ex- 
amined in  an  ordinary  cover-glass 
preparation  of  blood  and  without 
the  addition  of  any  reagents,  since 
it  is  extremely  sensitive  to  them. 
Von  Jaksch  states  that  the  mere 
addition  of  distilled  water  causes 
the  organisms  to  disappear.  Or- 
dinarily they  may  be  easily  de- 
tected through  the  disturbance 
they  create  among  the  red  blood  cells.  They  occur  singly  or  in  groups, 
and  may  be  seen  with  a  ^  inch  (Leitz)  objective,  though  it  is  desirable 
to  use  a  Y^2  i^ch  homogeneous  oil  immersion  lens  and  Abbe's  condenser. 

The  spirochsetse  are  found  in  the  blood  only  during  a  paroxysm 
of  fever,  and  disappear  shortly  before  the  end  of  the  paroxysm.  As  a 
rule,  they  do  not  appear  during  the  first  two  or  three  days  after  the 
onset  of  the  disease.  They  may  be  present  in  great  numbers  in  each 
field  of  the  microscope,  or  there  may  be  difficulty  in  finding  a  single 
organism.  What  becomes  of  the  organisms  during  the  period  of  inter- 
mission has  not  been  determined. 

The  small  number  of  cases  in  which  absence  of  the  spirochsetse  from 
the  blood  has  been  reported  may  be  disregarded  in  the  face  of  the  over- 

^  A  beaded  appearance  of  the  protoplasm  lias  been  noted  by  one  or  two  observers. 
Vol.  I.— 17  257 


Blood  of  relapsing  fever,  showing  Spirochaeta 
Obermeieri  among  the  red  corpuscles ;  mag- 
nified 1150  times  (Eichhorst). 


258  BELAPSINO  FEVER. 

whelmingly  positive  results  in  the  majority  of  cases.  It  is  a  notable 
fact  that  the  number  of  spirochsetse  varies  at  diiferent  times  in  the  same 
individual  during  the  same  paroxysm,  and  Heydenreich,  who  made  a 
careful  study  of  the  blood  during  an  epidemic  in  St.  Petersburg,  set 
forth  the  opinion  that  fresh  broods  of  the  organism  were  probably  pro- 
duced several  times  during  a  paroxysm.  This  opinion  was  based  upon 
the  finding  of  only  a  few  spirochsetse  in  the  blood  of  a  patient  at  one 
examination,  yet  a  specimen  taken  a  few  hours  later  revealed  their  pres- 
ence in  large  numbers.  The  same  observer  established  a  further  inter- 
esting fact,  that  the  spirochaetse  after  removal  from  the  body  survived 
but  a  short  time  at  the  body  temperature,  though  if  kept  at  a  tempera- 
ture from  60°  to  70°  F.  they  remained  alive  much  longer.  This  would 
seem  to  show  that  the  very  pyrexia  produced  by  the  organism  is  in  the 
end  the  means  by  which  the  paroxysm  is  brought  to  a  close.  Sarnow 
and  V.  Jaksch  have  observed  in  the  blood  between  the  paroxysms  highly 
refractive  bodies  resembling  diplococci,  which  they  suggest  may  be 
spores.  V.  Jaksch  states  that  at  times  he  has  seen  these  coccus-like 
bodies  grow  out  into  short  rods. 

Nothing  is  known  of  the  habitat  or  life  history  of  the  spirochsetse, 
and  up  to  the  present  time  all  attempts  at  artificial  cultivation  have 
failed. 

A  review  of  the  epidemics  which  have  occurred  since  Rutty  de- 
scribed relapsing  fever  in  1770  leads  to  the  conclusion  that  there  are 
certain  endemic  centres  (e.  g.  Ireland),  and  that  when  epidemics  occur  in 
other  places  infection  has  been  carried  to  them  by  persons  or  fomites. 
The  formerly-considered  autochthonous  origin  of  relapsing  fever  is 
evidence  that  the  disease  is  at  first  endemic.  All  authorities  are  agreed 
that  relapsing  fever  is  communicable  by  personal  contact,  and  the  more 
intimate  the  contact  the  greater  the  likelihood  of  infection.  Thus  in 
crowded  tenements  the  disease  spreads  rapidly ;  nurses  and  orderlies  are 
more  likely  to  contract  it  than  hospital  internes,  and  the  internes  than 
the  attending  physicians.  When  a  person  sleeps  in  a  bed  not  yet 
cleansed  which  has  been  occupied  by  a  relapsing  fever  patient,  infection 
almost  certainly  follows. 

As  regards  the  transmission  of  relapsing  fever  by  fomites,  there 
seems  to  be  some  difference  of  opinion.  Wyss  and  Bock,  Cormack  and 
Parry,  have  recorded  instances  where  the  disease  was  thus  conveyed, 
while  Loomis,  on  the  other  hand,  states  that  in  the  epidemic  in  ^ew 
York  City  in  1870  he  found  no  evidence  that  the  fever  was  conveyed 
by  clothing,  and  that  not  a  single  person  who  was  brought  into  imme- 
diate contact  with  the  clothing  contracted  the  disease. 

It  was  thought  formerly  that  relapsing  fever  originated  in  destitution 
and  filth,  hence  the  names  "  famine  fever  "  and  "  hunger-pest,"  but  it  is 
known  now  that  these  exert  simply  a  predisposing  influence. 

There  has  been  much  discussion  as  to  the  manner  in  which  relapsing 
fever  is  transmitted  from  person  to  person.  The  expired  air  and  the 
exhalations  from  the  skin  both  have  been  accounted  responsible  for  the 
spread  of  the  disease.  But  we  know  nothing  as  yet  concerning  the 
channel  through  which  the  organism  leaves  the  body  or  the  form  in 
which  it  leaves  it,  and  until  these  facts  can  be  ascertained  opinion  must 
be  held  in  abeyance.     The  spirochseta  is  not  present  in  the  bronchial 


PATirOLOaif'AL   .l.V.l'/'OJ/}'.  259 

secretion,  in  the  c()njuni'ti\;il  secretion,  or  in  the  scrum  of  the  herpetic 
or  sudaminal  vesicles  wliieh  occur  in  certain  cases,  and  is  found  in  the 
urine  and  matters  vomited  only  when  they  contain  blood.  Heydenreich 
states  that  it  does  not  leave  the  body  in  the  ftcees. 

We  are  equally  in  doubt  as  to  the  maiuiei"  in  which  the  spirochseta 
etfects  entrance  into  the  body.  It  has  been  thought  that  it  jiassed  in 
with  the  inspired  air.  But  such  a  theory  presupposes  the  formation  of 
spores  and  their  drying  outside  of  the  body,  and  appears  to  be  contra- 
dicted by  the  readiness  with  which  the  disease  is  transmitted.  From 
studies  during  the  Breslau  epidemic  Litten  concluded  that  the  spiro- 
chfetcie  were  not  contained  in  the  drinking  water,  and  the  oi-ganisms  found 
bv  Carter  in  water  from  a  tank  in  Bombay,  though  similar  in  form, 
were  larger  than  those  seen  in  the  blood  of  relapsing  fever  })atients.  A 
manner  of  infection  which  has  not  received  attention,  and  which  seems 
upon  a  priori  grounds  not  unlikely,  is  the  introduction  of  the  organism 
or  its  spores  into  the  mouth  by  unclean  fingers.  The  rapid  dissemina- 
tion of  the  disease  in  filthy,  overcrowded  apartments  lends  weight  to 
this  supposition.  But,  whatever  may  be  the  channel  of  infection,  the 
important  fact  remains  that  relapsing  fever  is  directly  communicable 
from  person  to   person. 

MotschutkofFsky  has  shown  that  relapsing  fever  may  be  reproduced 
in  man  by  inoculation  Avith  the  blood  of  a  patient  ill  with  the  disease, 
and  several  instances  are  recorded  where  infection  followed  wounding 
the  hands  at  autopsies.  Koch  and  Carter  have  produced  relapsing  fever 
experimentally  in  monkeys  by  inoculation. 

Relapsing  fever  may  occur  at  any  age,  though  the  greater  niunber 
of  cases  have  been  met  with  between  the  ages  of  fifteen  and  twenty- 
five. 

Neither  sex  nor  season  has  any  influence  upon  the  development  of 
the  disease.  That  more  males  are  attacked  than  females  may  be  ac- 
counted for  by  the  fact  that  males  constitute  by  far  the  greater  proportion 
of  tramps  and  vagrants.  One  attack  does  not  afford  immunity  against 
the  disease. 

Pathological  Anatomy. — The  pathological  changes  caused  by  re- 
lapsing fever  are  in  the  main  those  of  acute  infectious  diseases  generally. 

The  spleen  is  enlarged  during  the  active  periods  of  the  disease,  some- 
times enormously,  and  is  dark  and  soft.  Not  infrequently  it  is  the  seat 
of  anaemic  infarctions  and  focal  necrosis.  According  to  Nikiforoff 
(Ziegler),  microscopic  examination  reveals  extensive  degeneration  of  the 
pulp  cells,  amounting  in  places  to  actual  necrosis,  and  the  formation  of 
fibrin  in  the  veins  of  the  pulp.  The  spirochsetse  are  found  in  consider- 
able numbers  in  the  areas  which  are  not  entirely  necrotic.  Hyperplasia 
of  the  spleen  pulp  occurs  in  other  places.  Abscesses  occasionally  form, 
and  may  give  rise  to  peritonitis.  Rupture  of  the  spleen  has  occurred 
in  some  cases,  followed  by  rapidly  fatal  syncope. 

The  kidneys  are  swollen,  especially  their  cortical  portion,  lighter  in 
color  than  normal  from  a  granulo-fatty  change  in  the  epithelial  cells, 
and  streaked  with  the  red,  congested  bloodvessels.  Not  infrequently 
the  cut  surface  shows  minute  hemorrhages  into  the  kidney  substance. 

The  heart  muscle  undergoes  parenchymatous  degeneration.  The 
fibres  lose  their  striation  and  their  nuclei  may  show  fragmentation. 


260  RELAPSING  FEVER. 

The  liver  is  enlarged  and  congested,  and  its  cells  present  parenchym- 
atous changes. 

The  stomach  and  intestines  may  present  a  moderate  grade  of  inflam- 
mation, as  evidenced  by  injection  of  their  vessels  and  minute  extravasa- 
tions of  blood  in  their  mucous  membranes. 

The  lymph  nodes  are  often  infiltrated  and  swollen,  but  are  rarely 
ulcerated. 

Symptoms. — Incubation. — The  period  of  incubation  in  relapsing 
fever  varies.  Cases  have  been  recorded  in  which  the  disease  apparently 
followed  Avithin  a  day  or  two  of  exposure  (Murchison),  and  others  where 
the  symptoms  did  not  present  themselves  for  tAvelve  or  fourteen  days. 
The  average  period  of  incubation  appears  to  be  five  to  seven  days. 
After  experimental  inoculation  of  apes  with  the  blood  of  relapsing  fever 
patients  the  disease  does  not  appear  until  several  days  have  elapsed,  and 
in  the  case  of  experimental  inoculation  in  the  human  subject  by 
MotschutkoiFsky  symptoms  did  not  follow  for  seven  days. 

Prodromata. — Relapsing  fever  is  rarely  preceded  by  prodromal 
symptoms.  If  they  occur,  they  last  only  a  day  or  two,  cluring  which 
time  the  patient  suffers  from  anorexia,  lassitude,  slight  headache,  or 
vertigo.  Generally,  the  disease  is  ushered  in  abruptly  by  rigors  or  a 
chill  of  moderate  severity. 

Invasion. — The  attack  usually  begins  during  the  day.  Patients  often 
can  tell  the  exact  hour  of  invasion,  and  not  infrequently  are  seized 
while  at  work.  Following  the  chill,  there  is  a  rapid  rise  of  temperature^ 
the  thermometer  registering  104°  to  106°  F.  by  the  evening  of  the  first 
or  second  day.  In  many  cases  there  is  a  rise  of  2°  F.  or  more  during 
the  chill.  Hyperpyrexia  in  relapsing  fever,  however,  is  not  dangerous. 
Accompanying  the  rise  in  temperature,  the  pulse  speedily  becomes  ac- 
celerated, reaching  110,  120,  or  even  a  greater  frequency.  It  is  full  and 
strong  at  first,  and  in  the  average  case  continues  good  throughout  the 
paroxysm,  but  may  become  feeble,  compressible,  and  even  dicrotic. 

Early  in  the  disease  the  patient  suffers  from  extreme  giddiness,  so 
that  he  is  unable  to  walk  or  even  stand,  and  often  takes  to  his  bed  from 
this  cause.  Headache  of  a  most  intense  nature  soon  appears,  and  distress- 
ing pains  occur  in  the  muscles  of  the  trunk  and  extremities,  especially 
severe  in  the  calves  of  the  legs.  The  severity  of  the  pains  sometimes 
increases  as  the  paroxysm  progresses.  Muscular  hypersesthesia,  particu- 
larly marked  over  the  gastrocnemii,  adds  to  the  suffering  of  the  patient. 
Cutaneous  hyperaesthesia  may  be  present,  especially  in  women. 
Pains  occur  also  in  and  about  the  joints,  though,  as  a  rule,  the  joints  are 
not  swollen.  Patients  sometimes  come  into  the  hospital  under  the  im- 
pression that  they  are  suffering  from  acute  articular  rheumatism. 

Nausea  and  vomiting  usher  in  a  certain  proportion  of  cases.  At  first 
the  contents  of  the  stomach  are  expelled,  and  later  mucus  and  regur- 
gitated bile. 

The  face  is  flushed,  but  not  dusky.  The  tongue  is  moist  and  coated 
with  a  whitish  fur.  Thirst  is  intense.  There  may  be  anorexia  or  the 
appetite  may  be  increased.  The  skin  becomes  slightly  jaundiced  during 
the  first  few  days,  and  in  certain  cases  the  color  deepens.  The  jaundice 
is  thought  to  be  due  to  catarrh  of  the  bile  ducts.  The  bowels  may  be 
free  or  constipated.     There  is  tenderness  in  the  hypochondriac  regions. 


SYMPTOMS.  261 

aiul  upon  percussion  the  liver  is  found  eularg^ed.  The  spleen  increases 
rapidly  and  markedly  in  size,  extending  well  below  the  free  border  of 
the  ribs.  It  increases  in  size  so  rapidly  that  the  enlargement  may  be 
noted  from  morning  to  evening  of  the  same  day. 

A  petechial  eruption  occurs  in  about  10  per  cent,  of  the  cases  (Mur- 
chison).  Herpes  labialis  and  sudaminal  vesicles  are  met  with  in  some 
cases. 

The  urine  presents  the  characters  common  to  febrile  conditions.  It  is 
diminished  in  amount,  of  dark  color,  and  of  higher  specific  gravity  than 
normal,  and  it  not  infrequently  contains  albumin.  Blood  may  be  pres- 
ent.    AVheu  the  jaundice  is  marked  the  urine  contains  bile  pigment. 

The  headache  often  diminishes,  but  the  pains  continue,  sometimes 
with  increasing  severity  as  the  disease  advances.  The  suffering  occa- 
sioned by  moving  causes  the  patients  to  lie  perfectly  still,  but  they  are 
not  apathetic.  They  are  sleepless,  but  only  because  of  the  pains. 
Cerebral  symptoms  are  not  marked  even  w^hen  there  is  hyperpyrexia. 
Occasionally,  however,  there  is  delirium.  The  temperature  remains  at 
about  the  height  it  reached  on  the  first  or  second  day,  with  a  diurnal 
variation  of  2'^  F.  or  more.  The  time  at  which  the  remission  occurs 
varies  in  different  individuals.  The  pulse  retains  its  frequency  or  is 
increased  somewhat. 

Crisis, — AVhen  these  symptoms  have  continued  about  a  week,  and 
with  apparently  alarming  severity,  the  crisis  comes.  It  may  occur  as 
early  as  the  fifth  or  be  delayed  until  the  fourteenth  day.  There  is  a 
sudden  fall  of  temperature  ordinarily  of  from  5.4°  to  10.8°  F.  (Lebert) 
to  the  normal  or  below"  it.  There  is  no  disease  in  which  the  temperature 
falls  so  suddenly.  Lebert  has  recorded  a  case  in  Avhich  the  fall  amounted 
to  12.6°  F.,  and  Murchison  another  in  which  it  amounted  to  14.4°  F. 
in  twelve  hours.  The  pulse  rate  diminishes  correspondingly,  dropping 
from  120  to  70.  Occasionally  it  falls  as  low  as  52  or  48  (Lebert).  The 
headache  and  pains  disappear,  the  tongue  becomes  clean,  and  the  patient 
passes  into  a  fairly  comfortable  state.  The  crisis  occurs  most  frequently 
in  the  night  or  early  morning.  On  the  evening  of  the  last  day  of  the 
paroxysm  the  temperature  may  rise  suddenly  as  much  as  4°  F.  Profuse 
sweating,  diarrhoea,  epistaxis,  or  the  menstrual  flow  not  infrequently 
occurs  at  the  crisis,  or  the  patient  may  become  wildly  delirious  imme- 
diately before  the  crisis,  and  be  perfectly  rational  after  it  has  passed. 

As  a  rule,  the  pulse  continues  a  little  above  the  normal,  and  is  espe- 
cially likely  to  be  accelerated  if  the  patient  attempts  to  get  out  of  bed, 
but  the  appetite  returns  and  he  improves  rapidly,  feeling  perfectly  well 
in  a  short  time.  If  he  is  in  an  hospital,  he  may  insist  upon  returning  to 
work.     But  his  apparent  recovery  is  of  short  duration. 

Relapse. — A  relapse  is  sure  to  follow  except  in  a  limited  number  of 
cases^.  It  usually  occurs  on  the  seventh  day  and  at  night.  It  may 
occur  earlier,  even  as  early  as  the  second  or  third  day.  The  symptoms 
return  with  all  their  severity.  The  temperature  rises  to  about  the 
height  it  attained  during  the  first  paroxysm,  the  pulse  becomes  acceler- 
ated, and  again  the  patient  suffers  from  the  headache  and  muscular 
pains.  The  duration  of  the  relapse  is  variable,  the  average  being  from 
three  to  five  days,  after  which  a  second  crisis  comes. 

At  times  when  the  first  paroxysm  is  mild  in  character  the  relapse  is 


262     '  RELAPSING  FEVER. 

severe,  and  vice  versa.  In  the  majority  of  cases  convalescence  is  estab- 
lished after  the  relapse,  but  two,  three,  or  even  more  relapses  may- 
occur. 

Sudden  collapse,  occurring  without  any  apparent  cause,  is  a  danger- 
ous and  usually  fatal  symptom  in  a  limited  number  of  cases.  The 
attack  may  have  been  mild  and  have  been  progressing  favorably,  when 
suddenly  symptoms  of  cardiac  failure  come  on.  These  may  occur  at  any 
period  of  the  disease,  but  are  most  likely  to  manifest  themselves  at  the 
first  or  second  crisis.  The  pulse  becomes  small,  rapid,  and  feeble,  the 
skin  is  bathed  in  a  cold  clammy  sweat,  and  the  patient  passes  into  a  state 
of  unconsciousness,  to  be  rapidly  followed  by  death.  In  some  cases  the 
pulse  gives  evidence  of  the  impending  cardiac  failure  a  day  or  so  before 
the  crisis,  but  in  others  there  may  be  no  indication  of  the  danger  until 
it  arrives.  Murchison  found  the  heart  fatty  and  dilated  in  three  cases 
where  it  was  examined  jDost-mortem.  In  other  cases  a  sudden  effort, 
such  as  getting  out  of  bed,  induces  cardiac  failure. 

Occasionally  there  is  a  pseudo-crisis  toward  the  end  of  the  first 
paroxysm.  The  temperature  falls  suddenly,  perhaps  below  the  normal, 
and  the  distressing  symptoms  abate.  But  about  twenty-four  hours  after- 
ward the  temperature  rises  to  104°  F.,  the  headache  and  the  pains 
return,  and  the  actual  crisis  is  delayed  for  twenty-four  or  forty-eight 
hours  longer.  According  to  Carter,  the  blood  during  these  attacks 
shows  the  presence  of  the  spirochsetse. 

Duration. — The  average  duration  of  relapsing  fever  is  from  eighteen 
to  twenty  days.  After  an  attack  patients  regain  their  health  slowly. 
Convalescence  is  long  and  tedious.  Even  when  the  disease  ends  with  a 
single  relapse  it  is  often  six  weeks  before  patients  can  resume  work, 
whereas  if  they  have  more  than  one  relajDse  the  return  to  health  is  much 
longer  delayed. 

Abortive  cases  occur  in  relapsing  fever  as  in  many  other  specific 
infectious  diseases.  Convalescence  may  be  established  after  a  light  first 
paroxysm,  or  there  may  be  a  relapse  of  short  duration.  In  either  case 
patients  recover  their  health  quickly. 

Griesinger  introduced  the  term  bilious  typhoid  to  include  what  he 
considered  a  distinct  type  of  fever  attended  by  jaundice  and  by  a  typhoid 
condition.  There  is  some  doubt,  however,  as  to  what  disease  he  was 
describing.  Since  there  is  a  form  of  relapsing  fever,  proved  to  be  such 
by  the  presence  of  the  spirocheetse  in  the  blood,  and  attended  by  jaundice 
and  a  continuance  of  the  pyrexia  between  the  paroxysms,  Murchison 
concluded  that  all  the  cases  described  by  Griesinger  were  of  this  nature. 
Equally  eminent  authorities,  however,  contend  that  bilious  typhoid  is 
the  disease  now  known  as  acute  infectious  jaundice.  (See  Weil's  Disease, 
page  945.) 

Complications  and  Sequels. — Lobar  pneumonia  is  the  most  com- 
mon of  the  serious  complications  of  relapsing  fever,  though  the  fre- 
quency with  which  it  occurs  varies  greatly  in  different  epidemics.  It 
develops,  as  a  rule,  during  the  paroxysm  or  the  relapse,  and  is  especially 
likely  to  involve  both  lungs.  Persons  of  intemperate  habits  are  most 
often  affected.  The  cases  may  be  mild  or  severe.  Pulmonary  gangrene 
follows  the  pneumonia  in  a  small  proportion  of  cases.  In  many  epi- 
demics this  complication  has  increased  the  mortality  rate  perceptibly. 


DIAGyOSTS.  263 

Bronchitis  is  perhaps  tho  most  fVeqiicnt  complication  of  relapsing 
fever.     Generally  it   is  mild  in  character. 

Abscesses  may  form  in  the  spleen  and  render  convalescence  slow  and 
tedious,  or  may  lead  to  a  fatal  termination  through  peritonitis  or  meta- 
static pvooenic  processes  in  other  parts  of  the  body.  Jlnpture  af  the 
sph'oi,  without  abscess  formation,  has  occurred,  accompanied  by  sudden 
and  intense  pain  in  the  splenic  region  and  followed  by  a  ra])idly  fatal 
syncope. 

Dysentery  is  a  dangerous  and  oftentimes  fatal  complication  in  certain 
epidemics. 

Meschede  states  t\vA.t  purulent  otitis  occurs  in  about  10  per  cent,  of  the 
cases.     One  or  both  ears  may  be  affected. 

Parotiditis  is  rare.     When  it  does  occur  the  inflammation  usually 
proceeds  to  suppuration  and  delays  convalescence. 
Epistaxis  may  be  a  dangerous  complication. 

Though  the  urine  in  relapsing  fever  not  infrequently  contains  traces 
of  albumin,  symptoms  of  kidney  disease  rarely  occur.  When  symptoms 
of  ursemia  do  appear  in  the  course  of  the  disease,  they  usually  depend 
upon  a  pre-existent  nephritis. 

Pregnant  women  always  abort  or  have  premature  labor  when  at- 
tacked with  relapsing  fever.  In  the  majority  of  instances  the  mother 
survives,  but  the  child  dies,  even  though  viable  when  born. 

Among  the  more  important  of  the  sequelae  of  relapsing  fever  is  a 
post-febrile  ophthalmia,  which  occurs  in  two  stages — an  amaurotic  and 
an  inflammatory  stage.  The  inflammation  may  involve  the  iris  alone  or 
the  iris  and  choroid  coat,  and  is  accompanied  by  intense  intraorbital 
pain.  Optic  neuritis  occasionally  occurs.  As  a  rule,  only  one  eye  is 
affected.  Loss  of  vision  not  infrequently  follows.  At  times  the  head- 
ache and  muscular  pains  persist  after  the  paroxysms  subside,  and  render 
convalescence  long  aud  tedious. 

Diagnosis. — Difliculty  in  recognizing  relapsing  fever  can  occur  only 
during  the  first  few  days  of  the  disease,  and  before  the  spirochsetae  have 
appeared  in  the  blood.  In  its  mode  of  onset  it  is  not  unlike  typhus 
fever,  yellow  fever,  and  smallpox.  But  with  the  exception  of  tA^Dhus 
fever,  fully  developed  cases  present  little  difficulty.  Epidemics  of  relaps- 
ing fever  and  typhus  fever  have  prevailed  at  the  same  time,  and  under 
these  circumstances  it  may  be  impossible  to  decide  which  disease  one 
has  to  deal  with  until  positive  eviclence  of  the  one  or  the  other  presents 
itself.  There  is  the  same  absence  of  prodromal  symptoms  in  both 
diseases,  the  same  abruptness  of  invasion,  the  same  rapid  rise  of  tem- 
perature. In  both  diseases  headache  and  muscular  pains  are  prominent 
early  symptoms.  But  in  typhus  fever  prostration,  in  relapsing  fever 
giddiness,  compels  the  patient  to  seek  his  bed.  In  typhus  fever  the  face 
is  dusky — in  relapsing  fever,  flushed.  In  typhus  fever  dulness  of  mtel- 
lect  accompanies  the  headache — in  relapsing  fever  the  mind  remains 
clear.  And  by  the  third  day,  often  earlier,  the  spirochaetse  may  be  found 
in  the  blood  in  relapsing  fever. 

Peogxosis. — Relapsing  fever  is  not  a  dangerous  disease,  despite  the 
severity  of  its  symptoms,  and  is  not  often  a  cause  of  death  in  itself.  A 
fatal  termination  rarely  occurs  except  from  sudden  collapse  or  some 
complication.     The  extreme  limits  of  the  mortality  rate  in  the  epidemics 


264  RELAPSING  FEVER. 

which  have  occurred  are  2  and  11  per  cent.  The  higher  of  these  per- 
centages has  occurred  when  complications  were  frequent.  Pneumonia 
is  the  complication  to  be  most  feared,  with  the  exception  of  pygemia  fol- 
lowing splenic  abscesses  and  dysentery.  Eupture  of  the  spleen  may  be 
regarded  as  an  accident,  and  needs  scarcely  be  taken  into  consideration 
in  forming  a  prognosis.  Even  though  pneumonia  occurs,  the  case  may 
terminate^  favorably.  Eelapsing  fever  is  more  serious  in  chronic  alco- 
holic subjects  and  in  old  people. 

Cardiac  thrombosis  is  stated  to  be  a  cause  of  death  in  some  cases, 
especially  in  persons  whose  previous  health  has  been  bad  or  in  those  of 
intemperate  habits.  The  cardiac  thrombosis  is  probably,  however,  only 
a  concomitant  of  death,  the  actual  cause  being  a  degenerated  myo- 
cardium. 

Treatment. — The  treatment  of  relapsing  fever  is  wholly  expectant. 
The  use  of  various  drugs  has  been  proposed  with  a  view  to  abort  or 
modify  the  course  of  the  disease,  but  all  alike  have  proved  unsuccessful. 
We  are  powerless  to  do  more  than  combat  the  symptoms  as  they  arise. 
Quinine  is  of  no  avail. 

The  headache  which  is  such  a  pronounced  feature  at  the  onset  of  the 
disease  may  be  relieved  or  diminished  in  intensity  by  the  application  of 
an  ice-bag  to  the  head.  If  this  fails,  morphine  should  be  employed  in 
sufficient  quantity  to  relieve  the  headache  and  enable  the  patient  to 
sleep.  For  relief  of  the  muscular  pains  Lebert  recommends  rubbing 
with  a  mixture  of  equal  parts  of  oil  and  spirit  of  chloroform.  The 
bowels  should  be  moved  at  the  commencement  of  the  attack  with  a 
single  dose  of  calomel  and  sodium  bicarbonate,  or  Avith  small  doses  of 
calomel  repeated  every  half  hour  until  a  grain  and  a  half  or  two  grains 
have  been  given,  and  followed  by  a  saline  in  the  morning.  Later  in  the 
disease  hydragogue  cathartics  may  be  administered  to  keep  the  bowels 
open,  but  care  should  be  taken  not  to  push  their  action  too  far.  If  there 
is  diarrhoea,  it  should  be  stoj)ped  by  the  use  of  opium,  bismuth  sub- 
nitrate,  and  astringents. 

The  diet  should  consist  of  nutritious  and  easily  digested  foods. 
Further  than  this,  no  special  precautions  need  be  taken  in  the  majority 
of  cases.  Should  the  j)atient's  appetite  be  voracious,  there  is  no  objec- 
tion to  gratifying  it  within  reasonable  limits.  Patients  who  are  badly 
nourished  and  ill  fed  should  be  placed  ujjon  a  generous  diet  imme- 
diately. 

Sponging  the  body  with  tepid  or  cold  water  or  the  use  of  the  cold 
bath  is  the  best  means  of  controlling  the  temperature.  Internal  anti- 
pyretics are  not  to  be  recommended,  because  of  their  depressing  action 
on  the  heart.  If  delirium  is  present,  the  bromides  and  chloral  should 
be  used  to  control  it. 

Symptoms  of  uraemia  demand  the  active  employment  of  measures  to 
promote  the  excretion  of  urea.  Murchison  advises  that  one  or  two 
drachms  of  potassium  nitrate,  one  drachm  of  dilute  nitric  acid,  and 
half  a  drachm  of  the  tincture  of  digitalis  be  taken  in  divided  doses  dur- 
ing the  twenty-four  hours.  The  infusion  of  digitalis,  combined  with 
potassium  acetate,  potassium  citrate,  or  sweet  spirits  of  nitre,  will  be 
useful  for  this  purpose.  Water  should  be  taken  freely,  and  copious 
perspiration  should  be   induced   by  means  of  hot-air  or  vapor  baths. 


TREATMENT.  265 

Hv(lragot>ue  cathartics  may  be  used  to  cause  a  vicarious  excretion  of 
urea  by  the  intestines. 

In  old  and  otherwise  debilitated  subjects  stimulation  with  alcohol 
should  be  commenced  at  the  first  indication  of  enfeebled  heart  action. 
Sudden  collapse  demands  the  free  hypodermic  use  of  stimulants,  such  as 
ether,  nitroglycerin,  strychnine,  and  camphorated  oil  (camphor  1  part, 
olive  oil  8  parts). 

During  the  intermission  the  patient  must  be  watched  for  fear  that 
some  complication  may  develop.  It  may  not  be  necessary  to  confine 
him  to  bed,  but  it  is  advisable  that  he  should  remain  indoors.  If  com- 
plications arise,  they  must  receive  appropriate  treatment. 

Parotiditis  should  be  treated  with  hot  or  cold  applications,  whichever 
is  the  more  agreeable  to  the  patient.  As  soon  as  suppuration  is  detected 
a  free  incision  must  be  made,  the  pus  evacuted,  and  the  wound  dressed 
antiseptically. 

The  treatment  during  convalescence  may  be  summed  up  as  follows  : 
a  generous  diet,  tonics,  and  a  moderate  amount  of  alcohol  with  meals. 
Bitter  tonics  before  meals,  ale,  porter  or  port  wine  with  meals,  and  iron 
after  meals  will  hasten  the  recovery  of  the  patient. 


YELLOW  FEVER. 

By  GEORGE  M.  STERNBERG,  M.  D.,  LL.D. 


Definition. — Yellow  fever  is  a  specific  infectious  disease  in  which 
one  attack,  as  a  rule,  protects  from  subsequent  attacks.  The  febrile 
paroxysm  inaugurating  an  attack  usually  lasts  from  two  to  five  days, 
and  is  followed  by  a  period  of  great  depression  of  the  vital  powers, 
during  which  there  is  a  tendency  to  suppression  of  urine  and  to  passive 
hemorrhage  from  mucous  membranes.  The  urine  contains  albumin, 
the  skin  has  a  more  or  less  pronounced  icteric  hue,  and  in  fatal  cases 
"black  vomit"  is  usually  ejected  before  death. 

Etiology. — Yellow  fever  is  not  a  contagious  disease  in  the  strict 
sense  of  the  word — ^.  e.  it  is  not  usually  contracted  by  contact  with  the 
sick — but,  as  in  cholera  and  in  typhoid  fever,  the  infectious  element 
multiplies  in  the  body  of  the  sick,  and  epidemics  usually  extend  from 
foci  of  infection  originating  from  the  introduction  of  cases  of  the  disease 
into  localities  previously  free  from  it.  Although  not  definitely  demon- 
strated, it  seems  extremely  probable  that  this  occurs  in  the  same  way  as 
in  the  diseases  mentioned — viz.  through  the  excreta.  This  is  indicated 
by  the  fact  that  while  contact  with  the  sick  as  nurse  or  physician  does 
not  lead  to  infection,  the  soiled  clothing  and  bedding  of  yellow  fever 
patients  may  induce  an  attack  in  those  who  handle  them,  and  may  orig- 
inate an  epidemic  when  transported,  without  having  been  disinfected, 
to  another  locality.  When  yellow  fever  prevails  as  an  epidemic,  physi- 
cians and  nurses  are  very  liable  to  contract  the  disease  because  they  are 
necessarily  exposed  in  the  infected  localities,  not  because  they  come  in 
contact  with  sick.  This  is  an  important  fact  which  is  established  by 
abundant  evidence,  and  yet  it  is  denied  by  many  physicians  living  in 
cities  where  the  disease  is  endemic,  who  insist  that  the  disease  is  trans- 
mitted by  personal  contagion.  This  opinion  no  doubt  arises  from  the 
mistaken  assumption  that  successive  cases  in  the  same  house  or  neigh- 
borhood are  directly  connected  in  their  etiology  one  with  another,  as 
commonly  occurs  in  the  strictly  contagious  diseases — e.  g.  smallpox  or 
measles.  On  the  contrary,  they  all  contract  the  disease  from  a  common 
and  external  source — the  infected  locality.  It  is  well  known  that  cer- 
tain local  and  climatic  conditions  are  essential  for  the  development  of 
the  infectious  agent  ("  germ  ")  outside  of  the  human  body,  and  the  con- 
sequent establishment  of  an  external  focus  of  infection  and  the  epidemic 
prevalence  of  the  disease.  On  the  contrary,  we  have  numerous  obser- 
vations which  show  that  the  introduction  of  cases  or  of  fomites  into 
localities  where  conditions  are  not  favorable  for  the  external  multipli- 
cation of  the  infectious  agent  does  not  result  in  the  occurrence  of  other 

267 


268  YELLOW  FEVER. 

cases  in  the  vicinity,  as  would  follow  if  the  disease  was  propagated  by 
personal  contact.  This  is  well  illustrated  in  the  city  of  Mexico,  and  at 
Petropolis,  a  health  resort  in  the  mountains  a  few  hours'  journey  from 
Rio  de  Janeiro.  Yellow  fever  is  endemic  at  the  sea-coast  city  of  Vera 
Cruz,  and  during  the  summer  months  persons  from  the  interior  who 
visit  this  infected  locality  are  very  likely  to  contract  yellow  fever. 
Persons  coming  from  the  city  of  Mexico  for  a  short  visit  on  business 
or  pleasure  frequently  fall  sick  with  the  disease  after  their  return  to 
their  homes,  but  they  never  communicate  it  to  those  associated  with 
them,  and  no  focus  of  infection  is  developed  as  a  result  of  their  pres- 
ence in  the  crowded  and  rather  dirty  capital  city,  which  is  located  at  an 
elevation  above  that  at  which  the  infectious  agent  is  able  to  propagate 
itself  outside  of  the  body  of  the  sick.  The  same  is  true  as  regards 
Petropolis,  which  is  a  health  resort  during  the  epidemic  season  for 
unacclimated  persons  residing  in  Rio  de  Janeiro.  Communication 
between  the  two  places  is  unrestricted,  and  individuals  exposed  in  Rio 
not  infrequently  fall  sick  in  Petropolis,  but  they  never  communicate 
the  disease  to  others.  This  is  also  the  experience  of  physicians  in 
charge  of  hospitals  located  in  healthy  suburbs  of  infected  towns.  So 
long  as  the  hospital  and  its  vicinity  remain  uninfected,  cases  do  not 
originate  in  its  wards  as  a  result  of  the  admission  of  yellow  fever  cases, 
although  these  may  be  cared  for  by  susceptible  attendants  and  treated 
in  the  same  wards  with  patients  suffering  from  other  diseases. 

"  In  his  report  upon  the  camps  established  near  Memphis  in  the 
epidemics  of  1878  and  1879,  Colonel  Cameron  makes  the  following 
statement :  '  It  was  found  necessary  that  the  officer  in  authority  should 
set  an  example  of  constant  indifference  to  attack  in  order  to  appease,  as 
far  as  possible,  the  constant  anxiety  of  the  population  under  his  charge. 
Especially  was  this  true  in  1878,  as  depopulation  went  on  slowly  that 
year,  and  infected  people  poured  daily  into  the  camps  from  the  more 
pestilential  portions  of  the  city.  Very  many  reached  camp  Avith  the 
fever  on  them,  so  that  as  many  as  seventeen  persons  fell  victims  in  one 
night,  not  a  few  in  their  tents.  In  no  instance,  however,  did  they  com- 
municate the  disease  to  their  families  or  bed-fellows,  as  far  as  could  be 
traced.' 

"  In  the  same  epidemic  (1878),  Dr.  Minor  reports  that  over  thirty 
cases  were  discovered  among  refugees  in  Cincinnati,  O.,  and  says  :  '  No 
physician  or  nurse  contracted  the  disease,  and  in  no  instance  did  it 
exhibit  any  tendency  to  spread.'  The  same  was  true  in  Nashville  the 
same  year ;  twenty  imported  cases  occurred  in  different  parts  of  the 
city  without  any  local  cases  resulting  from  them.  Evidence  of  this 
kind  could  be  extended  to  fill  a  volume  ;  but  sufficient  has  been  pre- 
sented to  establish  the  statement  made,  and  the  reader  may  be  referred 
to  the  '  proofs  of  non-contagion '  in  the  second  volume  of  the  classical 
work  of  La  Roche  (pp.  236-566.)"  ' 

Formerly  many  of  those  who  denied  that  yellow  fever  could  be 
transmitted  by  personal  contagion  assumed  that  it  could  not  be  trans- 
mitted, and  ascribed  outbreaks  to  local  insanitary  conditions,  together 
with  the  favorable  meteorological  conditions  recognized  as  essential  for 

^Quoted  from  the  writei-'s  article  on  Yellow  Fever  in  Wood's  Mefereiice  Handbook 
of  the  Medical  Sciences,  vol.  viii.  p.  55. 


ETIOLOGY.  269 

the  development  of  an  epidemie.  These  l)elievers  in  the  "  loeal  oritrin  " 
of  the  disease  denied  the  neeessity  for  isolation  of  the  siek  and  qnaran- 
tine  restrictions,  while  the  "  contagionists "  insisted  upon  the  exotic 
origin  of  the  disease  and  its  transmissibility  by  ships,  persons,  and 
fomites.  That  this  latter  view  is  correct  is  beyond  question,  although, 
as  we  have  shown,  the  disease  is  not  usually  communicated  by  personal 
contact,  and  favorable  external  conditions  are  as  essential  for  the  devel- 
opment of  an  epidemic  as  is  the  introduction  of  the  specific  infectious 
agent. 

As  heretofore  suggested,  the  yellow  fever  patient,  like  the  patient 
with  cholera  or  typhoid  fever,  probably  carries  "  germs  "  in  his  intes- 
tine which  are  capable  of  abundant  development  outside  of  the  body 
when  loeal  conditions  are  favorable.  As  to  the  specific  germ,  we  have 
no  exact  information,  inasmuch  as  all  attempts  to  demonstrate  its  jDi'es- 
ence  in  the  bodies  of  the  sick  or  to  isolate  it  from  the  excreta  have  been 
unsuccessful.  But  the  conditions  favorable  for  its  development  are 
well  established. 

Yellow  fever  is  endemic  at  certain  places  upon  the  sea-coast  of  Xorth 
and  South  America  and  the  islands  in  the  Gulf  of  Mexico,  and  from 
these  places  it  is  disseminated  by  human  intercourse.  Epidemics  com- 
monly develop  as  a  result  of  the  arrival  from  an  infected  locality  of  an 
individual  who  has  been  taken  sick  en  route  or  after  his  arrival.  But 
they  may  originate  from  the  introduction  of  infected  articles,  independ- 
ently of  any  imported  case.  The  origin  of  several  epidemics  has  been 
traced,  with  great  probability,  to  the  unloading  of  earth  ballast  from 
the  vicinity  of  an  infected  city  upon  the  wharves  of  a  healthy  seaport 
during  the  season  favorable  for  the  development  of  the  disease. 

As  a  rule,  some  time  elapses  after  the  introduction  of  a  case  or 
of  "  fomites  "  before  the  outbreak  of  a  local  epidemic.  This  interval 
varies  according;  as  local  conditions  are  favorable  or  otherwise  for  the 
development  of  the  infectious  agent. 

Yellow  fever  is  essentially  a  disease  of  the  sea-coast,  and  especially 
of  large  cities  in  an  unsanitary  condition,  but  when  circumstances  are 
favorable  it  may  extend  into  the  interior,  following  routes  of  travel,  and 
especially  navigable  rivers. 

It  is,  however,  confined  to  the  lower  levels  even  in  tropical  or  sub- 
tropical regions.  In  the  Antilles  the  disease  rarely  prevails  at  an  alti- 
tude above  700  feet.  In  Mexico  the  cities  of  Orizaba,  Jalapa,  and 
Puebla,  which  are  more  than  3000  feet  above  the  sea  level,  have  never 
suffered  from  the  disease,  although  they  have  unrestricted  communication 
with  the  infected  seaport.  Vera  Cruz.  In  Spain,  where  several  severe 
epidemics  have  occurred,  the  disease  has  rarely  prevailed  at  an  altitude 
above  1000  feet.  The  epidemic  at  Madrid  (altitude  2000  feet),  which 
occurred  in  1878,  was,  how^ever,  an  exception  to  this  rule.  In  the 
United  States  a  severe  epidemic  occurred  at  Chattanooga,  Tenn.,  in 
1878.  This  town  has  an  altitude  of  745  feet,  which  is  the  highest 
point  at  which  the  disease  has  prevailed  in  this  country. 

Temperature  is  an  essential  factor  in  determining  the  prevalence  of 
yellow  fever  in  those  places  where  it  is  endemic  and  in  the  establish- 
ing of  new  centres  of  infection.  Although  the  disease  prevails  to  some 
extent  throughout  the  year  in  the  cities  of  Havana,  Vera  Cruz,  and 


270 


YELLOW  FEVER. 


Rio  de  Janeiro,  it  is  especially  prevalent  during  the  hot  season  in  these 
cities,  and  its  epidemic  extension  occurs  only  in  the  summer  months. 
The  seasonal  prevalence  in  the  city  of  Havana  is  shown  in  the  follow- 
ing table,  compiled  by  Chaille  :  ^ 

Mortality  from  Yellow  Fever  in  the  City  of  Havana  for  Ten  Years,  1870 
to  1879,  inclusive  {^Chaille). 


Month. 


January 
February- 
March     . 
April 
May    .    . 
June    .    . 
July    .    . 
August    . 
September 
October  . 
November 
December 


1870. 


4 

4 

6 

14 

66 

112 

201 

91 

77 

49 

35 


18 

23 

12 

34 

91 

201 

234 

138 

72 

55 

51 

42 


1872. 


1873. 


32 
23 

27 

37 

127 

378 

416 

127 

35 

28 

5 


Total I  665     991     515  1244  1425  1001  il619  1374  1559  11444 


1874. 


7 

4 

18 

22 

85 

172 

361 

416 

186 

91 

42 

21 


1875. 


16 
16 
32 
34 


1876. 


32  103 

142  1  292 

187  675 

144'  250 

102  97 


109 
105 

82 


1877. 


9 
11 

8 

16 

143 

249 
285 
234 
185 
150 
76 


1878. 


26 

13 

5 

28 

33 

184 

304 

374 

179 

106 

33 

34 


1879. 


11 

13 

6 

13 

40 

237 

475 

417 

148 

44 

31 


In  places  which  have  a  mean  winter  temperature  below  65°  F.  the 
disease,  when  introduced,  cannot  establish  itself  as  an  endemic.  The 
development  of  an  epidemic  requires  a  temperature  of  75°  to  80°  F., 
maintained  for  some  time,  and  upon  the  approach  of  cool  weather  the 
progress  of  the  disease  is  checked.  When  the  temperature  falls  below 
the  freezing  point  it  is  usually  completely  arrested,  and,  as  a  rule,  the 
disease  does  not  recur  during  the  succeeding  summer  unless  it  is  again 
introduced.  Epidemics  may  terminate  before  the  occurrence  of  cold 
weather  simply  because  all  susceptible  persons  in  the  infected  area  have 
suffered  an  attack  of  the  disease.  Under  these  circumstances  the  con- 
tinued activity  of  the  morbific  element  ("  germ  ")  is  shown  when  "  un- 
acclimated "  persons  venture  to  visit  the  infected  locality ;  and  many 
lives  have  been  sacrificed  by  the  premature  return  of  refugees  to  their 
homes  in  the  belief  that  they  could  safely  do  so,  as  no  new  cases  had 
recently  occurred  in  the  pest-stricken  town. 

Atmospheric  moisture  and  precipitation  influence  the  development 
of  yellow  fever  epidemics,  and  in  arid,  desert  regions  the  disease  is 
unknown.  But  while  a  certain  amount  of  atmospheric  humidity  and 
soil  moisture  is  essential,  the  disease  has  sometimes  committed  its 
greatest  ravages  during  unusually  dry  seasons.  Heavy  rains  by  puri- 
fying the  atmosphere  and  washing  away  accumulations  of  filth  may 
exercise  a  favorable  influence  upon  the  progress  of  an  epidemic.  The 
trade  winds  of  the  tropics,  and  strong  sea-breezes  in  general,  are  bene- 
ficial from  a  sanitary  point  of  view,  and  places  exposed  to  their  con- 
tinuous action  rarely  suifer  from  the  disease  under  consideration.  They 
dilute  and  carry  away  the  poisonous  emanations  from  insanitary  places, 
and  refresh  and  invigorate  those  who  inhabit  localities  exposed  to  their 
action. 


^  Report  to  the  National  Board  of  Health,  Washington,  1880. 


SANITARY  CONDITIONS— BACTERIOLOGY.  271 

The  wind  has  little  to  do  with  the  dissemination  of  the  disease. 
This  is  shown  by  the  faet  that  vessels  which  anchor  some  distance  from 
the  shore  in  the  vicinity  of  infected  places  do  not  suffer  i'rom  the  disease 
so  long-  as  they  are  kept  in  a  good  sanitary  condition  and  unacclimatized 
members  of  the  crew  are  not  permitted  to  go  on  shore,  while  vessels 
lying  at  the  wharves  are  very  liable  to  become  infected. 

The  board  of  experts  appointed  by  Congress  to  investigate  the  epi- 
demic of  1878  arrived  at  the  following  conclusion  :  "We  know  of  no 
instance,  either  from  our  own  observations  or  from  i\\Q  published  records 
of  yellow  fever,  in  which  it  has  been  established  that  the  disease  has 
been  carried  to  any  considerable  distance  by  atmospheric  currents  or  by 
any  modes  or  vehicles  of  conveyance  other  than  those  connected  with 
human  traffic  and  travel." 

Sanitary  Conditions. — When  the  infectious  agent  is  introduced 
by  the  sick  or  by  means  of  fomites  to  localities  in  the  "  yellow  fever 
zone "  during  the  season  favorable  for  the  epidemic  prevalence  of  the 
disease,  its  propagation  without  doubt  depends  largely  upon  local  insan- 
itary conditions,  and  it  is  doubtful  whether  it  could  effect  a  lodgement 
in  a  clean  and  well  paved  city.  Its  epidemic  prevalence  in  New  York 
and  Philadelphia  during  the  latter  part  of  the  last  and  the  early  part 
of  the  present  century  was  during  a  period  when  these  cities  were  for 
the  most  part  unpaved,  unsewered,  and  unclean.  And  it  is  in  similar 
localities  in  the  cities  now  most  subject  to  invasion  that  it  usually  first 
appears  and  most  persistently  remains.  In  Havana,  Rio  de  Janeiro, 
and  other  endemic  foci  of  the  disease  it  is  especially  prevalent  in  low- 
lying,  filthy  districts  with  unpaved  streets.  Organic  matter  of  animal 
origin  in  a  state  of  decomposition  appears  to  afford  a  favorable  nidus 
for  the  germ,  and  the  accumulation  of  fecal  matter  in  exposed  situations 
is  favorable  to  the  development  of  an  epidemic.  Reasons  have  already 
been  given  for  the  view  that  the  excreta  of  the  sick  contain  the  specific 
infectious  agent.  Dr.  Parkes,  the  English  hygienist,  maintained  the 
fecal  origin  of  the  disease.  He  says  :  "  To  use  a  convenient  phrase, 
yellow  fever,  like  cholera  and  typhoid  fever,  is  a  fecal  disease.  And 
here  we  find  the  explanation  of  its  localization  in  the  West  India  bar- 
racks in  the  olden  time.  Round  every  barrack  there  were  cesspits,  often 
open  to  sun  and  air.  Every  evacuation  of  healthy  and  sick  men  was 
thrown  into,  perhaps,  the  same  places." 

One  method  by  which  infectious  material  may  be  transported  from 
such  exposed  filth-beds  to  the  stomach  of  individuals  living  in  the 
vicinity  has  recently  attracted  considerable  attention  in  connection  with 
the  propagation  of  cholera.  This  is  through  the  agency  of  flies,  which 
may  come  directly  from  a  cesspool  to  the  kitchen  or  dining-room,  and 
there  contaminate  articles  used  for  food  or  drink.  In  this  connection, 
however,  it  is  well  to  call  attention  to  the  fact  that  the  epidemic  preva- 
lence of  the  disease  has  never  been  shown  to  depend  upon  the  use  of  a 
contaminated  water  supply,  as  is  the  case  in  cholera  and  typhoid  fever. 
In  cities  having  a  common  water  supply  the  disease  is  not  generally 
diffused  at  the  outset  of  an  epidemic,  but  it  extends  rather  slowly  from 
certain  infected  foci  to  which  it  has  been  introduced  in  the  first  instance 
or  subsequently. 

Bacteriology. — We  have  seen  that  the  development  of  a  yellow 


272  YELLOW  FEVER. 

fever  epidemic  depends  upon  conditions  external  to  the  human  body- 
relating  to  temperature,  filth  accumulation,  etc.,  and  in  the  present  state 
of  science  we  are  justified  in  the  inference  that  the  specific  infectious 
agent  which  multiplies  in  presence  of  such  conditions  is  a  living  micro- 
organism of  some  kind.  But  the  morphological  and  biological  charac- 
ters of  this  hypothetical  germ  have  not  yet  been  demonstrated.  This 
assertion  is  based  upon  the  personal  investigations  of  the  writer  made 
in  Brazil,  in  Cuba,  in  Mexico,  and  in  the  United  States  in  accordance 
with  an  act  of  Congress  (1887)  authorizing  such  an  investigation.  In 
my  report^  of  these  investigations  I  have  formulated  my  conclusions  as 
follows  : 

"  The  most  approved  bacteriological  methods  fail  to  demonstrate  the 
constant  presence  of  any  particular  micro-organism  in  the  blood  and 
tissues  of  yellow  fever  cadavers. 

"The  micro-organisms  which  are  sometimes  obtained  in  cultures 
from  the  blood  and  tissues  "  (immediately  after  death)  "  are  present  in 
comparatively  small  numbers,  and  the  one  most  frequently  found 
(Bacillus  coli  communis)  is  present  in  the  intestine  of  healthy  indi- 
viduals ;  consequently  its  occasional  presence  cannot  have  any  etiolog- 
ical import 

"  Having  failed  to  demonstrate  the  presence  of  a  specific  germ  in 
the  blood  and  tissues,  it  seems  probable  that  it  is  to  be  found  in  the 
alimentary  canal,  as  is  the  case  in  cholera.  But  the  extended  researches 
made,  and  recorded  in  the  present  report,  show  that  the  contents  of  the 
intestine  of  yellow  fever  cases  contain  a  great  variety  of  bacilli,  and  not 
a  nearly  pure  culture  of  a  single  species,  as  is  the  case  in  recent  and 
typical  cases  of  cholera. 

"  Comparatively  few  liquefying  bacilli  are  found  in  the  faeces  dis- 
charged during  life  or  in  the  intestinal  contents  collected  soon  after 
death  from  yellow  fever  cadavers 

"  Some  of  the  micro-organisms  present  in  the  dejecta  of  yellow  fever 
patients,  as  shown  by  stained  smear  preparations,  have  not  developed  in 
the  cultures  made,  either  aerobic  or  anaerobic.  One  extremely  slender, 
filiform  bacillus,  which  can  only  be  seen  with  high  powers,  and  which 
is  quite  abundant  in  some  of  my  preparations,  has  never  been  obtained 
in  the  cultures  made,  and  no  doubt  there  are  others  in  the  same  cate- 
gory. 

"  That  the  yellow  fever  germ  is  strictly  anerobic,  or  that  it  will  only 
grow  in  a  special  nidus,  may  be  inferred  from  certain  facts  relating  to 
the  extension  of  epidemics." 

It  may  eventually  be  found  that  the  micro-organism  which  produces 
this  disease  belongs  to  an  entirely  different  group  from  the  bacteria  :  we 
are  disposed  to  believe,  however,  that  it  is  an  anaerobic  bacillus  which 
multiplies  in  the  intestines  or  in  fecal  accumulations  outside  the  body, 
and  which  produces  a  deadly  toxin  (toxalbumin  ?)  to  which  the  phe- 
nomena of  the  disease  are  due. 

In  view  of  the  facts  heretofore  recorded  and  the  conclusions  reached 
as  a  result  of  experimental  investigations  it  is  evident  that  the  dejecta 
of  yellow  fever  patients  should  be  regarded  as  infectious  material,  and 

1  Report  on  the  Etiology  and  Prevention  oj  Yellow  Fever,  Government  Printing  OiEce, 
Washington,  1890. 


SUSCEPTIBILITY   AM)  IMMUMTY.  273 

should  never  be  thrown  into  privy  vaults  or  u]ion  tiic  soil  until  they 
have  been  completely  disiufeoted. 

SlTSCEPTlBiLiTY  AND  IMMUNITY. — When  vellow  fcver  prevails  as 
an  epidemic  all  persons  exposed  \vithiu  the  int'eeted  area  who  have  not 
previously  suflt'ered  an  attack  are  liable  to  contract  the  disease.  But  there 
is  considerable  diti'erence  in  the  susceptibility  of  individuals,  and  the 
negro  race  is  generally  believed  to  be  less  susceptible  than  the  white. 
This  is  manifested,  however,  by  the  comparatively  mild  character  of  the 
attack  rather  than  by  an  immunity  from  the  disease.  According  to  La 
Roche,  the  mortality  among  the  whites  on  the  island  of  Jamaica  was  102 
per  1000,  and  among  the  blacks  8  per  1000  ;  in  the  Bahamas  the  mor- 
tality of  the  whites  was  59  per  1000,  that  of  the  blacks  5.6  per  1000. 
In  the  great  epidemic  of  1878  the  negroes  appear  to  have  furnished  a 
considerable  proportion  of  the  cases,  and  in  certain  localities  the  mortal- 
ity among  them  was  considerable.  Thus  at  Brownsville  (Tenn.)  162 
cases  with  21  deaths  occurred  among  the  colored  population ;  at  Chatta- 
nooga, in  a  total  of  685  cases,  429  were  colored  and  256  white,  while 
the  mortality  among  the  blacks  was  46  and  among  the  whites,  118  ;  at 
Decatur  (Ala.)  64  cases  and  28  deaths  occurred  among  the  whites,  and 
186  cases  with  21  deaths  among  the  blacks.  The  natives  of  northern 
latitudes  are  generally  believed  to  be  more  susceptible  than  those  born 
in  tropical  or  subtropical  countries,  and  the  mortality  among  the  fair- 
skinned  natives  of  the  North  is  higher  than  among  natives  of  Southern 
Europe.  Blair,  as  a  result  of  observations  made  in  Guiana,  says  : 
"  The  lower  the  winter  temperature  in  the  native  country  of  those 
attacked,  the  more  severe  w^as  their  sickness  ;  so  that,  wdiile  the  mor- 
tality among  West  Indians  amounted  to  only  6.9  per  cent,  of  the  sick, 
it  rose  to  17.1  among  the  Italians  and  French,  19.3  among  the  English, 
20.2  among  the  Germans  and  Dutch,  and  27.7  among  the  Scandinavians 
and  Russians." 

The  mortality  among  the  indigenous  races  of  the  West  Indies  and 
of  those  parts  of  North  and  South  America  in  which  the  disease  pre- 
vails occasionally  or  habitually,  and  of  Mongolians  living  in  these 
regions,  is  also  less  than  among  the  whites  ;  but  none  of  these  races 
have  an  immunity  from  attack. 

A  single  attack  of  yellow  fever  usually  protects  from  subsequent  at- 
tacks, especially  if  the  individual  continues  to  reside  in  one  of  the  endemic 
foci  of  the  disease.  While  second  attacks  are  comparatively  rare,  and 
some  authors  of  experience  have  asserted  in  positive  terms  (Blair  and 
others)  that  they  never  occur,  there  is  ample  evidence  that  one  attack 
is  not  always  protective.  Thus,  "Dr.  Jackson  states  that  in  Spain, 
during  the  epidemic  of  1820,  20  Avell  authenticated  instances  came 
within  his  knowledge  of  persons  being  attacked  Mdio  had  had  the  dis- 
ease before."  Dr.  Wragg,  speaking  of  the  epidemic  in  Charleston  in 
1854,  says  :  "  Six  of  these  w^ere  so  well  proved  as  to  admit  of  no  doubt 
on  the  subject.  Some  of  the  patients  were  identified  as  having  gone 
through  the  fever  in  this  (the  Roper)  hospital  in  1852,  throwing  up 
black  vomit  on  both  occasions  "  (La  Roche).  Dr.  Rush  also  observed 
second  attacks  in  Philadelphia  in  persons  who  had  suffered  a  compara- 
tively mild  first  attack. 

In  localities  such  as  Havana  and   Rio   de    Janeiro,  w^here  yellow 

Vol.  I.— 18 


274  YELLOW  FEVER. 

fever  has  established  itself  as  an  endemic  disease,  the  adult  native  pop- 
ulation enjoys  an  immunity  which  is  almost  absolute,  and  has  been 
supposed  to  be  hereditary.  This  view,  until  recently,  was  generally 
accepted  by  physicians  residing  in  these  endemic  foci  of  the  disease. 
There  is,  however,  accumulating  evidence  that  the  immunity  enjoyed  by 
"Creoles"  is  not  inherited,  but  results  from  a  mild  and  usually  unrecog- 
nized attack  during  infancy  or  childhood.  Dowler,  writing  of  the  epi- 
demic of  1853  in  New  Orleans,  says  :  "  Many  creole  children  had, 
during  the  epidemic  of  1853,  a  fever,  a  slight  fever — yellow  fever,  if 
vou  please,  known  as  such  rather  by  the  coexistence  of  the  epidemic 
than  from  any  severe  symptoms  among  these  children — a  slight  fever 
never  yet  described,  having  generally  but  one  paroxysm,  lasting  from 
six  hours  to  one,  two,  or  three  days,  scarcely  ever  requiring  medication. 
That  a  few  of  these  cases  acquired  an  alarming  violence,  and  even 
proved  fatal,  is  most  true,  most  deplorable." 

Hinemann  writes  with  reference  to  Vera  Cruz  :  "  Until  lately  the 
phvsicians  and  people  of  Vera  Cruz  supported  with  fanaticism  the 
dogma  that  natives  were  absolutely  exempt  from  yellow  fever.  But 
the  fearful  epidemics  of  recent  years  (1875,  1877,  1878)  have  worked 
a  change,  for  so  many  native  children  and  adults  suffered  that  the 
truth  could  no  longer  be  denied  that  these  do  not  enjoy  an  absolute 
immunity." 

In  Cuba  the  dogma  that  Creoles  are  exempt  from  yellow  fever  did 
not  withstand  the  searching  investigation  made  by  the  Havana  yellow 
fever  commission  of  1879. 

In  the  epidemic  of  1887  at  Key  West  the  children  of  "  acclimated  " 
Cubans,  natives  of  Havana,  born  since  the  arrival  of  their  parents  at 
Kev  West,  showed  the  same  susceptibility  to  the  disease  as  other  chil- 
dren. The  recent  investigations  of  Guiteras  also  give  strong  support 
to  the  view  that  the  immunity  of  adult  Creoles  results  from  an  unrecog- 
nized attack  occurring  during  childhood.  Blair,  speaking  of  the  epi- 
demic in  British  Guiana  (1851-54),  says  :  "  Infancy  was  one  of  the 
most  favoring  causes  of  the  action  of  the  yellow  fever  poison.  The 
constitution  of  the  new-born  or  young  white  creole  was  highly  suscepti- 
ble.    He  or  she  was  truly  in  the  category  of  new-comers." 

The  great  susceptibility  of  new-comers  who  without  previous  "  ac- 
climatization"  are  exposed  during  the  prevalence  of  an  epidemic  is 
generally  recognized  in  those  places  where  the  disease  is  endemic ;  and, 
on  the  other  hand,  persons  who  have  resided  for  some  time  in  an  infected 
locality  seem  to  acquire  a  certain  degree  of  immunity  independently  of 
an  attack  of  the  disease.  The  fact  that  foreigners  may  remain  for  years 
in  Havana,  in  Rio  de  Janeiro,  and  other  endemic  foci  of  the  disease 
without  suffering  an  attack  is  well  established.  But  those  who  have 
escaped  for  several  years  are  liable  to  be  attacked  during  a  season  of 
unusual  epidemic  prevalence.  The  disease  is,  hoAvever,  less  fatal  in 
such  cases  than  among  unacclimatized  strangers. 

Owing  to  the  immunity  acquired  in  childhood  or  by  long  residence 
in  the  infected  area,  yellow  fever  is  a  disease  of  minor  importance 
among  the  native  population  in  cities  where  it  is  endemic.  This  is  shown 
by  the  following  figures  :  In  the  citv'-  of  Rio  Janeiro,  which  has  a  popu- 
lation of  400,000,  the  mortality  from  some  of  the  principal  causes  of 


PATHOLOGICAL  ANATOMY.  275 

death  in  the  year  1886,  an  ejiiiU-niic  year  so  far  as  yellow  fever  is  con- 
eerned,  was — from  tubercnlosis,  2077  ;  diseases  of  the  circulatory  appa- 
ratus, 1458  ;  diseases  of  the  cerebro-spinal  system,  1345  ;  diseases  of 
the  dig-estive  apparatus,  1097;  malarial  diseases,  1086;  yellow  fever, 
1015.  In  the  same  year  (1886)  more  than  twice  as  many  deaths  among; 
the  civil  population  of  Havana  resulted  from  tuberculosis  as  from 
yellow  fever.  That  the  immunity  enjoyed  by  the  poj)ulation  of  the 
infected  cities  mentioned  is  not  due  to  climate,  j)er  se,  is  shown  by  the 
fact  that  country  people  living  in  the  same  latitude  readily  contract 
yellow  fever  when  they  visit  these  cities  during  the  epidemic  season  ; 
also  by  the  fact  that  when  the  disease  w'as  first  introduced  to  Rio  JTinciro 
in  1849  the  native  population  gave  no  evidence  of  immunity,  and  for 
several  years  the  mortality  among  them  was  considerable. 

The  susceptibility  of  males  and  females  probably  does  not  difi'er 
materially,  although  a  larger  mortality  occurs  among  males,  because 
they  more  frequently  and  often  recklessly  visit  infected  localities,  and 
because  of  the  intemperate  habits  of  some  of  those  who  fall  victims  to 
the  disease — e.  g.  sailors  and  soldiers.  A  recent  debauch  is  generally 
recognized  as  a  predisposing  cause. 

Pathological  Anatomy. — An  inspection  of  the  exterior  of  the 
body  of  an  individual  who  has  recently  succumbed  to  yellow  fever  fur- 
nishes indications  which  should  at  once  arouse  suspicion  as  to  the  nature 
of  the  disease,  especially  in  localities  where  it  is  known  to  prevail.  The 
integument  presents  an  icteric  hue  which  differs  from  the  saffron  yellow 
color  of  jaundice  and  is  due  to  blood  pigment.  It  resembles  the  color 
which  is  seen  to  follow  a  bruise  causing  an  effusion  of  blood  into  the 
tissues,  and  is  less  intense  and  less  uniformly  distributed  than  the 
yellow  produced  by  bile  pigments.  Moreover  the  depending  portions 
of  the  body,  as  a  result  of  hypostatic  congestion  and  pressure,  have  a 
deeper  coloration  and  are  more  or  less  livid  and  mottled.  That  this 
appearance  is  due  to  pressure  and  position  is  shown  by  the  fact  that 
"when  the  body  is  placed  upon  the  side  or  abdomen  soon  after  death,  the 
most  dependent  part  still  shows  this  livid  and  marbled  appearance. 
The  face  often  has  a  livid  and  turgescent  appearance,  like  that  of  a 
person  recently  drow^ned,  or  the  face  and  hands  may  appear  cyanosed. 
The  lips  or  gums  are  often  soiled  with  dark  blood  as  a  result  of  passive 
hemorrhage  during  the  last  hours  of  life,  and  a  little  stream  of  black 
fluid  may  frequently  be  seen  trickling  from  the  corners  of  the  mouth  or 
nostrils.  This  is  the  so-called  "  black  vomit,"  which  flows  from  the 
distended  stomach  or  is  forced  out  by  an  accumulation  of  gas  in  the 
intestine.  Cadaveric  rigidity  is  established  soon  after  death.  In  the 
warm  latitudes  where  the  disease  habitually  prevails  putrefactive 
decomposition  quickly  occurs,  and  unless  the  autopsy  is  made  within 
a  few  hours  after  the  fatal  termination  of  a  case,  postmortem  changes 
are  likely  to  complicate  the  pathological  appearances  resulting  from  the 
disease. 

The  blood  in  yellow  fever  presents  no  changes  which  can  be  recog- 
nized by  a  microscopical  examination  during  the  progress  of  the  case  or 
immediately  after  death,  but  there  is  a  certain  degree  of  disorganization 
of  the  red  corpuscles  in  severe  and  fatal  cases,  as  is  shown  by  the  yellow 
color  of  the  serum  from  the  presence  of  free  haemoglobin.     This  may 


276  YELLOW  FEVER. 

be  observed  in  blood  drawn  as  early  as  the  third  or  fourth  day,  but  is 
much  more  pronounced  in  that  obtained  from  the  large  vessels  and 
cavities  of  the  heart  after  death.  The  serum  obtained  from  blisters  in 
advanced  cases  also  has  a  yellow  color.  That  this  is  not  due  to  bile 
pigments  is  shown  by  the  chemical  researches  of  Cunisset  and  others. 
Blood  drawn  during  life  does  not  coagulate  readily,  or  the  coagulum  is 
soft  and  loose,  and  the  blood  in  the  heart  and  large  vessels  after  death 
is  usually  fluid  and  dark  colored.  The  cavities  of  the  right  side  of 
the  heart  may,  however,  contain  soft  coagula,  and  the  right  ventricle 
sometimes  contains  a  more  or  less  decolorized  flbrinous  clot.  The 
"  disorganized  "  and  diffluent  condition  of  the  blood  has  been  supposed 
by  some  to  account  for  the  passive  hemorrhages  which  are  so  charac- 
teristic of  the  disease.  But  it  is  evident  that  if  the  capillaries  and 
larger  vessels  were  intact  no  escape  of  blood  could  occur  as  a  result 
of  its  loss  of  coagulability.  The  hemorrhagic  tendency  is  rather  to  be 
ascribed  to  changes  in  the  walls  of  the  small  vessels  and  capillaries 
which  weaken  their  resistance  to  pressure ;  and  several  competent 
observers  agree  that  the  walls  of  these  vessels  undergo  a  fatty  degen- 
eration. 

Upon  removing  the  calvarium  the  brain  and  its  meninges  are  usually 
found  to  give  evidence  of  congestion.  The  pons  and  medulla  are  espe- 
cially hypersemic.  The  surface  of  the  brain  often  presents  little  hem- 
orrhagic points  and  its  substance  is  tinted  yellow.  There  is  usually 
some  effusion  into  the  ventricles  and  in  the  subarachnoid  space,  the 
fluid  being  of  yellow  color  and  sometimes  turbid.  Schmidt  of  New 
Orleans  has  described  certain  changes  in  the  sympathetic  ganglia  tO' 
which  he  attaches  importance.  These  consist  in  a  disappearance  of  the 
nuclei  from  most  of  the  ganglion  cells,  and  in  a  "  peculiar  fatty  lustre"" 
which  they  presented,  even  in  specimens  mounted  in  balsam. 

The  lungs  occasionally  contain  hemorrhagic  infarctions,  and  are 
hypersemic,  otherwise  they  present  no  evidence  of  pathological  change. 

The  heart  has  been  described  by  some  authors  as  soft  and  friable. 
I  have  not  observed  this,  and  no  evidence  of  fatty  degeneration  was 
found  in  slides  mounted  by  Guiteras  (1879),  whose  autopsies  were 
made  very  promptly  after  death.  On  the  other  hand,  Schmidt  and 
Riddel  believe  that  the  muscular  fibres  undergo  a  fatty  degeneration. 
The  pericardium  frequently  contains  a  considerable  quantity  of  yellow 
serum. 

Upon  opening  the  ca^'ity  of  the  abdomen  the  most  important  and 
characteristic  pathological  appearances  will  be  found.  The  stomach 
almost  always  contains  a  considerable  quantity  of  a  grumous  black 
fluid  similar  to  that  commonly  ejected  during  the  last  hours  of  life — 
"  black  vomit."  There  is  no  mystery  as  to  the  nature  of  the  pigment 
in  this  black  fluid.  It  is  undoubtedly  blood  pigment  more  or  less 
changed  by  the  acid  secretions  of  the  stomach.  The  writer  has  repeat- 
edly verified  the  presence  of  numerous  decolorized  blood  corpuscles  by 
microscopical  examination.  These  are  often  massed  together  in  little 
clumps,  and  brownish  pigment  granules  are  seen  attached  to  these 
masses  or  in  their  vicinity.  The  pigment  is  not  dissolved  in  the  fluid, 
but  is  present  in  the  form  of  granules  which  are  insoluble  in  water  ; 
consequently,  the   spectroscope   fails  to  demonstrate  the  presence  of 


PATHOLOGICAL  ANATOMY.  277 

blood  pi>iniont.  But  wIk-ii  the  black  matter  is  dissolved  in  aeidified 
aleoliol  a  positive  result  may  be  obtained.  Freire  and  others  have 
imagined  that  this  blaek  pigment  is  a  product  of  the  vital  atttivities 
of  some  micro-organism.  But  this  view  is  entirely  without  scientific 
foundation.  By  adding  some  drops  of  hydrochloric  acid  to  blood 
diluted  with  water  a  dark  fluid  is  obtained  which  does  not  differ  in 
appearance  from  the  black  vomit  ejected  l)y  yellow  fever  patients 
(Dantes).  The  mucous  membrane  of  the  stomach  shows  patches  of 
congestion,  and  occasionally  small  red  spots  resemljling  ecchymoses, 
which,  according  to  Schmidt,  consist  of  "an  unbroken  network  of 
minute  vessels  congested  with  blood  and  identical  with  the  network 
of  large  capillaries  which  surrounds  the  aperture  of  the  gastric  glands." 
The  congested  patches  present  no  uniformity,  the  number  and  extent 
differing  in  different  cases.  Some  authors  have  supposed  that  the  most 
important  pathological  changes  in  yellow  fever  occur  in  the  stomach, 
iind  that  the  disease  is  essentially  an  infectious  gastritis.  Crevaux 
thinks  that  the  most  important  lesion  consists  in  a  fatty  degeneration 
of  the  cells  which  line  the  gastric  glands  and  of  the  capillaries  of  the 
mncous  membrane.  In  specimens  obtained  at  some  of  my  own  autop- 
sies in  Havana,  placed  in  alcohol  very  soon  after  death,  there  is  evi- 
dence of  inflammation  in  a  certain  proportion  of  the  cases.  This  is 
shown  by  the  presence  of  collections  of  leucocytes  in  the  submucous 
coat.     But  this  appears  to  be  rather  exceptional  than  otherwise. 

The  small  intestine,  and  especially  the  ileum,  often  contains  a  blaek 
fluid  similar  to  that  found  in  the  stomach  or,  more  frequently,  a 
grumous,  black  material  which  consists  of  mucus  and  blood  pigment 
and  is  smeared  over  the  mucous  coat  of  the  gut.  This  usually  comes 
from  the  stomach,  but  in  some  cases  is  due  to  a  passive  hemorrhage 
from  the  mucous  membrane  of  the  intestine  itself,  which  is  sometimes 
uniformly  red  as  a  result  of  hypersemia  or  may  present  arborescent 
patches  of  congestion  similar  to  those  seen  in  the  stomach.  The  large 
intestine  occasionally  shows  a  like  appearance,  but  is  usually  normal. 
The  liver  presents  the  most  constant  and  characteristic  pathological 
changes.  As  a  rule,  it  is  of  a  pale  yellow  or  brownish  yellow  color, 
like  that  of  new  leather  in  its  various  shades,  and  contains  comparatively 
little  blood.  But  it  is  sometimes  livid  and  gorged  with  blood,  present- 
ing a  dark  blue  or  purple  color.  This  is  especially  apt  to  be  the  case 
when  death  occurs  after  a  very  brief  illness — two  or  three  days.  As 
the  victims  of  chronic  alcoholism  are  especially  apt  to  succumb  to  an 
attack  of  yellow  fever,  evidence  of  interstitial  hepatitis  is  not  infre- 
quently found  associated  with  the  lesions  characteristic  of  yellow  fever. 
The  dimensions  of  the  liver,  except  in  comparatively  rare  cases  in  which 
it  is  gorged  with  blood,  do  not  differ  materially  from  the  normal.  The 
parenchyma  is  more  or  less  friable  and  easily  torn,  owing  to  the  fatty 
change  in  the  cells.  On  section  the  liver  tissue  is  found  to  be  drier 
than  normal  and  to  present  the  "  boxwood "  or  "  new  leather "  color 
characteristic  of  the  disease,  unless  death  has  occurred  during  the  stage 
of  hypersemia,  which  probably  usually  precedes  that  of  anemia  and 
fatty  degeneration.  The  cells  are  not  uniformly  changed,  but  areas  of 
greater  or  less  extent  are  seen  in  which  they  are  infiltrated  with  fat 
globules.     These  are  of  vart-ing  dimensions,  and  one  or  several  may  be 


278  YELLOW  FEVER. 

contained  in  a  single  cell.  The  nuclei  often  remain  intact  in  these  cells 
infiltrated  with  fat,  but,  according  to  Schmidt,  ''  a  great  number  of 
nuclei  may  also  undergo  fatty  degeneration."  Not  infrequently  the 
central  vein  is  surrounded  by  normal  cells,  while  those  cells  about  the 
periphery  of  the  lobule  contain  many  fat  globules. 

In  two  of  the  livers  brought  back  from  Havana  by  the  Yellow 
Fever  Commission  of  1879,  in  which  there  were  evidence  of  cirrhosis, 
Woodward  found  that,  in  addition  to  the  fatty  change  described,  "  an 
abundant  infiltration  of  leucocytes  was  observed,  not  merely  in  the 
abnormally  developed  interlobular  connective  tissue,  but  also  in  the 
parenchyma  of  the  lobules."  I  have  also  found  a  rather  extensive 
infiltration  of  leucocytes  in  two  cases,  and  in  one  of  these  a  veritable 
necrosis  of  the  cells  had  occurred  in  limited  areas  in  the  vicinity  of  the 
infiltration.  Councilman,  who  made  a  careful  study  of  material  ob- 
tained at  my  autopsies  in  Havana  (1888,  1889)  discovered  a  form  of 
necrosis  in  the  interior  of  the  cells  not  previously  described.  He  says  : 
"  The  most  interesting  results  were  obtained  from  the  examination  of 
the  liver.  It  has  long  been  held  that  fatty  degeneration  of  this  organ 
was  one  of  the  most  characteristic  lesions  of  yellow  fever,  and  it  was 
found  to  a  greater  or  less  extent  in  all  of  the  sections  examined.  It 
varied  greatly  in  intensity  in  the  diiferent  cases  ;  in  some  comparatively 
large  areas  of  liver  tissue,  which  showed  very  little  degeneration,  were 
found  ;  in  others  only  here  and  there  a  few  normal  liver  cells  were  seen. 
This  lesion,  however,  does  not  seem  to  me  to  be  the  most  important  one 
of  the  organ.  When  sections  of  the  liver  are  deeply  stained  with  eosin 
and  subsequently  with  a  nuclear  stain,  either  hsemotoxylin  or  methylene 
blue,  a  very  peculiar  appearance  results.  When  such  sections  are 
examined  with  a  low  power  the  liver  cells  are  found  to  be  stained  a  faint 
reddish  blue  or  purple  color,  the  nuclei  being  a  deep  blue  or  purple. 
Among  the  liver  cells  or  in  place  of  them  a  great  number  of  bodies 
stained  intensely  red  with  the  eosin  are  found  when  examined  with  a 
high  power.  These  bodies  are  found  to  differ  entirely  from  the  liver 
cells.  They  are  sharply  circumscribed,  are  highly  refractive,  and  are 
composed  of  a  perfectly  hyaline  mass  containing  numerous  vacuoles. 
Their  size  varies  greatly ;  in  some  cases  they  are  no  larger  than  a 
leucocyte,  in  others  as  large  as  two  liver  cells.  They  are  found  enclosed 
in  liver  cells  otherwise  perfectly  normal,  and  in  some  cases  they  entirely 
take  the  place  of  these  in  the  liver  beam-work  between  the  capillaries. 
In  some  cases  examined  they  apparently  made  up  the  mass  of  the  tissue, 
only  here  and  there  a  portion  of  a  liver  cell  or  a  nucleus  of  such  being 
seen.  Sometimes,  especially  where  the  liver  tissue  was  most  scanty, 
along  with  these  definite  circumscribed  masses  more  or  less  granular 
material  was  found  which  stained  in  the  same  way.  These  bodies  were 
generally  round  or  more  or  less  irregular  in  form.  In  some  of  the  liver 
cells  small  hyaline  masses  staining  in  the  same  way  were  found  which 
were  not  so  sharply  circumscribed  as  the  larger  bodies.  They  were 
found  most  abundantly  in  the  cases  where  the  fatty  degeneration  was 
most  extreme,  but  the  most  striking  pictures  were  obtained  where  the 
liver  was  least  altered. 

"  In  a  few  instances  liver  cells  were  found  which  only  differed  from 
the  normal  in  being  more  coarsely  granular,  the  granules  staining  with 


PATIIOLOaiCAL   ANATOMY.  279 

eosin,  but  not  so  distinctly  as  the  cosin-stainino-  bodies,  and  the  nucleus 
stained  more  faintly  blue  than  the  nuclei  of  the  surrounding  liver  cells. 
In  most  cases  these  bodies  were  without  any  nucleus ;  in  others  a 
nucleus  was  present.  This  always  was  at  the  periphery,  and  fjenerally 
took  the  lono-  irregular  form  of  the  nucleus  of  a  wandering-  leucocyte. 
Polynuclear  leucocytes  Avere  numerous  in  all  the  livers  examined.  In 
some  cases  there  were  well-defined  groups  of  them  in  the  capillaries 
and  in  the  liver  beam-work  between,  and  as  it  seemed  often  in  the  red- 
stained  bodies.  In  several  specimens  there  were  hemorrhages  in  the 
liver,  large  areas  being  occupied  by  red  blood  corpuscles,  between 
which  the  red  bodies  were  often  seen.  This  peculiar  condition  of  the 
liver  is  possibly  made  more  clear  by  staining  the  sections  deeply  with 
picrocarmine.  In  sections  so  treated  these  bodies  stain  an  intense 
bright  yellow  with  the  picro-acid.  Concerning  the  nature  of  these 
bodies  there  can  be  little  question.  When  first  seen  it  was  thought 
that  they  were  probably  some  form  of  lower  organism,  possibly  amoebse, 
but  a  more  extended  study  showed  that  this  could  not  be  so.  Bodies 
in  all  respects  similar  to  them  were  found  in  rapidly  advancing  cases 
of  cirrhosis  of  the  liver,  in  phosphorus-poisoning,  and  in  other  cases 
of  rapid  fatty  degeneration,  but  they  are  particularly  found  in  cases  of 
acute  yellow  atrophy  of  the  liver.  Areas  were  found  in  sections  from 
this  which  were  very  similar  to  the  advanced  cases  of  yellow  fever  liver. 
It  must  be  considered  that  in  yellow  fever,  along  with  the  fatty  degen- 
eration, there  is  a  necrosis  of  the  liver  cells  which  sometimes  affects 
only  portions  of  the  cells,  at  others  the  entire  cell.  Almost  every 
change  leading  up  to  the  formation  of  these  bodies  could  be  seen.  The 
exact  relation  of  the  fatty  degeneration  to  the  necrosis  could  not  be 
determined.  The  necrotic  masses  were  found  both  in  intact  liver  cells 
and  in  those  which  had  undergone  fatty  degeneration.  In  the  latter 
cases  it  seemed  probable  that  the  necrosis  preceded,  or  at  least  accompa- 
nied, the  degeneration.  If  it  only  represented  a  necrosis  of  the  small 
remnant  of  cell  protoplasm  between  the  fat  drops,  it  is  difficult  to  see 
how  so  large  a  body  could  be  formed  from  this.  When  the  necrotic 
masses  were  found  in  the  liver  cells  they  were  nearly  always  at  the 
periphery  of  the  cell  next  to  the  capillary."  ^ 

The  changes  in  the  kidneys  are  those  produced  by  an  acute  paren- 
chymatous nephritis.  The  macroscopic  examination  does  not  reveal 
any  marked  variation  from  the  normal  appearance,  except  that  when  a 
fatal  termination  has  occurred  after  a  very  brief  illness  they  may  be 
found  hypersemic  and  of  a  deep  red  color.  The  observations  of  Cre- 
vaux,  Schmidt,  and  others  indicate  that  there  is  always  a  brief  period 
of  congestion  in  advance  of  the  changes  in  the  renal  epithelium.  Small 
hemorrhagic  foci  are  not  infrequently  seen  beneath  the  capsule  or  in  the 
cortical  substance,  and  little  globular  hemorrhagic  points  have  been 
observed  on  section  which  proved  to  be  the  distended  capsules  of  the 
glomeruli. 

In  thin  sections,  properly  prepared,  the  renal  epithelium  is  found  to 
have  undergone  degenerative  changes  to  a  greater  or  less  extent,  and  in 
places  complete  degeneration  has  occurred.     Sometimes  whole  bundles 

^Quoted  from  the  writer' s  Report  upon  the  Etiology  and  Prevention  of  Yellow  Fever, 
"Washington,  1890,  p.  152. 


280  YELLOW  FEVER. 

of  tubes  are  denuded  of  their  epithelium  and  are  empty.  These  changes 
are  most  marked  in  the  tubules  of  the  labyrinth.  Councilman  describes 
the  changes  in  the  cells  as  follows  :  "  The  cells  often  contained  larger 
and  smaller  fat  drops,  shown  by  the  clear  spaces  remaining  after  they 
were  dissolved  out  by  the  alcohol,  but  the  principal  change  was  a  hyaline 
degeneration  of  the  cells.  The  cells  contained  an  immense  number  of 
clear  hyaline  granules  which  stained  more  brightly  with  eosin.  In  the 
dilated  tubules  there  were  large  and  smaller,  generally  round,  masses 
of  similar  hyaline  material."  Besides  these  hyaline  masses  there  are 
also  granular  infarctions  of  the  tubules,  and  others  in  which  there  is  a 
mixture  of  granular  debris  and  hyaline  material.  These  correspond 
with  the  granular  and  hyaline  tube  casts  found  in  the  urine  of  yellow 
fever  patients.  Again,  there  are  infarctions  of  another  kind  which 
attracted  the  writer's  attention  early  in  his  investigations,  but  the  exact 
nature  of  which  has  not  been  determined.  The  peculiarity  of  these 
consists  in  their  form  and  in  the  fact  that  they  are  deeply  stained  by 
the  aniline  colors.  They  are  made  up  of  disk-shaped  masses,  irregular 
lobate  clumps,  or  amorphous  fragments.  Councilman  speaks  of  this  as 
"  colloid  material,"  and  says  it  is  found  in  the  loops  of  Henle  and  the 
collecting  tubules.  The  writer  has  elsewhere  suggested  that  these  infarc- 
tions, which  are  stained  by  the  nuclear  staining  agents,  may  be  made 
up  of  the  nuclei  of  cells  which  have  undergone  the  hyaline  degenera- 
tion described  by  Councilman.  Another  unexplained  object  which  is 
not  infrequently  seen  in  sections  of  the  kidney  has  a  crystalline  appear- 
ance and  an  irregularly  circular  or  lobate  outline.  These  bodies  are 
highly  refractive,  and  are  marked  by  lines  of  fracture  radiating  from 
the  centre  to  the  periphery.  They  do  not  stain  with  any  of  the  re- 
agents used  in  the  preparation  of  sections  for  microscopical  examination. 
Occasionally  a  considerable  number  of  leucocytes  may  be  seen  in  the 
tubules,  and  sometimes  they  contain  red  blood  corpuscles.  Councilman 
concludes  his  report  of  the  examination  of  a  series  of  sections  which  I 
submitted  to  him  for  examination,  as  follows  :  "  The  changes  in  both 
the  liver  and  kidney  appear  to  be  due  to  a  general  toxaemia  rather  than 
to  the  local  presence  of  infectious  agents.  They  are  diifuse,  affecting 
the  whole  of  the  organs,  and  not  small  areas." 

We  have  heretofore  suggested  that  the  phenomena  of  the  disease  are 
due  to  the  action  of  a  deadly  toxin  formed,  probably,  in  the  intestine. 
My  experiments  in  Havana  (1889)  show  that  "the  material  obtained 
from  the  small  intestine  of  yellow  fever  patients  at  autopsies  made  soon 
after  death  is  very  virulent  when  injected  beneath  the  skin  of  guinea- 
pigs."  ^  The  examination  of  the  liver  and  kidney  for  micro-organmns 
has  given  results  which  correspond  with  those  obtained  by  the  method 
of  cultivation.  In  those  cases  in  which  my  cultures  made  from  blood 
or  liver  tissue,  obtained  as  soon  as  possible  after  death,  gave  a  positive 
result,  I  have  usually  found  the  same  micro-organisms  in  thin  sections 
of  the  same  material.  In  my  report,  heretofore  referred  to,  I  say  :  "  A 
summary  of  these  results  shows  that  I  have  obtained  micro-organisms 
in  my  aerobic  cultures  as  follows  :  In  blood  from  the  heart,  4  times  in 
19  cases  ;  in  the  liver  or  kidney,  or  both,  13  times  in  43  cases." 

Dr.  Councilman,  who  carefully  examined  a  series  of  thin  sections 

^  Report  on  Etiology  and  Prevention  of  Yellow  Fever,  Washington,  1890,  p.  131. 


INCUBA  TION.—S  YMPTOMS.  281 

j^ubmittod  to  him  by  n\v,  says  :  "  Bactoria  of  some  sort  were  found  in 
28  of  the  130  seetions  examined;  of  these,  IS  were  seetions  of  the 
liver,  8  of  the  kidney,  and  1  eaeh  of  stomaeh  and  lymj)h  ^land.  There 
was  notliinir  in  their  form  or  rehition  to  the  tissue  that  would  lead  one 
to  suppose  that  tlu'ir  presenee  was  otlier  than  aeeidental.  In  no  ease 
<'Ouhl  anv  eonnection  he  shown  between  their  presence  and  the  essential 
lesions  of  the  disease.  In  no  case  was  there  any  lesion  in  the  surround- 
ing tissue  which  could  be  attributed  to  their  presence.  Among  the 
bacilli  were  some  Avhicli  agreed  in  form  witli  the  colon  bacillus." 

Intubation. — The  period  of  incubation  is  comparatively  short, 
iind  probably  never  exceeds  five  days.  Instances  of  attacks  occurring 
inside  of  twenty-four  hours  after  exposure  are  well  authenticated. 
Several  authors  have  insisted  that  the  period  of  incubation  may  be 
prolonged  to  two  weeks  or  more,  but  we  believe  this  to  be  an  error 
based  upon  a  misinterpretation  of  the  facts  observed.  Thus  w^hen  a 
<'ase  develops  on  a  shij)  some  time  after  leaving  port,  it  does  not  follow 
that  it  resulted  from  exposure  while  on  shore.  On  the  contrary,  such  a 
•case  is  usually  quickly  followed  by  others,  and  is  evidence  that  the  ship 
is  infected. 

Symptoms. — There  are  no  constant  or  well  defined  premonitory 
.<<i/injjfoins  in  advance  of  an  attack  of  yellow  fever,  but  in  a  certain 
proportion  of  the  cases  the  individual  complains  of  loss  of  appetite, 
lassitude,  a  tendency  to  perspire  upon  slight  exertion,  giddiness  or 
slight  headache,  and  indisposition  to  make  any  mental  or  physical  exer- 
tion for  trsvo  or  three  days  before  the  initial  chill,  which  usually  inaugu- 
rates an  attack.  In  other  cases  there  is  not  the  slightest  intimation  of 
ill  health  up  to  the  moment  of  the  sudden  seizure.  This  often  occurs 
at  night  or  in  the  early  morning  after  an  uninterrupted  sleep.  It  may 
also  occur  during  the  day  while  the  individual  is  engaged  in  his  usual 
occupations.  Out  of  225  cases  in  the  Roper  Hospital,  Charleston, 
observed  by  Wragg  during  the  epidemic  of  1854,  the  attack  was  with- 
out premonitory  symptoms  in  92,  and  in  the  remainder  there  was  more 
or  less  malaise,  etc.  in  advance  of  the  attack. 

Although  the  attack  is  commonly  inaugurated  by  a  decided  chill  or 
by  a  slight  sensation  of  coldness,  this  is  sometimes  absent,  especially  in 
mild  cases  occurring  in  the  tropics.  In  certain  grave  forms  of  the  dis- 
ea.se,  also,  the  outset  of  the  attack  is  insidious  and  without  any  notice- 
able chilly  sensation.  The  temperature  is  already  above  the  normal,  as 
shown  by  a  thermometer  placed  in  the  mouth  or  axilla,  when  the  patient 
is  suffering  from  the  initial  rigor.  Accompanying  the  chill  or,  in  its 
absence,  with  the  access  of  fever,  there  is  apt  to  be  more  or  less  cephal- 
algia, Avhich  is  usually  located  in  the  frontal  or  supraorbital  region.  The 
eyeballs  also  are  painful,  and  there  is  frequently  considerable  photo- 
phobia. The  outset  of  the  attack  is  also  usually  accompanied  by  severe 
jmin  in  the  loins  and  in  the  calves  of  the  legs,  which  may  continue  after 
the  febrile  stage  of  the  disease  is  fully  developed.  As  the  chill  passes 
off  the  temperature  rapidly  rises  ;  the  face  becomes  flushed  or  of  a  con- 
gested and  swollen  appearance ;  the  eyes  are  fiery  red  or  shining  and 
suffused ;  the  skin  becomes  dry  and  hot ;  and  in  nervous  patients  there 
are  great  restlessness  and  jactitation. 

The  symptoms  connected  with  the  onset  of  the  attack  as  above  stated 


282  YELLOW  FEVER. 

evidently  present  no  features  which  are  peculiar  to  the  disease  under 
consideration,  which  has,  however,  a  well  characterized  clinical  history 
when  a  complete  and  typical  case  is  considered.  In  such  a  case,  ending- 
in  recovery,  we  have  three  tolerably  well  marked  periods  :  First,  a 
fehrile  stage,  which  consists  of  a  single  paroxysm,  lasting  usually  from 
forty-eight  hours  to  four  or  five  days,  and  in  which  the  acme  of  temper- 
ature is  reached  early  in  the  attack — usually  on  the  first  day.  Second^ 
the  stage  of  calm,  which  follows  defervescence  and  is  marked  by  great 
depression  of  the  vital  powers,  with  a  slow  pulse  and  sometimes  a  sub- 
normal temperature.  The  temj)erature  may,  however,  remain  a  degree 
or  two  above  the  normal  throughout  this  stage.  Third,  the  'period  of 
convalescence,  during  which  the  vital  forces  reassert  themselves,  and  the 
patient  often  passes  quickly  from  a  condition  of  extreme  danger  to  one 
of  comparative  comfort  and  safety.  In  severe  cases,  however,  the  stage 
of  calm  is  usually  followed  by  a  reactionary  fever  of  irregular  duration 
which  has  a  more  or  less  remittent  character. 

Numerous  varieties  of  the  disease  have  been  described  by  authors, 
but  yellow  fever  presents  the  same  clinical  features  in  all  parts  of  the 
world  where  it  prevails  and  in  different  epidemics.  The  so-called 
varieties  for  the  most  part  represent  different  degrees  of  severity  or 
depend  upon  complications  and  individual  peculiarities.  Berenger- 
Feraud,  who  had  an  extended  experience  in  the  French  Antilles,  names 
the  following  varieties  of  the  graver  forms  of  the  disease  :  (a)  ordinary 
forms,  including  the  gastric,  adynamic,  ataxic,  congestive,  and  typhoid 
forms ;  (6)  rare  forms,  including  the  hypersesthetic,  gangrenous,  algid 
or  choleraic,  and  hydrophobic.  In  some  epidemics  death  has  been 
known  to  occur  within  a  few  hours  of  the  first  manifestations  of  the 
disease.  These  rapidly  fatal  attacks  are  classified  by  French  authors 
as  siderante.  They  are  usually  algid,  congestive,  or  apoplectic  in  form, 
and  are  most  likely  to  occur  in  the  victims  of  chronic  alcoholism,  whose 
organs  have  undergone  degenerative  changes,  and  are  consequently  less 
able  to  resist  the  action  of  the  deadly  toxin  of  yellow  fever. 

The  severity  of  the  disease  differs  greatly  in  different  epidemics. 
This  depends  partly  upon  the  character  of  the  population  in  the 
invaded  area  and  partly  upon  local  and  meteorological  conditions. 
When  the  population  consists  largely  of  negroes  or  of  the  Creole  resi- 
dents of  semitropical  countries,  the  number  of  cases  of  the  more  fatal 
varieties  above  mentioned  will  be  comparatively  small.  Not  infre- 
quently, also,  the  earlier  cases  in  an  epidemic  are  comparatively  mild, 
the  poison  seeming  to  gain  in  activity  as  the  epidemic  progresses. 
Probably  in  this  as  in  other  infectious  diseases  the  severity  of  an  attack 
depends  to  some  extent  upon  the  dose  of  the  infectious  agent  introduced 
into  the  system  at  the  time  of  exposure,  and  this  is  influenced  by  con- 
ditions which  favor  its  rapid  development  in  the  infected  localities, 
especially  by  accumulations  of  organic  material  of  animal  origin,  by 
heat,  and  by  moisture. 

In  an  account  of  the  clinical  history  of  yellow  fever  the  temperature 
of  the  body  is  of  prime  importance,  both  as  regards  diagnosis  and  prog- 
nosis. The  acme  of  temperature  is  commonly  reached  within  a  few 
hours  of  the  onset  of  the  attack,  and  rarely  later  than  the  evening  of 
the  third  day.     From  this  time,  in  uncomplicated  cases,  the  tempera- 


SYMPTOMS.  283 

ture  line  is  a  descondiiifi;  one,  intcmiptt'd  somotimos  by  a  slight  evening 
exacerbation,  until  defervescence  occurs,  usually  in  from  three  to  five 
days.  At  the  end  of  this  single  febrile  paroxi/fiiii  the  temperature,  during 
the  succeeding  period  of  depression,  may  be  normal  or  sul)nt)rmal,  or 
occasionally  a  degree  or  more  above  the  normal.  The  initial  paroxysm 
is  sometimes  divided  into  two  or  more  distinct  periods  of  from  two  to 
four  days'  duration  by  a  more  or  less  complete  remission  of  brief  dura- 
tion, but  this  is  so  rarely  the  case  that  it  does  not  call  for  any  modifica- 
tion of  the  o-eneral  statement  that  the  disease  under  consideration  is  a 
continued  fever  of  a  single  })aroxysm. 

"  In  an  analysis  of  192  cases  recorded  by  Faget,  Jones,  and  myself 
the  acme  of  temperature  was  reached  on  the  first  day  in  102,  on  the 
second  in  54,  on  the  third  in  33,  and  on  the  fourth  in  3.  The  highest 
temperature  recorded  by  Paget  was  107.2°  F.  Thornton,  in  a  total  of 
143  cases  occurring  at  Memphis,  noted  a  temperature  of  108"^  F.  in  a 
single  instance.  "With  this  exception,  106.5°  F.  was  the  highest  tem- 
perature recorded  by  him.  In  my  own  observations  106°  F.  has  been 
the  highest  temperature  noted.  The  temperature  often  rises  rapidly 
just  before  death,  and  a  very  high  post-mortem  temperature  (108°  F. 
to  110°  F.)  is  a  common  phenomenon."  ^ 

The  typical  temperature  curve  may  be  disturbed  by  visceral  conges- 
tions, indiscretions  in  diet,  moving  the  patient — as  from  shipboard  to 
hospital — and  by  excessive  fright  or  grief.  The  same  causes  may  in- 
duce a  relapse  after  the  termination  of  the  initial  paroxysm,  as  a  result 
of  which  all  the  phenomena  which  characterize  this  may  be  repeated, 
although  in  non-fatal  cases  the  duration  of  the  febrile  movement  is 
usually  less. 

At  the  outset  of  the  attack  the  pulse  is  usually  full  and  strong,  the 
number  of  pulsations  being,  as  a  rule,  not  more  than  100  to  110  per 
minute.  The  force  and  rapidity  diminish  in  a  notable  manner  as  the 
disease  progresses,  and  this  early  failure  in  the  strength  and  rapidity 
of  the  heart's  action,  even  while  the  febrile  movement  is  still  at  its 
height,  is  a  feature  of  the  disease  which,  as  pointed  out  by  Faget,  is 
of  diagnostic  importance.  During  the  period  of  depression — "  stage  of 
calm  " — which  follows  the  febrile  paroxysm  the  pulse  is  very  compres- 
sible and  slow,  the  number  of  beats  falling  not  infrequently  to  40  per 
minute,  and  in  exceptional  cases  even  as  low  as  30.  This  feebleness 
of  the  heart's  action  during  the  second  stage  of  the  disease  at  a  time 
when  the  patient  often  imagines  that  he  is  on  the  high  road  to  recovery, 
inasmuch  as  all  of  his  pains  and  uncomfortable  sensations  have  dis- 
appeared, is  a  very  characteristic  feature  of  yellow  fever,  and  one  which 
indicates  to  the  skilled  physician  a  critical  condition  calling  for  careful 
treatment. 

The  tongue  presents  nothing  which  is  characteristic.  Usually  it  is 
moist,  and  becomes  quickly  coated  with  a  white  coating,  except  at  the 
margins,  which  remain  red.  It  differs  from  the  tongue  of  the  malarial 
fevers  in  being,  usually,  narrow  and  pointed,  instead  of  broad  and  flabby, 
as  is  the  rule  in  these  diseases.  As  the  disease  advances  the  tongue  may 
become  dry  and  the  coating  assume  a  brownish  color.  In  protracted 
cases  it  is  likely  to  be  very  foul  and  loaded  with  sordes, 

^  Quoted  from  my  article  in  Reference  Handbook  of  the  Medical  Sciences,  vol.  viii.  i>.  61. 


284  YELLOW  FEVER. 

At  the  outset  of  the  attack  the  face  is  flushed  or  congested  and 
swollen  ;  sometimes  in  plethoric  subjects  it  may  be  of  a  dusky  violet 
color :  this,  with  the  deep  red  suifusion  of  the  eyes  which  is  commonly 
present  in  severe  cases,  together  with  the  absence  of  any  eruption,  forms 
a  striking  feature  of  the  first  period  of  the  disease.  The  countenance 
may  be  expressive  of  anxiety  and  pain,  but  is  often  dull  and  apathetic 
in  appearance.  Later,  in  fatal  cases,  the  eyes  often  become  sunken,  the 
•eyelids  ecchymosed,  the  brows  contracted,  and  the  features  shrunken,  or 
the  face  may  be  bloated  and  flabby.  In  mild  cases  the  hypersemia  of 
the  conjunctivae  and  flushing  of  the  face  are  of  brief  duration  ;  in  more 
severe  cases  they  often  last  through  the  febrile  stage  of  the  disease ;  in 
rapidly  fatal  cases  the  eyes  may  remain  deeply  injected  throughout.  A 
faint  yellowish  tinge  of  the  conjunctivae  may  usually  be  recognized  by 
the  third  or  fourth  day  ;  this  becomes  more  intense  as  the  disease  pro- 
gresses, and  often  lasts  after  convalescence  is  fairly  established. 

The  skin  is  sometimes  hot  and  dry  throughout  the  febrile  stage ; 
more  frequently  it  soon  becomes  moist,  and  free  perspiration  is  readily 
induced  by  warm  drinks  and  covering  with  blankets.  During  the  sec- 
ond stage  the  skin  is  usually  cool  and  moist,  and  when  death  occurs 
during  this  period  of  depression  it  is  often  preceded  by  a  clammy  sweat 
and  coldness  of  the  general  surface  of  the  body.  In  exceptional  cases 
the  skin  remains  hot  and  dry,  and  the  temperature  elevated  up  to  the 
time  of  the  fatal  termination,  which  may  be  less  than  forty-eight  hours 
from  the  inauguration  of  the  attack. 

A  peculiar  odor  given  off"  from  the  surface  of  yellow  fever  patients 
has  been  recognized  by  numerous  physicians  who  have  had  experience 
in  the  treatment  of  this  disease,  but  attempts  to  describe  it  have  not 
been  very  successful.  Kush  compared  it  to  the  "washings  from  a 
gun,"  and  Jackson  says  it  is  "  sickly  and  faint,  and  not  unlike  the 
smell  of  a  fish-market." 

The  yellow  color  of  the  skin  which  has  given  the  disease  the  name  by 
which  it  is  generally  known  among  English-speaking  people  is  not 
always  present,  or  may  be  so  slight  as  to  be  recognized  with  difficulty. 
In  severe  cases,  however,  it  is  usually  seen  toward  the  end  of  the  febrile 
stage,  and  becomes  more  intense  during  the  "  stage  of  calm,"  lasting 
until  convalescence  is  fully  established  and  even  longer.  The  color  of 
the  skin  varies  from  a  faint  yellow  tint  to  a  deep  orange  or  saffron  yellow, 
or  it  may  occasionally  be  a  bronze  or  mahogany  color.  This  yellow  color 
is  developed  at  a  time  when  the  urine  is  albuminous  and  free  from  bile, 
and  without  doubt  is  due  to  the  presence  of  blood  pigment  in  the  liquor 
sanguinis  and  not  to  bile  pigments.  But  in  certain  cases  jaundice  from 
bile  pigments  is  developed  at  the  end  of  the  second  period  or  during 
convalescence,  and  is  accompanied  by  the  presence  of  an  abundance  of 
bile  pigments  in  the  urine.  In  these  cases  the  yellow  color  of  the  skin 
is  more  intense  and  lasts  longer.  The  characteristic  yellow  discolor- 
ation, which  coincides  with  the  period  during  which  hemorrhages  are 
likely  to  occur,  may  first  be  recognized  by  a  slight  yellow  tinge  of  the 
conjunctivae,  of  the  face,  and  of  the  skin  over  the  superficial  blood- 
vessels. In  fatal  cases  the  cadaver  presents  a  well  marked  yellow  dis- 
coloration, especially  the  dependent  portions  subject  to  pressure,  even 
when  this  was  not  noticeable  during  the  last  hours  of  life. 


.^Y^fPTO^fs.  285 

Bereno;er-Fc'ran(l  has  noticed  an  crytlicniatons  eruption  about  tlic 
scrotum  in  yellow  lever  })atients  whieli  he  believes  to  be  a  cliurueteristic 
feature  of  the  disease.  Other  eruptions  mentioned  by  various  authors 
as  occasionally  observed  are  erythematous  patches  about  the  knees  and 
elbows,  pustules  about  the  mouth  and  elsewhere,  petechite,  furuncles,  etc. 

The  uritic  is  scanty  even  during  the  first  period  of  the  disease,  and 
in  fatal  cases  complete  suppression  occurs  some  time  before  death.  The 
presence  of  albumin  is  so  constant  a  symptom  as  to  be  ])roperly  con- 
sidered a  pathognomonic  feature  of  the  disease.  In  mild  cases  only  a 
trace  may  be  found  during  a  brief  period,  but  when  frequent  and  care- 
ful tests  are  made  it  will  seldom,  if  ever,  prove  to  be  entirely  absent. 
In  cases  of  moderate  severity  it  is  usually  present  in  considerable 
quantity,  especially  during  the  second  stage  of  the  disease,  when  the 
amount  of  urine  secreted  falls  to  a  minimum.  In  severe  cases  the 
coagulated  albumin  precipitated  by  heat  or  nitric  acid  frequently  occu- 
pies one  half  the  contents  of  the  test-tube  or  even  more  than  this.  The 
deposit  is  usually  sufficiently  abundant  after  the  second  day  to  leave  no 
doubt  as  to  its  character,  and  increases  in  quantity  during  the  second 
period  of  the  disease.  The  amount  present  is  to  some  extent  an  index 
of  the  gravity  of  the  attack. 

In  a  series  of  16  non-fatal  cases  in  which  the  writer  (1875)  made 
careful  observations  upon  the  quantity  and  specific  gravity  of  the  urine 
the  following  averages  were  obtained  : 

Fluidounces.    Spec.  gray. 

First  day 1023 

Second  dav 11.5  1025 

Third  day' 16  1028 

Fourth  dav 18  1022 

Fifth  day" 19  1022 

Sixth  dav 20  1022 

Seventhday 22  1021 

Eighth  day 22  1019 

Ninth  dav ■    •    •        -23  1016 

Tenth  day 28  1013 

Eleventh  day 37  1011 

Twelfth  day 41  1013 

It  will  be  noticed  that  the  amount  of  urine  secreted  gradually  increased 
and  the  specific  gravity  diminished  after  the  third  day.  When  these 
two  factors  are  considered  together,  it  will  be  seen  that  the  total  solids 
excreted  were  about  the  same  from  the  third  to  the  eleventh  day.  The 
amount  of  urea  eliminated  by  the  kidneys  is  in  inverse  proportion  to  the 
severity  of  the  attack,  and  corresponds  closely  with  the  quantity  of  urine. 
This  is  always  considerably  less  than  normal,  and  in  severe  non-fatal 
cases  often  falls  to  a  few  ounces  in  the  twenty-four  hours,  while  in  fatal 
cases  complete  suppression  usually  occurs  in  from  a  few  hours  to  twenty- 
four  hours  before  death.  According  to  Cuniset,  the  amount  of  uric  acid, 
although  reduced,  is  not  diminished  to  the  same  extent  as  the  urea. 
The  urine,  as  a  rule,  has  a  decidedly  acid  reaction.  Occasionally  it 
contains  blood  as  a  result  of  renal  or  vesical  hemorrhage.  In  non-fatal 
cases  bile  pigments  commonly  make  their  appearance  in  the  urine  about 
the  time  that  convalescence  is  established. 

There  is  usually  complete  anorexia  during  the  febrile  stage,  and  in 


286  YELLOW  FEVER. 

severe  cases  this  may  last  through  the  following  period  of  depression ; 
but  in  mild  cases  the  appetite  usually  returns  with  the  disappearance  of 
the  fever,  and  the  patient  often  at  once  enters  upon  convalescence.  In 
cases  of  moderate  severity,  although  the  desire  for  food  may  return,  the 
stomach  is  not  able  to  retain  anything  but  the  simplest  forms  of  liquid 
nourishment,  and  any  indulgence  of  the  appetite  is  likely  to  cause  vom- 
iting and  to  lead  to  serious  consequences. 

Thirst  is  constant  during  the  febrile  stage,  and  in  a  less  degree  during 
the  succeeding  period  of  depression,  especially  when  there  is  copious  and 
frequent  vomiting. 

Voraiting  frequently  occurs  during  the  febrile  period,  the  vomited 
matters  consisting  for  the  most  part  of  fluids  ingested,  containing  in 
suspension  flocculi  of  mucus  from  the  stomach ;  occasionally  the  fluid 
ejected  at  the  outset  of  an  attack  has  a  yellow  color  from  the  presence 
of  bile.  The  vomited  matters  almost  always  have  an  acid  reaction.  In 
cases  which  run  a  favorable  course  vomiting  ceases,  with  the  other  dis- 
tressing symptoms,  at  the  termination  of  the  febrile  paroxysm ;  but  in 
severe  and  fatal  cases  it  is  likely  to  return  after  an  interval  of  twenty- 
four  hours  or  more,  during  which  the  patient  complains  of  a  feeling  of 
weight  and  discomfort  in  the  epigastric  region.  This  gastric  distress 
may  be  slightly  relieved  for  a  brief  period  after  the  act  of  vomiting, 
although  often  nothing  is  thrown  up  but  a  few  spoonfuls  of  a  clear  acid 
fluid.  In  other  cases  the  amount  of  fluid  ejected  is  considerable ;  in 
severe  and  fatal  cases  this  presents,  in  a  more  or  less  marked  degree,  the 
characters  of  "black  vomit."  At  first  the  black  pigment  is  usually 
seen  in  the  form  of  a  few  little  flocculi  suspended  in  a  transparent  fluid ; 
in  severe  and  fatal  cases  the  number  of  these  flocculi  increases,  and  the 
vomited  matters  may  present  the  appearance  known  as  "  cofiee-ground 
vomit,"  or  they  may  be  so  numerous  as  to  give  the  fluid  a  uniformly 
black  color  when  first  ejected.  But  upon  standing  this  black  vomit 
usually  separates  into  two  portions,  the  lower  containing  the  black 
matter  in  suspension,  while  above  this  a  transparent  liquid  is  seen. 
Under  the  microscope  the  little  pigmented  masses  are  seen,  by  trans- 
mitted light,  to  have  a  yellowish  brown  color,  and  a  careful  examination 
shows  that  they  contain  decolorized  blood  corpuscles  and  granular  leuco- 
cytes as  well  as  the  brownish  pigment  granules.  In  short,  there  is  no 
doubt  that  the  appearance  of  black  vomit  depends  upon  the  escape  of 
blood  from  the  gastric  mucous  membrane  into  the  cavity  of  the  stomach. 
Occasionally  there  is  a  more  active  hemorrhage  and  the  patient  throws 
up  pure  blood.  Recovery  sometimes  occurs  after  the  characteristic 
black  vomit  has  been  ejected,  although  this  is  generally  recognized  as  a 
very  grave  symptom,  presaging  death.  The  name  "  vomito  "  given  to 
the  disease  in  Spanish- American  countries  has  reference  to  the  dreaded 
black  vomit,  but  is  scarcely  appropriate,  inasmuch  as  a  majority  of  the 
cases  ending  in  recovery  do  not  present  this  symptom. 

That  the  gastric  mucous  membrane  is  seriously  implicated  in  the  dis- 
ease under  consideration  is  shown  by  a  marked  tenderness  on  pressure 
over  the  epigastrium,  by  the  constant  feeling  of  discomfort  and  pain  in 
the  epigastric  region  in  severe  cases,  and  by  the  tendency  to  passive 
hemorrhage  above  referred  to. 

The  bowels  at  the  outset  of  an  attack  are  apt  to  be  somewhat  consti- 


IJIA(;\0STS.  287 

patcd  ;  later  thov  ofton  romaiii  t()r|)i<l,  hut  easily  moved  by  a  mild 
catliartie  or  })nr^ative  enema  ;  or  there  may  he  more  or  less  diarrlio'a 
diiriiiii'  the  seeond  period  of"  tlie  (hscase.  In  fatal  eases  the  discharges 
from  the  bowels  are  often  similar  in  character  to  the  black  fluid  ejected 
from  the  stomach,  and  are  of  the  same  nature.  This  may  come  from 
the  stomach  or  may  be  due  to  a  passive  liemorrha<>:e  from  the  mucous 
membrane  of  the  small  intestine.  Occasionally  there  is  more  active 
iiemorrhaue  and  a  (liseharj>:e  of  pure  blood  from  the  bowels.  Hemor- 
rhag'es  may  also  occur  from  the  mouth,  nose,  bladder,  or  uterus,  or  even 
from  the  eyes  and  ears  in  rare  cases.  Epistaxis  and  oozing  of  blood 
from  the  gums,  tongue,  or  lips  is  the  most  frequent  form  of  hemorrhage 
after  that  from  the  gastric  mucous  membrane. 

The  symptoms  connected  with  the  nervous  system  arc  those  which  might 
be  expected  in  a  disease  characterized  by  a  febrile  paroxysm  and  sui)se- 
quent  stage  of  depression.  At  the  outset,  "when  the  fever  is  at  its  height, 
there  is  usually  severe  frontal  headache  and  rhachalgia ;  the  patient  is 
apt  to  be  wakeful  throughout  the  first  stage,  or  his  sleep  is  fitful  and 
disturbed  by  distressing  dreams ;  his  mind  is  in  a  state  of  tension,  and 
he  is  anxious,  watchful,  and  easily  excited ;  but,  as  a  rule,  there  is  no 
active  delirium.  Certain  cases  are  characterized  by  sluggishness  of 
mental  action,  apathy,  and  indiiference ;  in  others  there  are  hallucina- 
tions and  more  or  less  incoherency  of  ideas  ;  occasionally  there  is  active 
delirium,  which  may  call  for  restraint  in  order  to  keep  the  patient  in 
bed,  but  the  intellect  often  remains  unclouded  throughout  even  in  severe 
and  fatal  cases ;  more  frequently  the  fatal  termination  is  preceded  by  a 
torpid  condition  of  the  mind  with  a  disposition  to  somnolence,  gradu- 
ally passing  into  complete  coma.  Occasionally  death  is  preceded  by 
convulsions,  and  tetanic  rigidity  of  a  more  or  less  complete  character 
has  been  noted  as  a  rare  occurrence.  There  is  frequently  great  restless- 
ness, with  deep  sighing  res])iration,  often  spasmodic  in  character.  The 
respiration  is  accelerated  during  the  febrile  stage,  but  the  respiratory 
apparatus  is  not  implicated  in  this  disease. 

In  severe  cases  convalescence  is  often  slow,  and  may  be  complicated 
by  the  occurrence  of  parotitis,  abscesses,  furuncles,  hepatitis,  or  diar- 
rihoea.  In  mild  cases,  on  the  contrary,  the  patient  frequently  is  out 
of  bed  and  ready  to  resume  his  usual  occupations  within  a  day  or  two 
after  the  termination  of  the  febrile  paroxysm.  Army  experience  shows 
that  those  attacked  are  rarely  able  to  resume  their  duties  in  a  less  time 
than  ten  days  or  a  fortnight  from  the  date  of  attack,  and  that  a  consid- 
erable number  must  be  retained  in  hospital  a  month  or  more,  on  account 
of  the  debility  following  a  severe  attack. 

Relapses  are  not  infrequent  as  a  result  of  some  indiscretion  com- 
mitted during  the  early  period  of  apparent  convalescence  or  during  the 
second  stage  of  the  disease.  Relapses  are  said  to  occur  occasionally  as 
late  as  from  two  to  four  weeks  after  the  termination  of  the  primary 
febrile  paroxysm. 

Diagnosis. — A  prompt  diagnosis,  especially  of  the  first  cases  in  an 
epidemic,  is  often  a  matter  of  very  great  importance.  But  notwith- 
standing the  well  marked  clinical  features  of  the  disease  and  its  charac- 
teristic pathological  lesions,  the  diagnosis  of  early  cases  has  often  been  a 
matter  of  dispute,  even  after  the  autopsy.     This  may  be  due  to  inex- 


288  YELLOW  FEVER. 

perience  on  the  part  of  physicians  encountering  it  for  the  first  time,  or 
to  mistaken  ideas  as  to  the  nature  of  the  disease  among  those  who  have 
seen  much  of  it,  but  have  failed  to  recognize  its  specific  character  and 
to  differentiate  it  from  certain  fevers  of  malarial  origin  encountered  in 
tropical  or  subtropical  regions.  When  a  case  of  yellow  fever  is  im- 
properly diagnosed  as  "  bilious  fever "  or  "  remittent  fever,"  and  after 
the  administration  of  several  full  doses  of  quinine  at  the  end  of  three 
or  four  days  the  temperature  falls  to  the  normal,  the  diagnosis  is  sup- 
posed to  be  confirmed,  and  this  defervescence,  which  is  a  characteristic 
feature  of  the  disease,  is  supposed  to  have  resulted  from  appropriate 
medication.  If  the  case  results  fatally,  the  prejudice  which  so  often 
goes  with  a  positive  but  mistaken  diagnosis  sometimes  leads  to  the  asser- 
tion that  the  case  was  one  of  "  pernicious  malarial  fever."  Formerly  a 
considerable  number  of  the  physicians  in  our  Southern  seaport  cities 
maintained  that  yellow  fever  and  the  malarial  fevers  are  closely  allied 
if  not  identical  diseases,  and  under  this  idea  the  milder  cases  in  an 
epidemic  were  often  called  "  malarial  fever,"  and  only  those  in  which 
black  vomit  and  a  yellow  discoloration  of  the  skin  completed  the 
clinical  picture  of  a  severe  case  were  recognized  as  yellow  fever.  Simi- 
lar mistakes  in  diagnosis  occur  not  infrequently  at  the  present  day 
in  some  of  the  Spanish -American  seaports  where  this  disease  is  most 
prevalent. 

The  fact  that  the  early  cases  in  an  epidemic  are  sometimes  of  a  mild 
character  has  led  to  much  confusion  in  attempts  to  trace  the  origin  of 
certain  outbreaks.  These  early  cases  having  been  called  by  some  other 
name,  it  is  not  until  a  typical  severe  or  fatal  case  occurs  that  a  diagnosis 
of  yellow  fever  is  made  :  this  being  considered  the  first  case,  the  origin 
of  the  epidemic  which  follows  remains  a  mystery,  or  it  is  supposed  to 
have  originated  de  novo  as  a  result  of  insanitary  conditions  which  it  is 
not  difficult  to  discover. 

There  is  nothing  in  the  symptoms  at  the  outset  of  an  attack  of  yellow 
fever  which  will  justify  a  positive  diagnosis  in  the  absence  of  a  prevail- 
ing epidemic.  The  chill  followed  by  fever,  with  flushed  face,  injected 
conjunctivae,  full  pulse,  frontal  headache,  and  lumbar  pains,  might  mean 
smallpox  or  some  other  eruptive  fever  or  an  attack  of  one  of  the  malarial 
fevers.  But  the  eruptive  fevers  will  soon  be  ruled  out  by  the  absence 
of  an  eruption  ;  intermittent  fever,  by  the  brief  duration  of  the  paroxysm 
and  speedy  return  to  a  nearly  normal  state  of  health ;  remittent  fever 
after  two  or  three  days,  by  the  difference  in  the  temperature  curve  and 
the  absence  of  albumin  from  the  urine.  It  is  true  that  in  certain  severe 
forms  of  malarial  fever  the  urine  may  contain  albumin,  but  this  is  not  an 
early  symptom  in  these  cases,  and  does  not  greatly  detract  from  the 
diagnostic  value  of  this  symptom.  In  yellow  fever,  even  when  the 
attack  is  of  a  mild  character,  a  distinct  deposit  of  albumin  will  usually 
be  obtained  by  the  third  or  fourth  day,  and  in  cases  of  moderate  severity 
the  precipitate  will  be  so  abundant  as  to  justify  a  positive  diagnosis  as 
early  as  this  (third  or  fourth  day)  when  this  symptom  is  considered  in 
connection  with  the  temperature,  the  pulse,  etc.  Or  if  doubt  still  exists, 
the  symptoms  which  characterize  the  second  stage  of  the  disease  will 
serve  to  differentiate  it  from  those  forms  of  malarial  fever  for  which  it 
has  most  often  been  mistaken.    As  an  aid  to  diagnosis  I  introduce  here 


nfA(;y(MSis. 


289 


scvt'i-al  ti'iupcratuiv  charts  of  typical  cases  which  show  tlie  characteristic 
features  of  the  febrile  paroxysm  : 


] 

Kk 

i.   3 

1. 

a! 

S 
liJ 

1- 

DAY  OF  DISEASE 

I 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14     1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

103 

\ 

V 

102 

\ 

\ 

101 

\ 

1 

100 

Ce 

se 

1 

\ 

Case 

2 

99 

\ 

u 

- 

98 

104 

103 

/ 

[l 

L 

102 

\ 

V 

Ca 

se 

3 

/ 

■»«, 

Ca 

se 

4 

101 

A 

V 

1 

1 

1 

100 

^ 

1 

\ 

/ 

V 

I 

> 

1  A  A  i 

99 

\ 

y.Kh 

J 

U 

\m 

WYl 

98 

^ 

J 

V 

^ 

V 

Y 

V 

y 

1 

105 

^ 

■*! 

/ 

■/ 

104 

/ 

;V, 

103 

Cc 

se 

5 

W 

Ca 

se 

6 

102 

/ 

' 

101 

\ 

\ 

\ 

\ 

100 

^ 

iA 

\ 

/ 

i. 

jT 

*> 

<w 

/ 

■^ 

99 

r 

V 

/ 

V 

►-> 

r 

\ 

98 

V 

!\ 

\ 

105 

A 

104' 

r 

V\a 

y 

/^ 

\ 

103' 

y 

I 

Ca 

se 

7 

1 

Cc 

se 

8 

102' 

1 

\ri 

A 

K 

>» 

A 

101 

/ 

V 

\ 

,v 

V 

^ 

looi 

V 

\ 

A 

/ 

^ 

7 

99 

\ 

/ 

/ 

4 

^ 

^ 

98 

1 

Cases  Represented  by  Temperature  Chaiis. 

Xo.  1.  ^lild  case  of  brief  duration  ;  boy,  aged  three  vears  (Xew 
Orleans,  1873)  ;   reported  by  Dr.  T.  C.  Faget. 

Xo.  2.  Mild  case  of  brief  duration  ;  young  female  (Xew  Orleans, 
1873) ;  reported  by  Dr.  Touatre. 

Vol.  I.— 19 


290  YELLOW  FEVER. 

No.  3.  Protracted  mild  case  ;  male,  aged  twenty-seven  years  (Fort 
Barrancas,  Fla.,  1873) ;  reported  by  Dr.  Sternberg. 

No.  4.  Typical  case  of  moderate  severity  ;  male,  aged  thirty-one  years 
(Fort  Barrancas,  Fla.,  1873) ;  reported  by  Dr.  Sternberg. 

No.  5.  Typical  severe  case ;  male,  aged  twenty-seven  (Fort  Barran- 
cas, Fla.,  1873) ;  reported  by  Dr.  Sternberg. 

No.  6.  Typical  severe  case  ;  male,  aged  twenty-seven  years  (New 
Orleans,  1873) ;  reported  by  Dr.  Layton. 

No.  7.  Protracted  severe  case  ending  in  recovery ;  reported  by 
Berenger-Feraud  (French  Antilles). 

No.  8.  Fatal  case ;  death  on  ninth  day  ;  male,  aged  twenty-eight 
(Fort  Barrancas,  Fla.,  1873) ;  reported  by  Dr.  Sternberg. 

It  is  true  that  certain  cases  of  malarial  fever  exhibit  a  temperature 
curve  which  presents  considerable  similarity  to  that  of  yellow  fever,  but 
as  a  rule  "remittent  fever"  has  a  series  of  febrile  paroxysms  separated 
by  more  or  less  complete  remissions,  instead  of  a  single  paroxysm  of 
several  days'  duration  ending  in  defervescence,  complete  or  nearly  so. 

As  regards  the  presence  of  albumin  in  the  urine,  the  following  obser- 
vations by  Donnet,  made  during  an  epidemic  in  Jamaica,  are  of  interest : 
In  61  cases,  carefully  studied,  albumin  was  found  for  the  first  time  on 
the  first  day  in  2  ;  on  the  second  day  in  11 ;  on  the  third  day  in  19  ;  on 
the  fourth  day  in  14 ;  on  the  fifth  day  in  6  ;  on  the  sixth  day  in  4 ; 
on  the  seventh  day  in  4;   on  the  eighth  day  in  1. 

The  desquamative  nephritis  to  which  the  presence  of  albumin  is  due 
is  also  shown  by  the  presence  of  numerous  granular  casts  in  the  urine, 
which  may  usually  be  found  as  early  as  the  third  or  fourth  day. 

If  a  diagnosis  has  not  been  made  before,  the  symptoms  which  charac- 
terize the  second  period  of  the  disease  should  serve  to  diiferentiate  it 
from  all  forms  of  "  malarial  fever,"  properly  so  called.  The  cool  and 
usually  moist  skin,  the  abnormally  slow,  soft  pulse,  the  gastric  distress 
and  pain  or  pressure  in  the  epigastrium,  the  yellow  tinge  of  the  conjunc- 
tivae, and  the  albuminous  urine  in  a  patient  whose  temperature  is  normal 
or  subnormal,  following  a  febrile  paroxysm  such  as  is  represented  by  our 
temperature  charts,  certainly  furnish  a  clinical  picture  which  should  be 
recognized.  But  experience  shows  that  it  frequently  is  not  recognized, 
and  cases  which  present  the  additional  feature  of  black  vomit  have  been 
called  "  hemorrhagic  malarial  fever,"  "  pernicious  fever,"  etc. 

It  is  true  that  severe  cases  do  not  always  present  the  typical  course 
which  we  have  described  :  the  temperature  may  remain  a  degree  or  two 
above  the  normal  during  the  stage  of  depression  ;  the  skin  may  be  dry, 
and  a  reactionary  fever  of  a  remittent  character  may  quickly  follow  the 
initial  paroxysm  ;  but  we  still  have  the  albuminous  urine,  the  abnor- 
mally slow  pulse,  the  yellow  tinge  of  the  conjunctivse,  and  in  certain 
cases  the  hemorrhages  so  common  in  this  disease — black  vomit,  etc.  In 
addition  to  this  there  are  other  difPerences  in  symptoms  which  have 
more  or  less  value.  The  tongue  in  yellow  fever  is  usually  narrow  and 
pointed,  with  red  margins,  and  is  apt  to  be  tremulous ;  it  is  often  com- 
paratively clean  at  the  outset,  and  rarely  presents  the  thick  yellowish 
or  brownish  coating  seen  in  remittent  fever.  The  tongue  in  the  mala- 
rial fevers  is  usually  broad  and  flabby,  and  marked  upon  its  margins  by 
indentations  made  by  the  teeth.     The  yellow  color  of  the  skin  in  bilious 


DIAdSOSIS.  291 

remittent  fever  is  due  to  ii  .stainin<>;  by  liilc  pigments,  and  does  not  differ 
from  that  of  simple  jaundice  ;  it  is  more  intense  in  color  and  more  j)er- 
sistent  than  the  yellowish  tint  seen  in  yellow  fever  :  it  should  be  remem- 
bered, however,  that  a  true  biliary  jaundice  maybe  developed  in  xunx- 
fatal  eases  of  yellow  fever  durinu-  tlie  jx-riod  of  convalescence. 

The  spleen  is  not  involved  in  yellow  fever,  while  in  the  malarial 
fevers  it  is  more  or  less  swollen  and  tender.  Vomiting  of  bili(»iis  matter 
is  a  common  symptom  in  severe  forms  of  malarial  fever ;  in  yellow 
fever  it  is  rare,  and  only  occurs,  if  at  all,  at  the  outset  of  the  attack  ; 
the  vomited  matters  later  are  transparent  and  colorless.  In  yellow 
fever  the  amount  of  uric  acid  excreted  is  diminished,  Avhile,  according' 
to  La  Hoche,  it  is  notably  increased  in  remittent  fever.  Suppression 
of  urine  is  a  common  feature  in  fatal  cases  of  yellow  fever ;  it  rarely 
occurs  in  bilious  remittent  fever. 

That  form  of  fever  which  the  French  denominate  jievre  bilieuse 
meloiwrique,  and  which  has  been  called  "  hemorrhagic  malarial  fever" 
by  certain  American  authors,  presents  features  which  differ  essentially 
from  th(^se  of  yellow  fever.  These  are  well  stated  by  Berenger-Feraud, 
as  follows  : 

"  Prolonged  residence  in  a  malarial  country  is  the  most  powerful, 
and,  indeed,  indispensable,  predisposing  cause. 

*'  The  disease  is  always  preceded  by  numerous  attacks  of  malarial 
fever,  simple  at  first,  then  more  and  more  complicated,  and  taking  on 
in  general  more  and  more  of  a  bilious  aspect,  producing  a  very  decided 
anaemia. 

"  Icterus  appears  at  the  outset  of  the  attack,  and  is  never  wanting  ; 
it  gives  from  the  commencement  and  throughout  the  attack  a  uniform 
yellow  color  to  the  patient,  varying  from  greenish  yellow  to  a  decided 
yellow  ochre. 

"  The  march  is  intermittent  or  remittent  from  the  first,  and  the 
pulse,  urine,  and  vomiting  follow  very  exactly  the  variations  of  temper- 
ature. 

"  The  vomiting  is  bilious,  of  a  decided  green  color ;  it  is  a  constant 
symptom  at  the  outset  of  an  attack,  and  is  arrested  with  the  termina- 
tion of  one  attack  to  reappear  with  the  next. 

"  After  the  first,  or  febrile,  period  the  vomiting  continues,  but  pre- 
serves the  same  characters ;  it  stains  linen  a  bright  green,  and  when 
collected  in  a  basin  it  appears  transparent  and  is  of  a  beautiful  emerald 
green  or  olive  color. 

"  The  tongue  is  moist,  broad,  covered  at  first  with  a  heavy  white  fur, 
which  soon  receives  a  greenish  tint  from  the  vomited  matters.  The 
tongue  is  not  red,  either  upon  its  tip  or  edges  ;  it  remains  broad,  heavily 
coated,  and  moist  to  the  end  of  the  malady. 

"  The  urine  is  black  from  the  commencement,  and  its  color  is  cha- 
racteristic, so  that  the  patient  himself  is  struck  with  it.  It  is  usually 
abundant  and  frequently  passed,  and  only  has  the  melanuric  aspect  dur- 
ing the  attack." 

Dengue,  as  regards  its  epidemic  prevalence,  somewhat  resembles 
yellow  fever.  It  is  an  acute,  infectious  disease,  which  prevails  in  those 
latitudes  which  are  most  subject  to  invasion  by  yellow  fever  during  the 
season  most  favorable  for  the  epidemic  extension  of  this  disease.     It, 


292  YELLOW  FEVER. 

also,  is  characterized  by  a  febrile  stage  of  comparatively  short  duration, 
but  the  characteristic  features  of  yellow  fever  are  absent — albuminous 
urine,  stage  of  depression,  hemorrhages,  etc. — and  it  is  accompanied  by 
severe  arthritic  and  muscular  pains  which  have  led  to  its  being  called 
"  breakbone  fever."  Moreover,  there  is  usually  a  well  marked  eruption, 
resembling  that  of  scarlet  fever  and  commencing  on  the  third  day,  and 
after  the  termination  of  the  initial  febrile  paroxysm  a  second  commonly 
occurs,  accom])anied  by  a  rubeoloid  eruption  which  often  ends  in  des- 
quamation of  the  cuticle.  There  is  a  wide  difference  also  in  the  com- 
parative fatality  of  the  two  diseases.  Dengue,  although  the  most  dis- 
tressing to  the  patient,  is  by  far  the  least  serious  in  its  results,  and  rarely 
is  the  cause  of  death. 

Certain  circumstances  connected  with  the  personal  history  of  the 
patient  will  aid  greatly  in  establishing  an  early  diagnosis.  A  stranger 
in  Havana  or  Rio  de  Janeiro  during  the  epidemic  season,  who  has  an 
attack  of  fever  presenting  the  symptoms  described  as  attending  the 
febrile  stage  of  this  disease,  and  whose  urine  is  found  at  the  end  of  two 
or  three  days  to  be  albuminous,  is  sent  without  hesitation  to  the  yellow 
fever  hospital.  And  a  person  arriving  at  one  of  our  seaports  from  an 
infected  locality,  presenting  similar  symptoms,  would  be  isolated  and 
placed  under  careful  observation,  even  if  the  diagnosis  was  not  at  once 
established.  But  in  a  similar  case,  with  no  history  of  exposure  in  an 
infected  locality,  there  is  often  doubt  as  to  the  diagnosis  or  an  absolute 
denial  of  the  possibility  that  the  disease  is  yellow  fever. 

When  we  hear  of  the  prevalence  of  a  "  malignant  form  of  malarial 
fever"  in  a  seaport  city  located  within  the  limits  of  yellow  fever  inva- 
sion, we  are  always  justified  in  suspecting  that  the  disease  is  in  fact 
yellow  fever.  For  malignant  and  fatal  forms  of  malarial  fever  belong 
to  the  country  rather  than  to  the  city,  and  cases  of  this  kind  do  not 
occur  in  groups  among  the  residents  of  a  restricted  area  within  the  limits 
of  a  city.  Even  when  a  localized  epidemic  does  not  appear  to  be 
"malignant"  in  character,  especially  when  it  occurs  among  a  native 
Creole  or  negro  population,  the  fact  of  its  prevalence  in  a  large  town  or 
city  is  opposed  to  the  view  that  it  is  of  malarial  origin — properly  so 
called — and  it  is  more  likely  to  be  yellow  fever  than  anything  else, 
unless,  indeed,  it  should  prove  to  be  dengue. 

Prognosis. — Yellow  fever  is  an  extremely  fatal  disease,  and  even  in 
apparently  mild  cases  a  guarded  prognosis  should  be  made,  as  they  may 
suddenly  assume  a  serious  character.  The  prognosis  is  especially  unfa- 
vorable in  the  case  of  plethoric  persons  and  in  those  of  intemperate 
habits.  It  is  more  favorable  in  women  and  children  than  in  men — 
more  favorable  in  the  case  of  native  Creoles  and  negroes,  in  warm  lati- 
tudes where  the  disease  prevails,  than  for  recently  arrived  strangers 
from  more  northern  latitudes. 

The  writer's  personal  observations  and  studies  have  led  him  to 
attach  great  value  to  the  temperature  observations  made  during  the  first 
two  or  three  days  of  the  attack  as  a  guide  in  prognosis.  When  the 
temperature  of  the  body,  as  shown  by  a  clinical  thermometer  placed  in 
the  mouth  or  axilla,  does  not  go  above  103°  to  103^°  F.  during  the  first 
forty-eight  hours,  a  favorable  result  may  usually  be  anticipated.  If,  on 
the  contrary,  the  temperature  reaches   105°  or  more,  the  case  must  be 


viO(J^'(),sh^. 


293 


considered  a  severe  one  and  the  prognosis  is  orave.  This  is  shown  by 
tlie  foll»)\vin«i-  table,  ('onij)iled  by  the  writer  some  years  since  from  u 
series  of  2(j!)  cases  recorded  by  various  authoi's,  in  which  careful  tem- 
perature observations  had  been  made  : 


Cases  in  w iiii-h  ilio  teiuperaturo  was 

107°  and  above 

U)0°-1U7°   

105°-] 0G°    

104°-10r)° 

103"-104°   

102°-103°       

10r-102° 

Total 


No.  of  cases. 


13 


36 
80 

87 
29 
15 


269 


No.  of  deaths. 


13 
9 

22 

24 

6 

0 

0 


74 


I'cTcc'iitaKo  <jf 
deatlis  to  oases. 


100 
100 

61 

30 
7,  nearly 


27.5 


The  amount  of  urine  secreted  and  the  quantity  of  albumin  it  con- 
tains will  also  furnish  an  important  prognostic  indication.  However 
favorable  the  symptoms  may  appear  otherwise,  if  the  urinary  secretion 
is  scanty  and  it  is  heavily  loaded  with  albumin,  the  case  is  a  grave  one. 
On  the  other  hand,  great  depression,  black  vomit,  or  hemorrhages  are 
not  necessarily  fatal  symptoms,  and  hopes  of  recovery  may  be  enter- 
tained if  the  urinary  secretion  is  satisfactory  in  amount  and  the 
quantity  of  albumin  small.  Great  distress  and  tenderness  in  the 
epigastric  region,  Avith  frequent  vomiting,  are  unfavorable,  as  is  great 
restlessness  with  sighing  respiration  or  delirium.  The  early  appear- 
ance of  the  hsematogenous  jaundice  characteristic  of  the  disease  is  not 
favorable. 

The  mortality  differs  greatly  in  different  epidemics,  and,  as  hereto- 
fore pointed  out,  depends  largely  upon  the  character  of  the  exposed 
population.  AVhere  a  considerable  proportion  of  those  attacked  are 
children,  native  Creoles,  or  negroes,  the  mortality  is  comparatively  low 
— from  5  to  10  per  cent.  But  among  unacclimated  male  adults  the 
mortality  is  rarely  less  than  20  and  frequently  above  50  per  cent.  The 
mortality  in  the  great  epidemics  which  occurred  in  Philadelphia  at  the 
end  of  the  last  and  commencement  of  the  present  century  was  from  20 
to  80  per  cent.  The  mortality  in  the  seaman's  hospital  at  Georgetown 
(Demerara)  in  1838  was  19.5  per  cent.  (Blair).  The  mortality  at  Vera 
Cruz  during  the  seven  years  ending  1881  was  41  per  cent,  in  the  hos- 
pital for  women  and  41.48  per  cent,  in  the  hospital  for  men  (Molina). 
In  1855  the  mortality  among  the  Spanish  stroops  in  Cuba  w^as  24.31 
per  cent.  In  1873  the  mortality  in  Rio  de  Janeiro  was  23.3  per  cent. 
In  the  epidemic  of  1878,  27,000  cases  and  4600  deaths  occurred  in 
the  city  of  New  Orleans  (17  per  cent.)  ;  18,500  cases  and  5000  deaths 
in  Memphis  (27  per  cent.) ;  at  Ticksburg  5000  cases  and  872  deaths 
(17  per  cent.)  —  2000  cases  and  231  deaths  among  the  colored  popula- 
tion. These  figures  are  from  the  re]iort  of  a  "  Board  of  Experts " 
appointed  by  Congress  to  investigate  the  epidemic.  The  total  number 
of  cases  and  deaths  collected  by  the  Board,  as  occurring  in  132  cities 
and  towns  in  the  infected  area,  was — cases  74,265;  deaths  15,934 
(besides   254  "  reported  without  any  report   for  the   number   of  cases 


294 


YELLOW  FEVER. 


corresponding  thereto ").  This  gives  a  mortality  of  a  little  over  21 
per  cent,  for  the  entire  epidemic.  These  figures,  however,  are  only 
approximate,  and  no  doubt  the  mortality  rate  would  be  reduced  some- 
what if  all  of  the  cases  had  been  reported.  It  must  be  remembered 
also  that  the  figures  relate  to  both  the  white  and  colored  populations, 
and  that  in  many  localities  the  negro  population  was  equal  to  or  in 
excess  of  the  white  population,  as  many  of  the  latter  class  deserted 
their  homes  and  sought  refuge  in  healthy  places  farther  north.  Bemiss 
has  given  the  following  table  showing  the  mortality  according  to  age, 
among  whites  only,  during  this  epidemic.  The  figures  include  the  cases 
treated  in  private  practice  by  four  of  the  leading  practitioners  of  the 
city  of  New  Orleans  : 


Age. 

Under  5  years  of  age     .    . 
From  5  to  10  years  of  age 
From  10  to  20  years  of  age 
From  20  to  40  years  of  age 
From  40  to  60  years  of  age 
From  60  to  80  years  of  age 

Total 


905 


Cases. 

Deaths. 

Per  cent. 

206 

26 

12.67 

233 

20 

8.58 

183 

9 

4.9 

232 

39 

16.7 

47 

6 

12.7 

4 

2 

50.0 

102 


11.28 


The  day  of  death,  as  ascertained  in  1059  fatal  cases  occurring  in  the 
French  Antilles,  is  given  by  Berenger-Feraud  as  follows  :  On  the  second 
day  of  sickness,  16  (1.5  per  cent.) ;  on  the  third  day,  56  (5.3  per  cent.) ; 
on  the  fourth  day,  141  (13.4  per  cent.)  ;  on  the  fifth  day,  165  (15.7  per 
cent.) ;  on  the  sixth  day,  177  (16.9  per  cent.) ;  on  the  seventh  day,  151 
(14.3  per  cent.)  ;  on  the  eighth  day,  89  (8.5  per  cent.) ;  on  the  ninth 
day,  42  (3.9  per  cent.) ;  on  the  tenth  day  35  (3.3  per  cent.) ;  on  the 
eleventh  day,  28  (2.6  per  cent.) ;  on  the  twelfth  day,  34  (3.2  per  cent.) ; 
on  the  thirteenth  day,  25  (2.3  per  cent.) ;  on  the  fourteenth  day,  21  (1.9 
per  cent.) ;  on  the  fifteenth  day,  8  (0.7  per  cent.) ;  on  the  sixteenth  day, 
7  (0.6  per  cent.)  ;  on  the  seventeenth  day,  13  (1.2  per  cent.) ;  on  the 
eighteenth  day,  6  ;  nineteenth  day,  6  ;  twentieth  day,  7  ;  twenty-first 
day,  3 ;  twenty-second  day,  2 ;  twenty-third  day,  5 ;  twenty-fourth  day, 
3 ;  twenty-fifth  day,  3 ;  twenty-sixth  day,  5 ;  twenty-seventh  day,  1 ; 
twenty-eighth  day,  1 ;  twenty-ninth  day,  2 ;  thirtieth  day,  1  ;  thirty-first 
day,  3 ;  thirty-second  day,  1  ;  thirty-third  day,  1  ;  thirty-sixth  day,  1. 
Out  of  the  total  number  of  deaths,  67  per  cent,  occurred  during  the 
first  week  and  82  per  cent,  during  the  first  ten  days  of  sickness.  This 
corresponds  closely  with  the  results  obtained  by  Surgeon  Clements  as 
regards  111  fatal  cases  occurring  in  the  U.  S.  Army.  Of  these,  73  per 
cent,  died  during  the  first  week  and  82  per  cent,  during  the  first  ten  days. 

Treatment. — All  attempts  to  "  cure  "  yellow  fever  by  a  specific 
treatment  have  been  unsuccessful,  and  those  physicians  who  have  had 
most  experience  in  the  treatment  of  the  disease  generally  agree  that 
active  medication,  except  for  the  purpose  of  meeting  symptomatic  indi- 
cations, is  mischievous.  But  it  is  possible  that  a  specific  treatment  may 
yet  be  found,  and  further  efforts  should  be  made  in  this  direction. 
Reasoning  from  analogy,  it  seems  probable  that  the  immunity  which 
results  from  an  attack  of  yellow  fever  is  due  to  the  presence  of  an  anti- 


TRKATMEST.  295 

toxin  in  the  body  fluids  of  the  inininnc  individual.  And  if  this  anti- 
toxin eould  he  utilized  for  the  protection  of  exposed  individuals  oi-  ior 
the  cure  of  those  already  attacked,  its  s[)ecitie  power  niii;ht  he  mani- 
fested, l^ut  in  the  present  state  of  kno\vled<;e  there  are  serious  dii- 
ficulties  in  the  way  of  testing  the  possible  efficacy  of  such  a  specific 
mode  of  treatment.  The  speeiiic  infectious  ajjent  not  having  been 
demonstrated,  and  no  one  of  the  lower  animals  havino;  been  shown  to 
be  susceptible  to  infection,  the  only  method  which  suoocsts  itself  for 
obtaininii'  a  supply  of  antitoxin  is  to  tap  the  veins  of  an  immune  pi'rson 
for  the  purpose  of  obtaining  blood  serum  to  inject  into  the  vellow  fever 
patient.  It  is  to  be  hoped  that  the  experiment  will  be  made  at  as  earlv 
a  date  as  possible,  as  the  result  would  be  of  great  scientific  interest,  and 
if  favorable  some  method  of  more  general  utility  might  ho  disco\ered. 

The  idea  that  yellow  fever  is  closely  allied  to  the  malarial  fevers, 
which  at  one  time  was  entertained  by  many  physicians  in  regions  subject 
to  invasion,  led  to  the  attempt  to  abort  the  disease  by  the  use  of  (piinine 
in  large  doses.  This  experiment  has  been  fully  tried,  and  the  treatment 
abandoned  by  most  physicians  of  experience.  Some,  however,  still 
think  that  a  large  dose  of  quiuine  (20  to  30  grains),  given  at  the  outset 
of  the  attack,  has  a  favorable  effect  in  modifying  the  severity  of  the 
febrile  paroxysm  and  allaying  nervous  excitement.  On  the  other  hand, 
it  is  generally  admitted  that  it  sometimes  induces  cerebral  congestion, 
and  that  a  repetition  of  the  dose  may  lead  to  unpleasant  results.  Blair, 
who  had  an  extended  experience  in  the  British  West  Indies,  was  in  the 
habit  of  giving  20  grains  of  calomel  and  25  grains  of  quinine  at  the 
outset  of  an  attack,  and  in  certain  cases  the  dose  was  repeated.  Dr. 
Porcher  of  Charleston  approves  of  Blair's  treatment  so  far  as  the  first 
dose  is  concerned,  but  protests  against  its  repetition.  The  amelioration 
of  the  symptoms  which  has  been  ascribed  to  this  dose  may  be  due  in 
part  to  the  antipyretic  action  of  the  quinine,  but  the  free  movement  of 
the  bowels  usually  induced  by  the  calomel  is  entitled  to  at  least  a  portion 
of  the  credit.  It  must  be  remembered  also  that  the  natural  tendency 
of  the  disease  is  in  the  direction  of  a  more  or  less  prompt  defervescence, 
and  that  the  acme  of  febrile  action,  with  its  accompanying  headache, 
pain  in  the  loins,  etc.,  is  reached  very  soon  after  the  inauguration  of  the 
attack.  This  amelioration  of  the  symptoms  attending  the  onset  of  the 
disease  has  no  doubt  often  been  improperly  ascribed  to  the  medicine 
administered,  and  the  novice  in  the  treatment  of  this  disease  is  apt  to 
congratulate  liimself  upon  the  success  of  his  treatment  when  the  patient 
is  in  reality  in  the  greatest  danger — a  danger  which  may  be  the  greater  as 
a  result  of  over-active  medication,  by  which  the  sensitive  stomach  is  apt 
to  be  disturbed,  the  weak  heart  still  further  enfeebled,  and  the  inflamed 
kidneys  taxed  beyond  their  power  of  resistance. 

In  the  days  of  "  antiphlogistic  treatment "  emetics  were  considered 
an  important  element  in  this  treatment,  and  it  was  part  of  the  rou- 
tine to  administer  them  at  the  outset  of  every  case.  This  is  still 
the  practice  with  certain  of  the  South  American  physicians.  AA'hen 
the  stomach  contains  undigested  and  fermenting  material  which  causes 
nausea  and  distress,  it  is  well  to  aid  the  efforts  of  nature  by  the 
administration  of  a  simple  emetic,  otherwise  it  is  not  likely  to 
do  any  good,  and    m'c    do    not    approve    of  its    routine    use.     Purga- 


296  YELLOW  FEVER. 

'  lives  are  generally  believed  to  be  useful  at  the  outset  of  an  attack, 
and  most  physicians  commence  the  treatment  by  giving  some  medi- 
cine to  promptly  unload  the  bowels.  Opinions  dilfer  as  to  the  best 
form  of  cathartic  medicine,  but  preference  is  given  by  many  to  a  full 
dose  of  oleum  ricini.  On  account  of  its  non-irritating  properties  and 
prompt  action  it  is  a  favorite  in  our  own  Southern  cities,  in  the  West 
Indies,  and  in  Brazil.  From  two  to  four  ounces  are  commonly  given  to 
an  adult  in  a  single  dose.  Experience  shows  that  this  is  not  excessive 
and  that  it  has  a  prompt  and  favorable  action.  Some  physicians  prefer 
a  mercurial,  followed,  if  necessary,  by  a  saline  cathartic,  and  calomel  is 
still  the  favorite  with  many.  One  reason  for  promptly  emptying  the 
primm  vice  is  found  in  the  fact  that  later  the  administration  of  cathartic 
medicine  is  likely  to  do  harm  by  inducing  vomiting  difficult  to  control, 
and  by  increasing  the  depression  which  follows  the  febrile  paroxysm. 
If  it  seems  desirable  to  move  the  bowels  after  the  second  day  of  the  dis- 
ease, this  had  better  be  done  by  a  purgative  enema. 

In  the  present  state  of  knowledge  a  carefully  managed  symptomatic 
treatment  will  give  the  best  results  attainable  and  will  do  much  toward 
reducing  the  mortality.  We  have  pointed  out  the  fact,  in  speaking  of 
prognosis,  that  the  temperature  of  the  body,  as  shown  by  the  clinical 
thermometer,  is  a  fair  index  of  the  severity  of  the  attack.  It  does  not 
follow  from  this  that  the  high  temperature  in  severe  cases  is,  pjer  se,  a 
cause  of  danger.  If  this  were  true,  the  evident  indication  would  be  to 
keep  down  the  temperature  by  means  of  cold  baths  or  antipyretic  medi- 
cines. The  intensity  of  the  pathogenic  action  of  the  specific  poison  is 
indicated  by  the  height  and  duration  of  the  febrile  movement,  but  we  do 
not  neutralize  the  pathogenic  action  when  we  reduce  the  temperature  of 
the  body.  In  the  malarial  fevers  the  temperature  frequently  rises  to  a 
higher  point  in  cases  which  are  not  attended  with  any  special  danger. 
Nevertheless,  it  is  desirable  that  this  symptom — high  temperature — 
should  receive  appropriate  treatment,  and  a  reduction  of  the  febrile  heat 
is  usually  attended  with  an  amelioration  of  other  more  or  less  distressing 
symptoms — thirst,  headache,  sleeplessness,  jactitation,  etc. 

The  use  of  the  cold  bath  is  not  to  be  recommended,  unless  it  should 
be  at  the  very  outset  in  a  case  presenting  an  unusually  high  temperature 
with  evidence  of  cerebral  congestion.  The  tepid  bath  is  better,  but  the 
most  judicious  and  experienced  practitioners  in  yellow  fever  regions 
agree  that  it  is  better  not  to  disturb  the  patient  to  the  extent  necessary 
in  administering  frequent  baths,  and  that  after  the  first  twenty-four 
hours,  at  least,  they  had  better  be  omitted.  The  object  in  view  may  be 
accomplished  with  less  disturbance  to  the  patient  by  frequently  sponging 
the  hands,  arms,  and  chest  with  cold  water  or  with  an  evaporating 
lotion.  Berenger-F^raud  recommends  a  mixture  of  1  part  of  "  aromatic 
alcohol"  with  3  parts  of  water.  Porcher  advises  the  "assiduous  and 
protracted  application  of  ice-cold  water  to  the  head,  hands,  and  arms  as 
long  as  they  are  abnormally  hot."  Some  practitioners  are  afraid  of  cold 
water  and  prefer  to  sponge  the  surface  with  tepid  water.  In  our  judg- 
ment, cold  water  and  evaporating  lotions  may  safely  be  used  as  appli- 
cations to  the  head  and  for  sponging  the  surface  so  long  as  the  skin  is 
hot  and  dry  and  the  temperature  elevated.  When,  however,  the  febrile 
stage  is  approaching  its  termination,  it  will  be  prudent  to  discontinue 


TllKATMF.Sr.  297 

tho  spoiiiiiiio;  of  the  surfhco  or  to  use  tepid  instead  of  cold  water,  on 
aet'oiint  of  tlie  <;reat  tendeney  to  visceral  eonn;estions  at  this  time.  A 
hot  mustard  foot-bath  is  very  commonly  administered  at  the  outset  of 
the  attack  in  domestic  practice  and  l)y  many  physicians  of  experience. 
This  may  he  rejieated  several  times  durin>>-  the  first  twentv-four  hours, 
and  often  induces  a  free  ])ers])iration,  with  relief  of  the  headaclie  au(l 
other  distrcssiuii"  sym})t(>ms  which  occur  at  this  time.  The  usual  j)ro- 
cedure  is  to  have  the  j)atient  sit  \\\)im  the  edge  of  his  bed  with  a  blanket 
wrapped  around  him  and  his  feet  and  legs  immersed  in  a  bucket  of  Avater 
as  hot  as  he  can  bear  and  containing-  a  liberal  quantity  of  mustard  flour. 

Berenger-Feraud  recommends  the  use  of  large  enemata  of  cold  water 
as  an  antipyretic  measure.  These  may  be  frecpiently  repeated,  and  are 
said  to  be  (piite  harmless.  Cold  enemata  have  also  been  recommended 
for  the  relief  of  the  congested  and  inflamed  kidneys. 

The  knowledge  that  exposure  to  cool  currents  of  air  or  a  sudden  fall 
in  the  external  temperature  is  dangerous  for  yellow  fever  patients  on 
accounl  of  the  visceral  congestions  which  are  likely  to  be  induced  by 
such  exposure — especially  of  the  kidneys — has  led  many  ])hysicians  to 
refrain  from  the  use  of  cold  lotions  to  the  surface  as  an  antipyretic 
measure,  and  by  some  the  use  of  cold  drinks  is  denied.  This  we  believe 
to  be  a  mistake,  and  the  excessive  use  of  blankets  and  hot  drinks  to 
induce  perspiration  may  cause  great  discomfort  to  the  poor  patient  with- 
out any  corresponding  benefit.  AVhen  the  febrile  stage  is  ap})roaching 
its  termination,  and  during  the  stage  of  depression  which  follows,  ex- 
posure to  cold  currents  of  air  or  a  sudden  fall  in  the  external  tem])era- 
ture,  not  compensated  by  artificial  heat  or  a  sufficient  supply  of  bed- 
covering,  may  be  fatal.  But  when  there  is  considerable  fever  the  patient 
should  be  lightly  covered,  care  being  taken,  however,  to  protect  him 
from  draughts.  If  the  skin  is  hot  and  dry,  warm  aromatic  drinks  may 
be  given  to  promote  perspiration,  but  it  is  a  mistake  to  suppose  that  the 
course  of  the  disease  can  be  arrested  or  the  deadly  poison  eliminated  by 
maintaining  a  free  perspiration ;  aiid  when  the  patient  is  loaded  dow^n 
with  blankets,  the  profuse  perspiration  which  is  often  induced  by  this 
treatment  does  not  materially  reduce  the  body  heat.  Antipyrine  has  been 
given  f(U'  its  sedative  and  anti]iyretic  effect,  and  is  considered  useful  by 
some  of  those  physicians  who  have  had  an  opportunity  to  test  its  value. 
AVe  should  be  disposed  to  administer  it  with  caution  and  during  the 
acme  of  febrile  heat  only — prefera1)lv  at  night,  with  a  view  to  securing 
rest. 

The  use  of  arterial  sedatives  in  small  but  repeated  doses  is  approved 
by  many  experienced  physicians  :  they  may  reduce  the  febrile  action  to 
some  extent.  Aconite  mav  be  given  in  combination  with  some  mild 
diaphoretic  during  the  first  day  or  tAvo  ;  later,  (JIf/ifalis  will  be  prefer- 
able on  account  of  the  tendency  to  heart  failure,  Bemiss  says  :  "  We 
have  seen  digitalis  produce  unquestionably  good  effect  in  mitigating 
fever,  and  have  often  administered  it  in  doses  of  thirty  to  sixty  drops 
of  the  tincture  every  third  or  fourth  hour.  It  is  best  to  give  it  in  solu- 
tions of  acetate  of  ammonia  or  potash."  AVe  should  prefer  to  give  it,  in 
proper  doses,  with  a  solution  of  sodium  bicarbonate  in  ice-cold  Avater, 
administered  as  recommended  by  the  Avriter  in  1887. 

Bicarbonate  of  soda  has  frequently  been  prescribed  as  an  occasional 


298  YELLOW  FEVEB. 

dose  to  neutralize  the  acid  secretions  of  the  stomach  and  to  allay  vom- 
iting, but  in  the  treatment  above  referred  to  the  writer  proposed,  by  the 
systematic  administration  of  this  salt,  to  neutralize  the  acid  secretions 
from  the  outset,  and  thus  to  prevent,  if  possible,  the  nausea  and  vomit- 
ing which  are  so  frequently  distressing  features  of  the  disease.  An 
alkaline  treatment  seemed  to  be  indicated  also  by  the  highly  acid  condi- 
tion of  the  urine,  and  it  was  hoped  that  it  might  have  a  favorable  action 
on  the  kidneys.  And  on  theoretical  grounds  it  was  thought  that  it 
might  be  well  to  administer  at  the  same  time  the  powerful  antiseptic, 
mercuric  chloride,  in  a  minute  and  perfectly  safe  dose.  Accordingly 
the  following  prescription  was  made  : 

I^.  Bicarbonate  of  soda,  10.       (150  gr.). 

Bichloride  of  mercury,  0.02  (^  gr.). 

Pure  water,  1000.       (1  qt.). 

M.  Sig.  50  cc.  (3  tablespoonfuls)  every  hour ;  to  be  given  ice-cold. 

Another  object  in  view  was  to  give  a  moderate  quantity  of  ice-cold 
water  at  regular  intervals,  as  this  would  be  less  likely  to  induce  vomit- 
ing than  larger  amounts  taken  at  the  patient's  option,  and  if  absorbed 
would  quench  thirst  better  than  larger  quantities  quickly  rejected.  I 
have  had  no  personal  experience  in  the  treatment  of  yellow  fever  since 
this  plan  was  suggested,  but  have  received  very  favorable  reports  as  to 
its  value  from  various  sources. 

The  treatment  referred  to  has  been  tested  by  a  number  of  physicians 
in  the  United  States,  in  Cuba,  and  in  Brazil,  and  I  have  had  reports  of 
374  cases  treated  by  ten  physicians.  -  Of  these,  301  were  whites,  with  a 
mortality  of  7.3  per  cent,  and  73  cases  blacks,  with  no  mortality. 

During  the  last  epidemic  at  Jacksonville,  Florida  (1888),  Sollace 
Mitchell  treated  106  cases  in  the  "  Sand  Hills  Hospital "  with  5  deaths 
— a  mortality  of  4.7  per  cent.  Of  the  106  cases,  79  were  whites,  and 
of  this  number  73  were  adult  males.  All  of  the  deaths  occurred  among 
these,  and  the  mortality  among  this  class,  considered  separately,  was 
6.8  per  cent. 

La  Guardia  and  Martinez  in  1889  treated  44  cases  in  the  Mer- 
cedes Hospital,  Havana,  with  a  mortality  of  15.9  per  cent.  They  say  : 
"  We  have  observed  the  following  facts  :  The  patients  have  offered  a 
notable  gastric  tolerance  during  the  medication  ;  when  treated  from  the 
first  day  vomiting  has  rarely  occurred.  The  secretion  of  urine  has 
always  been  considerable  ;  even  in  the  grave  cases,  when  death  occurred, 
they  did  not  die  anuric."  Whether  this  treatment  is  still  in  use  in  the 
Mercedes  Hospital  and  elsewhere  in  the  city  of  Havana  I  am  not  in- 
formed, but  the  evidence  published  is  certainly  sufficient  to  justify  a 
more  extended  trial.  To  what  extent  the  small  amount  of  mercuric 
chloride  added  to  the  formula  is  concerned  in  the  favorable  results 
reported  I  am  unable  to  determine.  This  salt  remains  in  solution  in 
presence  of  sodium  bicarbonate,  but  would  be  precipitated  by  potassium 
carbonate,  which  salt  is  also  contraindicated  in  a  disease  in  which  there 
is  a  tendency  to  ursemic  poisoning. 

The  addition  of  tincture  of  digitalis  in  suitable  doses  to  the  formula 
given  might  prove  to  be  an  advantage,  but  this  can  only  be  determined 


TRKATMKXT.  299 

bv  earottilly  condnotccl  clinical  experiments.  The  administration  of  the 
ice-cokl  alkaline  mixture  at  regular  intervals,  with  or  without  the 
addition  of  one  of  the  agents  mentioned,  appears  to  us  to  be  a  rational 
feature  in  the  symptomatic  treatment  of  tiie  disease,  and,  as  stated,  is 
supported  by  favorable  clinical  evidence. 

It  is  very  desirable  to  ])revent  vomiting,  inasmuch  as  the  attempt  to 
arrest  it  by  medicini's  administered  per  os  is  usually  a  failure.  Morphia 
given  hypodermieally  suggests  itself,  but  ex])erience  shows  that  this  is 
a  dangerous  remedy,  and  only  very  minute  doses  are  tolerated.  Blair 
has  seen  stupor,  prostration,  and  complete  narcotism  follow  the  admin- 
istrati<in  of  one  tenth  of  a  grain.  ^^\'  agree  with  him  that  it  should  be 
placed  in  the  IikJcv  e.rpmyatoriKs  so  far  as  yellow  fever  is  concerned. 

Diuretics  ajipear  to  be  indicated  on  account  of  the  scanty  secretion  of 
urine,  but  experience  teaches  that  they  are  of  little  value,  and  that  it  is 
better  to  relieve  the  strain  upon  the  hypersemic  and  inflamed  kidneys  by 
diaphoretics  and  revulsants  than  to  attempt  to  stimulate  them  to  greater 
activity.  When  there  is  a  tendency  to  suppression  the  application  of 
kirge  mustard  poultices  to  the  loins  and  the  use  of  cold  water  enemata, 
together  with  measures  appropriate  to  maintain  a  free  transpiration  by 
the  skin,  will  be  more  likely  to  give  relief  than  any  diuretic  medicine. 
After  complete  suppression  has  occurred  no  method  of  treatment  is  likely 
to  be  of  any  avail.  Where  the  skin  is  hot  and  dry  and  the  urinary 
secretion  scanty,  it  might  be  worth  while  to  administer  a  hypodermic  in- 
jection of  the  muriate  of  piloearpin  (0.008  to  0.016  gm.=  i  to  ^  grain). 
Hebersmith  reports  that  when  given  in  this  way  the  dose  mentioned  pro- 
duces a  profuse  perspiration  with  reduction  of  temperature. 

Cerebral  congestion  is  best  relieved  by  cold  applications  to  the  head 
and  sina2:)isms  applied  to  the  extremities.  The  feeling  of  weight  and 
distress  in  the  epigastric  region,  attended  with  nausea  and  due  to  hyper- 
semia  of  the  gastric  mucous  membrane,  also  calls  for  the  local  applica- 
tion of  cold — best  secured  by  swallowing  bits  of  ice  or  small  quantities 
of  ice-cold  water,  which  may  be  charged  with  COg — and  for  revulsion 
to  the  surface  by  sinapisms  applied  to  the  epigastrium.  These  often 
give  great  relief,  and  are  to  be  preferred  to  vesicants,  which  have  no 
special  advantage  over  sinapisms  for  the  relief  of  the  symptoms  referred 
to,  while  the  blistered  surface  gives  much  distress  to  the  patient  after  it 
has  ceased  to  do  any  good  as  a  revulsive. 

Stimulants  are  of  the  greatest  utility  in  the  second  stage  of  the  disease 
to  sustain  the  feeble  heart.  They  are  rarely  required  before  the  fourth 
day,  and  should  be  given  in  small  amounts,  so  as  not  to  provoke  vomit- 
ing. A  little  iced  champagne  will  often  be  retained  when  the  stomach 
rejects  everything  else,  or  brandy  given  ice-cold  and  with  the  addition 
of  very  little,  if  any,  water,  may  be  given  in  teaspoonful  doses  at  short 
intervals.  Later,  when  the  patient  enters  upon  convalescence,  milk 
punch,  English  ale,  or  a  sound  wine  may  be  given  in  liberal  quantities. 
Blair  prefers  Rhine  wine,  and  says  :  "  When  of  good  quality  it  is 
retained  when  everything  else  is  rejected,  and  is  universally  liked  by  the 
patients.  The  happy  effect  of  the  judicious  use  of  stimulants  is  shown 
not  only  by  increased  force  and  ra])idity  of  the  heart's  action,  but  fre- 
quently by  a  relief  of  the  distressing  nervous  phenomena  often  present 
during  the  stage  of  depression — sighing  respiration,  sleeplessness,  jacti- 


300  YELLOW  FEVER. 

tation,  hiccough.  There  is  a  tendency  to  syncojDC  during  the  second 
stage  of  the  disease,  which  is  especially  manifest  during  the  latter  part 
of  the  uight,  when  the  poAvers  of  nature  seem  to  be  at  the  lowest  ebb. 
This  is  often  fatal,  especially  when  the  nurse  or  physician  is  not  at  hand 
to  administer  the  stimulant  which  is  so  essential  for  the  rescue  of  the 
patient  at  this   critical  moment." 

Hemorrhage  from  the  nose,  stomach  (black  vomit),  or  bowels  will 
often  resist  all  treatment.  An  eifort  should  be  made  to  arrest  it  by  the 
administration  of  ergotin  by  the  hypodermic  method,  as  some  authors 
have  reported  favorable  results  from  this  treatment. 

During  convalescence,  which  is  often  protracted  after  severe  attacks, 
tonics  will  be  found  useful,  and  especially  the  salts  of  quinine,  strychnine 
and  iron,  either  separately  or  in  combination. 

The  aUmentatioii  in  cases  of  yellow  fever  requires  special  attention. 
The  stomach  for  some  days  is  not  in  a  condition  to  digest  any  food  : 
during  the  first  part  of  the  febrile  stage  the  patient  usually  has  no  desire 
for  food,  nor  should  any  be  given  him.  In  mild  cases  there  will  often 
be  a  demand  for  food  as  soon  as  the  fever  subsides,  but  great  caution 
must  be  exercised  in  complying  Avith  this  demand.  At  first  only  the 
simplest  forms  of  liquid  nourishment  should  be  permitted,  and  milk  or 
chicken  broth  will  usually  be  found  the  most  acceptable  to  the  patient 
and  the  least  apt  to  disturb  the  stomach.  In  severe  cases  Avith  much 
gastric  irritability  the  milk  should  be  mixed  with  lime-water  and  given 
at  first  in  quantities  not  exceeding  a  tablespoonful,  at  intervals  of  an 
hour  or  two.  If  this  is  not  retained,  nutritive  enemata  should  be  ad- 
ministered, and  the  stomach  should  be  given  a  further  period  of  com- 
plete rest.  When  liquid  food  is  retained  and  assimilated,  it  should  be 
given  in  moderate  quantities  at  intervals  of  tAvo  or  three  hours  for  a 
couple  of  days  in  mild  cases,  and  for  a  longer  time  in  those  of  a  more 
serious  nature,  after  Avhich  the  simplest  forms  of  solid  food  may  be  cau- 
tiously given.  It  should  be  constantly  borne  in  mind,  hoAA'^ever,  that 
premature  indulgence  in  solid  food  is  a  frequent  cause  of  relapse,  and 
that  relapses  are  extremely  fatal. 


CHOLERA. 

By  JOHN  M.  BYllOX,  M.  D. 


Defixitiox. — Cholera  is  an  exceedingly  acute  infectious  disease, 
caused  by  the  action  of  a  pathogenic  germ — the  cholera  spirillum,  or 
comma  bacillus  of  Koch — and  characterized  by  a  group  of  clinical 
s\Tnptoms,  the  most  striking  of  which  are  vomiting,  ver\-  profuse 
watery  dejecta,  muscular  cramps,  rapid  emaciation,  anuria,  asphvxia, 
and  collapse. 

Syxoxyms. — Cholera  Asiatica  ;  Cholera  maligna  ;  Cholera  infectiosa  : 
Cholera  algida  ;  Epidemic  cholera. 

"  Cholerine"  is  an  unscientific  term  which  is  iudefinitelv  used  to 
describe  either  mild  cases  of  Asiatic  cholera  in  which  the  stage  of  col- 
lapse is  cut  short,  or  more  frequently  it  is  applied  to  those  cases  of 
severe  and  usually  fatal  diarrhoea  or  gastro-enteritis  which  are  apt  to 
prevail  during  a  cholera  epidemic  or  to  precede  or  follow  it.  The  latter 
use  of  the  word  was  common  in  France  in  the  epidemic  of  1892-93,  and 
large  numbers  of  cases  of  this  t^-pe  were  recorded  in  Paris  and  other 
cities. 

History'. — The  epidemiology  of  cholera  is  an  interesting  study,  but 
an  elaborate  discussion  of  the  history  of  recent  epidemics  must  give 
place  in  this  work  to  brief  mention  of  the  more  important  ones.  It 
has  lonff  been  known  that  cholera  in  its  invasion  of  countries  follows 
only  the  Avell-worn  routes  of  travel,  both  by  sea  and  land,  and  that 
it  never  proceeds  faster  than  the  ordinary  means  of  communication 
between  different  towns.  The  disease  has  doubtless  been  known  for 
very  many  centuries  under  the  general  names  of  plague  or  scourge,  but 
intelligent  accounts  of  it  are  not  to  be  found  earlier  than  those  of  the  tenth 
century.  Cholera  undoubtedly  owes  its  birthplace  to  India,  chiefly  in  the 
delta  of  the  Ganges,  and  in  that  country  it  is  endemic,  affording  a  nur- 
sery from  which,  at  irregular  intervals,  it  is  widely  transplanted  and 
disseminated  through  neighboring  Asiatic  countries  and  Europe.  The 
invasion  of  India  by  foreign  peoples  has  done  much  to  extend  the 
original  limits  of  the  disease,  and  the  more  peaceful  invasions  of  today 
through  pilgrimages,  especially  to  Mecca  and  Medina,  afford  the  most 
favorable  conditions  for  its  spread.  An  epidemic  starting  near  Bombay 
or  Calcutta  will  oftentimes  spread  in  several  different  directions,  invad- 
ing China,  Japan,  Ceylon,  the  Philippines,  and  other  islands  of  the 
Eastern  Archipelago.  At  the  same  time  it  may  extend  westward  into 
Persia,  Turkey,  Egypt,  and  adjoining  countries,  also  passing  across  the 
Black  and  Caspian  Seas  and  entering  Russia.  It  may  even  extend  to 
St.  Petersburg.     The  disease  is  carried  along  the  Mediterranean  shores, 

301 


302  CHOLERA. 

giving  rise  to  outbreaks  in  Italy,  France,  Spain,  and  different  African 
states.  It  may  progress  thus  far  in  a  single  year,  or  two  or  three  years 
may  be  occupied  in  reaching  these  limits.  Unless  the  epidemic  is 
checked  it  extends  to  Germany,  and  occasionally  into  England.  Hav- 
ing reached  such  ports  as  Xaples,  Hamburg,  or  Havre,  it  is  brought 
across  the  Atlantic  to  the  United  States,  to  the  eastern  coast  of  South 
America,  Mexico,  and  Cuba,  whence  the  United  States  may  be  again 
invaded  through  the  States  bordering  on  the  Gulf.  This  is  a  brief 
outline  of  what  has  been  the  progress  of  many  epidemics.  Fortu- 
nately, these  epidemics  are  often  cut  short,  apparently  more  from  the 
disease  itself  dying  out  from  natural  causes  than  from  any  influence  of 
sanitation,  which  is  still  so  imperfect  in  most  Eastern  countries. 

For  many  centuries  epidemics  were  recorded  recurring  at  intervals  in 
India,  Mesopotamia,  Persia,  Egypt,  Turkey,  and  adjacent  south-eastern 
Russian  provinces.  The  sacred  city  of  Hundwar  is  the  special  nursery 
from  which  epidemics  have  started  for  invasion  of  Western  European 
countries.  Throughout  India  the  filthy  habits  of  the  natives  are  most 
favorable  to  the  dissemination  of  cholera.  Many  of  their  religious  cus- 
toms, especially  in  regard  to  bathing,  and  their  indulgence  in  pilgrim- 
ages to  sacred  shrines,  during  which  they  live  under  conditions  of  over- 
crowding and  fatigue,  predispose  them  to  contracting  the  disease.  In 
Mecca  as  many  as  150,000  sheep  may  be  slaughtered  annually  for 
religious  ceremonies,  and  their  entrails  are  allowed  to  decompose  on 
the  hot  ground.  The  irregularity  in  the  water  supply  of  the  country 
necessitates  its  storage  in  large  pools  and  tanks,  which  for  the  most 
part  are  entirely  unprotected  from  scAvage  and  excreta,  the  same  tank 
being  often  used  for  drinking  purposes,  bathing,  and  the  washing  of 
food  utensils.  Such  water,  once  contaminated  with  a  few  cholera  germs, 
may  spread  the  disease  among  thousands  of  people  in  an  incredibly  short 
time.  In  laro-e  overcrowded  cities  of  India  and  China  methods  of 
modern  sanitation  are  almost  wholly  unknown. 

In  1817  a  widespread  epidemic  of  cholera  originated  in  India,  passing 
southward  from  Calcutta  and  embracing  Central  India,  Ceylon,  Mada- 
gascar, and  China.  It  also  passed  eastward  and  afflicted  Delhi  and  Da- 
mascus and  other  Eastern  cities,  and  was  carried  across  the  Caspian  Sea 
to  Astrakhan.  Eventually,  the  epidemic  involved  almost  the  whole  of 
Asia,  but  it  did  not  invade  Europe.  jS^ine  years  later  another  epidemic, 
likewise  originating  on  the  Ganges  in  the  neighborhood  of  Calcutta, 
spread  over  very  much  the  same  route,  but  penetrated  into  Southeastern 
Russia  and  reached  as  far  as  Moscow.  By  other  routes  the  plague  pene- 
trated Austria-Hungary,  visiting  Poland,  finally  attaining  to  St.  Peters- 
burg and  the  principal  capital  cities  of  Europe,  including  Bremen,  Ham- 
burg, Paris,  and  Madrid  ;  some  cases  also  occurred  in  London.  Shortly 
afterward  another  epidemic  passed  from  the  Ganges  into  Arabia,  Egypt, 
and  European  Turkey. 

Another  decided  outbreak  of  cholera  occurred  in  Eastern  Europe  in 
1832,  making  frightful  ravages,  and  causing  120,000  cases  in  France 
alone.  In  this  year  also  the  disease  first  reached  the  United  States, 
being  brought  over  to  Quebec  in  an  emigrant  vessel  from  Ireland, 
and  spreading  thence  to  New  York  City  and  elsewhere  in  the  United 
States.     Three  thousand  five  hundred  victims  met  their  death  in  New 


UISTOllY.  303 

York  City  alone.      It  was  {'arried  to  ("iiha,  and   then   hack   atiaiii  to  the 
United  States  through  New  Ork-ans. 

In  1S4U  a  severe  epidemic,  orijiinatiiiji-,  lii<c  all  the  others,  in  the 
vicinity  of  tlie  Ganges,  penetrated  China  and  the  Eastern  Areliipelago. 
It  also  ag:ain  invaded  Euro})e  both  by  hind  and  from  the  Mediterranean 
jH)rts,  and  finallv  reached  New  York  bv  the  wav  of  Havre  in  Novem- 
ber, 184S. 

In  1S4'J  another  invasion  of  cholera  attlieted  this  country,  enterinjj^ 
bv  the  way  of  New  Orleans.  Having  once  obtained  a  foothold,  it  ex- 
tended asfast  as  the  various  means  of  travel  allowed,  and  the  year  fol- 
lowing 5000  deaths  took  place  in  New  York. 

A  similar  widespread  epidemic,  originating  in  1851,  involved  all  the 
European  countries,  and  entered  the  United  States  in  the  two  successive 
vears  1853  and  1854.  From  this  epidemic  2000  more  deaths  Avere 
recorded  in  New  York  City. 

In  November,  1865,  New  York  was  once  more  invaded,  the  disease 
having  travelled  the  usual  route  from  India  along  the  Mediterranean, 
through  France  to  Havre.  Eight  years  later  it  was  again  brought  into 
the  United  States  by  the  way  of  New  Orleans,  and  it  passed  on  to 
South  America. 

A  few  cases  appeared  again  throughout  the  United  States  in  isolated 
localities  in  1873,  but  a  general  epidemic  was  prevented  by  the  fact  that 
the  disease  was  better  understood,  and  it  was  soon  stamped  out  by  active 
sanitary  measures.  In  1883  an  epidemic  in  Egypt  gave  rise  to  50,000 
deaths,  and,  according  to  Parke,  more  than  600  natives  died  daily  in 
Cairo.  In  the  same  year  another  epidemic,  starting  from  Bombay,  was 
cut  short  at  New  York  Quarantine,  which  it  reached  four  years  later. 

Another  pandemic  fluctuated  between  various  European  cities  in 
1884  and  1887,  making  its  way  eventually  to  Paris.  In  1886-87  one 
of  the  largest  South  American  epidemics  occurred,  and  22,000  deaths 
took  place  in  Chili.  In  1890  the  disease  prevailed  with  some  severity 
in  widely  separated  regions  of  the  globe,  principally  in  India,  Japan, 
Corea,  Asiatic  Turkey,  Italy,  Spain,  Natal,  and  Abyssinia. 

In  the  winter  of  1891-92  cholera  ajjpeared  in  isolated  towns  in 
Persia,  and  in  1892  an  epidemic  wave  started  from  Meshed  in  Persia, 
and  followed  the  line  of  the  Transcaucasus  Railway  into  Russia,  finally 
reaching  Nijui-Novgorod,  Moscow,  and  St.  Petersburg.  The  disease 
also  broke  out  in  Havre  and  Hamburg,  though  by  what  means  it 
reached  these  cities  has  never  been  clearly  established.  In  the  spring 
of  this  same  year  a  number  of  patients  died  in  Paris  and  elsewhere  in 
France  of  gastro-intestinal  symptoms,  which  were,  however,  reported 
under  the  name  of  "  cholerine."  About  this  time  the  disease  invaded 
Russia  along  the  borders  of  the  Caspian  Sea.  It  rapidly  spread  through 
Central  Russia,  and  on  the  l8th  of  July,  1892,  it  again  reached  the 
populous  market  city  of  Nijni-Novgorod,  where  it  met  most  favorable 
conditions  for  development  and  extension  among  travellers  from  all 
parts  of  Russia,  It  soon  invaded  St.  Petersburg.  In  the  month  of 
August  in  the  same  year  the  disease  appeared  in  Hamburg,  but  author- 
ities differ  as  to  its  method  of  conveyance  there.  The  river  Elbe 
became  infected,  and  the  poorer  inhabitants  of  the  city,  who  drank  this 
water   unfiltered,  were   aflected   with   the   disease    in    larije    numbers. 


304  CHOLERA. 

Efforts  were  at  first  made  by  the  local  authorities  to  conceal  the  exist- 
ence and  extent  of  the  epidemic,  which  only  resulted  in  confusion  and 
in  danger  to  others. 

From  the  foregoing  brief  account  of  recent  epidemics  of  cholera  it 
will  be  seen  that  there  is  a  tendency  of  late  years  for  the  disease  to 
recur  in  more  frequent  epidemics  and  to  travel  more  rapidly  and  more 
widely  than  heretofore.  This  is  unquestionably  due  to  the  extension 
of  facilities  for  travel  between  the  different  countries  involved  and  the 
enormous  increase  in  the  amount  of  commercial  interchange.  So  long- 
as  India  remained  a  comparatively  isolated  country  the  disease  was  kept 
for  the  most  part  within  its  borders,  and  when  of  late  years  it  has  ex- 
tended throughout  Europe  and  has  penetrated  to  the  United  States,  and 
even  South  America,  its  propagation  has  been  due  to  emigration,  for  it 
is  the  poorer  and  more  ignorant  classes  of  the  community,  those  who 
suffer  most  from  inanition,  overcrowding,  and  the  consequences  of  infrac- 
tion of  all  hygienic  laws,  who  are  the  chief  agents  in  conveying  the  dis- 
ease in  their  persons  and  filthy  clothing.  In  the  last  epidemic  which 
reached  New  York,  although  182  cases  were  brought  over  from  Ham- 
burg by  several  different  steamships,  they  were  confined  entirely  to  emi- 
grants, mainly  the  poorest  of  Russian  exiles ;  the  cabin  passengers,  who 
lived  under  better  conditions,  escaping  entirely,  although  they  were  on 
the  same  ship. 

Etiology. — Predisposing  Causes. — The  causes  predisposing  to  chol- 
era infection  are  those  common  to  severe  infectious  diseases  in  general — 
namely,  prevalence  of  famine,  inanition,  debauchery,  chronic  wasting 
diseases,  over-exertion,  either  mental  or  physical,  and  alcoholism.  In 
addition,  it  is  believed  that  the  individual  is  more  liable  to  infection  if 
the  germs  enter  the  alimentary  canal  during  periods  of  indigestion  or 
diarrhoea.  While  an  epidemic  prevails,  therefore,  it  becomes  exceed- 
ingly important  to  avoid  the  use  of  unwholesome  food,  such  as  decom- 
posing meats,  over-ripe  fruit  or  vegetables,  etc.,  and  foul  water. 

Isolated  cases  of  cholera  may  occur  from  time  to  time  in  remote 
regions  into  which  the  germs  have  been  conveyed,  but  in  general  it  is 
emphatically  a  disease  of  populous  cities  and  camps  and  overcrowded 
localities  where  conditions  of  inanition  and  filth  obtain.  The  infectious 
principle  is  not  communicated  by  direct  contact  of  one  person  with 
another,  nor,  as  far  as  known,  through  the  atmosphere,  but  is  propa- 
gated solely  by  the  stools  of  patients  having  the  disease  which  have 
been  allowed  to  contaminate  clothing,  transportation  vehicles,  baggage, 
or  drinking  water.  It  is  often  conveyed  for  long  distances  in  over- 
crowded vessels  and  railway  coaches. 

Climate;  Season  of  the  Year. — Although  it  is  well  known  that  chol- 
era is  not  propagated  through  the  atmosphere,  nevertheless,  epidemics 
are  favored  by  certain  atmospheric  conditions,  especially  warmth  and 
moisture.  The  disease  has  been  known  to  occur  in  every  season  and 
in  every  climate,  with  the  exception  of  that  of  the  Arctic  regions,  but 
its  progress  is  usually  checked  by  moderate  cold,  and,  though  isolated 
cases  may  occur  during  the  winter  season,  epidemics  do  not  prevail  at 
that  time. 

Sex  and  age  are  two  factors  which  exert  comparatively  little  influ- 
ence with  cholera.     Young  children  often  acquire  the  disease,  but  it  is 


THE  COMMA    BACILLUS.  305 

not  common  after  tifty-Hvo  or  sixty  years  of  age.  Many  eases  occur 
amono-  young  adults,  aud  males  seem  to  be  somewhat  more  susceptible 
to  infection  than  females. 

lidce  (Did  Social  Poxltion. — ,\ll  races  are  affected  by  the  disease,  and 
apparent  difference  in  susceptibility  can  be  traced  more  to  general  habits 
of  life,  personal  cleanliness,  religious  observances  in  regard  to  bathing, 
etc.,  than  to  any  inherent  quality  of  the  race  itself.  Ow  ing  t(»  similar 
conditions  the  lower  strata  of  society  are  very  much  more  suscej)tible  to 
the  disease  than  those  whose  intelligence  and  circumstances  enable  them 
to  secure  better  hygienic  surroundings.  The  very  poor,  being  subject 
to  all  manner  of  filth  diseases  and  diseases  of  overcrowding,  fall  readv 
victims  to  the  scourge  of  cholera. 

During  the  fortnight  from  August  30  to  September  15,  1892,  seven 
steamships  infected  with  cholera  arrived  at  the  New  York  Quarantine. 
For  a  few  days  longer  the  disease  continued  to  spread  while  in  port, 
and  in  all  128  suspects  and  patients  ill  ^^'ith  cholera  were  removed  to 
the  hospitals  at  Swinburne  Island  for  treatment  or  to  be  held  for  obser- 
vation. Of  the  suspects,  all  except  10  were  subsequently  proved  by 
bacteriological  examination  to  have  the  disease.  There  were  many  fatal 
cases  which  occurred,  solely  among  the  emigrants,  while  the  vessels 
were  at  sea,  and  the  fact  that  the  majority  originated  either  at  the 
beginning  or  end  of  the  voyage  is  probably  to  be  accounted  for  as 
follows  :  The  drinking  water  of  the  infected  vessels  was  not  found  to 
contain  the  germs  of  the  disease,  for  it  had  been  steamed  as  a  prophy- 
lactic measure ;  hence  those  cases  which  had  developed  immediately 
after  leaving  port  were  undoubtedly  contracted  upon  shore,  while  those 
which  developed  at  or  near  the  end  of  the  voyage  must  have  been  due 
to  eating  food  which  the  emigrants  of  the  class  affected — the  poorly  fed 
and  poorly  clad — carried  with  them  to  supplement  the  ship's  rations. 
This  food,  which  consisted  of  such  articles  as  sausage,  bread,  and 
cheese,  they  stowed  in  their  bunks  among  their  bedding  and  often 
wTapped  up  in  soiled  clothing.  Being  seasick  during  the  early  part 
of  the  voyage,  which  to  most  of  them  was  an  entirely  novel  experience, 
they  did  not  resort  to  eating  their  own  food  until  they  had  become 
somewhat  accustomed  to  the  sea,  and  thus  were  not  infected  until  near 
the  end  of  the  voyage.  The  death-rate  among  these  patients  at  sea 
was  enormous,  corresponding  to  the  extreme  malignancy  of  the  disease 
at  Hamburg,  the  port  of  departure  of  the  vessels. 

In  August,  1893,  21  cases  developed  among  steerage  passengers 
quarantined  at  the  hospitals  in  New  York  harbor,  since  which  time  no 
further  cases  have  reached  the  United  States,  although  the  disease  still 
prevails  in  Eastern  countries. 

The  Comma  Bacillus. 

That  the  comma  bacillus,  discovered  by  Koch  in  1883,  and  so  thor- 
oughly described  by  him  in  his  memorable  address  to  the  Berlin  Chol- 
era Conference,  held  on  the  26th  of  July,  1884,  has  a  direct  causal 
connection  with  the  production  of  Asiatic  cholera  cannot  be  doubted. 
All  observers  in  all  countries  where  this  unwelcome  visitor  has  made 
its  appearance  w^ho  have  impartially  studied  this  important  problem  of 

Vol.  I.— 20 


306  CHOLERA. 

epidemiology  are  unanimous  in  accepting  the  comma  bacillus  as  the 
pathogenic  germ  of  this  disease.  That  in  some  undoubted  cases  of 
cholera  the  most  careful  bacteriological  examination  has  proved  nega- 
tive is  also  true.  Such  a  result,  however,  depends  upon  the  divers  con- 
ditions of  season  and  locality  that  belong  to  each  individual  case  under 
examination.  My  own  experience  in  three  epidemics  of  Asiatic  cholera 
(1884  to  1893j  compels  me,  bv  the  results  of  an  overwhelming  majorit}^ 
of  examinations,  to  accept  Koch's  views  regarding  the  causality  of  the 
comma  bacillus  as  true.  I  have  unquestionably  met  with  cases  in 
which  all  efforts  to  detect  the  presence  of  the  specific  germ  by  the  ordi- 
nary methods  proved  fruitless,  but  the  examination  was  made  with 
material  obtained  either  from  advanced  cases  where  the  bacilli  were 
eliminated  or  substituted  by  other  germs,  as  often  occurs,  or  it  was 
obtained  from  small  children,  in  whom  it  is  extremely  difficult  to  find 
the  comma  l^acillus.  In  infants  the  cholera  poison  seems  to  act  so  vio- 
lently that  the  last  stages  of  the  disease  are  reached  before  the  germ  has 
had  time  to  propagate  abundantly  in  the  intestines. 

The  comma  bacillus  of  Koch  is  a  spirillum  presenting  a  curved  form, 
which  sometimes  appears  like  a  comma,  and  again  as  a  crescent  or  a 

Fig.  32.  Fig.  33. 

A  B. 


/ 


•    i  9  /.  -^ 

Spirillum    of   Asiatic    cholera.      Impression         Involution  forms  of  the  spirillum  of  Asiatic 
cover-slip  from  a  colony  thirty-four  hours  cholera,  as  seen  in  old  cultures  (Abbott), 

old  ( Abbott j. 

double  curve  like  an  S,  The  bacillus  is  short,  measuring  not  more  than 
.5// 1€  1/7.,  and  it  is  somewhat  broader  than  the  tubercle  bacillus.  The 
germ  grows  rapidly  upon  a  variety  of  culture  media  when  subjected  to 
very  moderate  moisture.  It  has  been  found  thus  growing  upon  pota- 
toes and  other  raw  vegetables,  befouled  clothing,  and  damp  earth. 
According  to  Sternberg,  it  is  easily  destroyed  by  a  temperature  of  140° 
r.,  but  it  survives  freezing  to  even  10°  C,  its  activity  being  only  tem- 
porarily suspended  thereby.  It  is  also  suspended  by  a  moderate  acid 
medium,  and  the  germ  is  destroyed  by  strong  acids.  For  this  reason  it 
is  not  developed  in  the  stomach,  and  hence  the  desirability  of  prevent- 
ing dyspepsia  and  an  alkaline  reaction  of  the  stomach  during  the  prev- 
alence of  cholera  epidemics. 

The  germ  often  presents  one  or  two  cilia  at  one  extremity,  which 
give  it  active  motion.  It  is  among  the  most  active  of  germs  in  repro- 
duction, which  is  accomplished  by  direct  fission  and  not  through  the 
intervention  of  spores.  The  germ  flourishes  and  j)ropagates  rapidly  in 
foul  and  brackish  water,  and  hence  it  is  in  almost  constant  prevalence 
along  the  delta  of  the  Ganges  (Koch).  The  researches  of  Klein  and 
Gibbes,  conducted  in  India  for  the  British  government,  demonstrated 


THE  COMMA  BACILLUS.  307 

the  oxistenco  of  sovoral  otiior  species  of  bacilli  which  present  slight 
niorphological  differences  from  the  cholera  bacillus,  but  which  produce 
somewhat  analogous  symptoms  in  the  lower  animals  ;  but  there  is  no 
difficulty  in  isolating  the  comma  bacillus,  even  when  associated  with 
other  foruis,  when  the  proper  methods  of  culture  before  described  are 
closely   followed. 

The  individual  germ  does  not  appear  to  be  very  long  lived,  but  it 
propagates  with  such  rapidity  that  the  species  is  easily  perpetuated. 
Exposure  to  drying  and  sunlight  is  fatal  to  it  in  a  short  time.  Koch 
has  proved  conclusively  that  the  spirillum  is  promptly  destroyed 
by  drying  or  exposure  to  dry  air.  In  a  thin  film  of  fluid  con- 
taining the  germs  they  do  not  survive  more  than  three  hours  when 
dried  in  the  atmosphere.  Sternberg  tested  small  squares  of  sterilized 
blanket  which  he  moistened  with  a  bouillon  culture  of  the  spirillum 
and  then  exposed  to  strong  sunlight.  Four  hours  sufficed  to  render  the 
germs  inactive.  The  prevalence  of  cholera  epidemics  has  been  very 
largely  checked  in  many  instances  by  draining  salt  marshes  and  placing 
the  soil  in  better  condition.  The  germ  undergoes  a  curious  change  out- 
side of  the  body  in  regard  to  air.  Within  the  body,  its  habitat  being 
the  intestine,  it  is  necessarily  anaerobic,  but  after  the  evacuated  germs 
have  been  out  of  the  body  for  some  time  they  become  distinctly  aerobic, 
and  so  behave  in  regard  to  culture  media  ;  hence  when  artificially  culti- 
vated in  an  alkaline  fluid  medium  they  form  surface  colonies.  This 
fact  points  to  the  desirability  of  the  prompt  disinfection  of  cholera 
stools  before  the  germs  have  had  time  to  change  their  character. 

The  germs  grow  rapidly  in  peptone  solution,  forming  large  cultures 
in  six  hours  or  less. 

For  a  long  time  it  was  believed  that  the  low^er  animals  were  immune 
to  cholera — at  least,  that  they  could  not  be  saturated  with  the  disease — 
but  the  researches  of  Koch  and  Pasteur,  conducted  on  dogs  and  guinea- 
pigs,  have  demonstrated  that  these  animals  at  least  may  harbor  the 
cholera  bacilli,  and  be  affected  by  symptoms  closely  resembling  genuine 
cholera. 

In  the  human  body  the  germs  are  found  only  in  the  alimentary 
canal,  principally  upon  the  surface  and  within  the  open  tubules  of  the 
mucous  glands  of  the  ileum. 

Method  of  Exomination  of  the  Stools  for  Bacilli. — During  the  month 
of  August,  1893,  I  had  the  opportunity  of  treating  21  cases  of  cholera 
at  the  Quarantine  Hospital  on  Swinburne  Island  in  New  York  harbor. 
This  outbreak  of  the  disease  took  place  among  the  five  hundred  steerage 
passengers  of  the  steamship  Karamania  after  her  arrival  in  quarantine 
on  August  3,  1893.  The  vessel  sailed  from  Naples,  which  was  at  that 
time  an  infected  port,  and  during  the  Transatlantic  voyage  four  or  five 
fatal  cases  of  "  gastro-enteritis "  W' ere  reported  by  the  ship's  surgeon, 
although  the  drinking  water  on  board  was  uncontaminated  by  the  spiril- 
lum of  Asiatic  cholera. 

In  each  of  my  cases,  wdth  but  a  single  exception,  that  of  a  young 
child,  the  comma  bacillus  w^as  found.  This  child  presented  an  un- 
doubted case  of  cholera,  although  no  comma  bacilli  were  present  in  the 
stools.  The  child  was  subject  to  infection,  and  had  both  the  premoni- 
tory and  secondary  symptoms  of  the  disease  in  a  most  typical  degree ; 


308  CHOLERA. 

but,  as  above  stated,  there  are  instances  among  children  in  which  a  most 
conscientious  and  painstaking  bacteriological  examination  fails  to  dem- 
onstrate the  commas. 

The  method  used  by  me  at  Swinburne  Island  for  the  bacteriological 
diagnosis  of  Asiatic  cholera  was  the  following  :  As  soon  as  the  patient 
arrived  at  the  hospital  an  enema  of  sterilized  lukewarm  water  was 
given.  By  this  means  material  for  examination  was  obtained  almost 
immediately,  thus  avoiding  delays  in  the  treatment  and  the  bacterio- 
logical examination,  as  is  the  case  when  a  spontaneous  stool  is  awaited. 
The  material  voided  was  collected  in  sterilized  tubes  and  taken  to  the 
laboratory  and  cover-glass  preparations  were  made  and  stained.  In 
the  mean  time  tubes  containing  Dunham's  solution  of  gelatin  and  agar 
were  seminated  with  the  suspicious  material.  The  details  of  these  ex- 
aminations follow  : 

1.  Ilieroscojncal  examination  of  the  dejecta  is  easily  performed,  but  is 
valuable  only  as  a  positive  test.  In  very  many  instances  I  have  found 
the  result  either  negative  or  uncertain,  and  the  typical  grouping  of  the 
bacilli  described  by  Koch  was  rarely  observed.  The  method  employed 
was  quite  simple :  a  cover-glass  preparation  was  made  and  stained  with 
a  dilute  Ziehl's  solution  of  carbolic  fuchsin. 

2.  Cidtures  were  implanted  in  the  following  media  : 

(1)  Tubes  of  peptone  salt  solution  in  the  proportion  of  peptone 

15,  sodium  chloride  5,  distilled  Avater  1000. 

(2)  Gelatin  tubes  prepared  by  addition  of  10  per  cent,  gelatin 

to  the  above  peptone  solution  (1). 

(3)  Agar-agar  tubes,  prepared  by  addition  of  1  per  cent,  agar- 

agar  to  the  peptone  solution  (1). 

Precaution  must  be  exercised  to  maintain  a  distinctly  alkaline  re- 
action in  all  culture  media  employed,  for  gelatin  especially  is  liable  to 
alter  in  reaction,  and  it  may  become  neutral  or  slightly  acid — an  occur- 
rence which  is  fatal  to  the  growth  of  the  germ — or  else  it  so  modifies  it 
as  to  render  a  diagnosis  impossible.  In  my  experience  a  strongly  alka- 
line reaction  is  more  favorable  for  the  growth  of  the  germs  than  the 
faintly  alkaline  reaction  generally  employed  in  laboratories. 

(1)  The  peptone  tubes  were  immediately  placed  in  an  incubator  at  a 
temperature  of  37°  C,  and  from  the  gelatin  cultures  in  Petri  dishes  were 
made.  The  former  were  kept  at  a  temperature  of  22°  C.  and  the  latter 
at  37°  C.  in  the  incubator.  Each  tube  or  plate  was  regularly  examined 
at  intervals  of  three  or  four  hours,  and  the  conditions  of  growth  were 
noted.  Over  200  examinations  were  made  from  the  21  patients  kept  in 
the  hospital,  both  during  life  and  post-mortem  in  the  fatal  cases.  Further- 
more, as  soon  as  a  vestige  of  growth  appeared  in  the  peptone  solution 
tubes,  which  invariably  takes  place  after  a  few  hours  (four  to  eight),  a 
new  series  of  gelatin  plate  cultures  was  made  as  a  control. 

Dunham's  culture  method  is  a  modification  of  that  practised  by  Scho- 
tellius,  which  is  to  be  strongly  recommended.  A  wide  test-tube  is  filled 
with  a  sterilized  solution  consisting  of  peptone  1,  sodium  chloride  0.5, 
water  IQO.  Into  this  mixture  is  dropped  a  small  quantity  of  fseces  or 
a  flake  of  mucus  from  a  rice-water  stool,  and  the  tube  is  then  placed  in 
an  incubator  at  37°  C.  for  from  six  to  twelve  hours,  when  the  germs, 
if  present,  will  be  found  floating  in  almost  pure  culture  upon  the  sur- 


Till':  COMMA    llACILLUS. 


309 


face,  from  which  in  time  cover-glass  prejxirations  and  gelatin  roll  cul- 
tures are  made. 

(2)  GeUit'ni  Roll  CulfiircK. — Esmarch's  modilication  of  Koch's  method 
gives  very  satisfactory  results.  Rapid  cultures  are  made  after  Dun- 
ham's method  described  above  (1),  and  the  bouillon  gelatin  is  rolled 
after  transplantation  with  a  drop  from  the  cultures.  The  tubes  are 
kept  at   20°  C,  and  are  examined  after  from  twelve  to  twenty-four 


Hours. 


There  are  certain  characteristics  regarding  the  individual  form  of  the 
bacilli,  the  appearance  of  the  colonies  on  gelatin  and  agar  plates,  and  the 


Fig.  34. 


Developmental  stages  of  colonies  of  the  spirillum  of  Asiatic  cholera  at  20°  to  22°  C.  on  gelatin. 
X  about  75  diameters:  a,  after  sixteen  to  eighteen  hours;  b,  after  twenty-four  to  twenty-six 
hours ;  c,  after  thirty-eight  to  forty  hours  ;  d,  after  forty-eight  to  fifty  hours  ;  e,  after  sixty-four 
to  seventy  hours  (Abbott). 

property  of  absorbing  color  by  the  bacteria,  which  should  be  emphasized, 
as  in  some  cases  they  may  be  confusing  to  an  observer  of  limited  expe- 
rience. The  direct  examination  of  the  dejecta  is  not  to  be  relied  upon. 
Some  authors  advance  the  opinion  that  a  diagnosis  can  be  made  by  this 
means.  Such  would  be  the  fact  if  in  every  case  we  met  with  the  cha- 
racteristic disposition  in  swarms  of  well  developed  comma  bacilli  as 
described  by  Koch,  but  this  seldom  happens.  It  is  astonishing  that 
fseces,  which  under  culture  yield  only  pure  colonies  of  comma  bacilli, 
when  examined  microscopically  present  a  great  variety  of  bacteria, 
among  wdiich  the  commas  are  in  the  minority  or  are  not  at  all  to  be 
found.  We  cannot,  and  should  not,  rely  at  all  upon  such  examination, 
especially  when  upon  the  diagnosis  depends  the  welfare  of  the  commu- 
nity. A  thorough  bacteriological  analysis  requires  but  a  few-  hours  and 
then  a  positive  diagnosis  can  be  given. 

The  comma  bacillus  presents  some  peculiarities  in  form  and  grouping 
which  are  noticeable.  Cunningham  described  a  series  of  transforma- 
tions in  this  germ  w^hich  other  authors  have  contradicted,  but  it  is  a 
fact  that  such  modifications  do  occur,  and  that  the  modified  characters 
are  present  in  succeeding  generations.  In  1892  all  the  cultures  obtained, 
using  identical  media,  gave  rise  to  a  very  delicate,  long,  slender  comma 
bacillus,  which  I  still  keep  in  the  laboratory.  This  race  of  comma 
bacilli  can  be  actually  differentiated  from  the  bacillus  of  1893.  But 
even  during  the  same  epidemic  a  difference  can  be  noticed  in  the  indi- 
vidual morphology  of  some  cultures.     This  does  not  include  the  modifi- 


310  CHOLERA. 

cations  induced  either  by  a  change  of  reaction  of  the  media  or  change 
of  the  temperature  in  which  the  germs  live,  nor  the  age  of  the  culture. 
I  refer  simply  to  such  forms  as  are  obtained  cFemblee,  and  which  con- 
tinue to  grow  with  the  same  characteristics.  In  1893  a  very  striking 
example  of  such  variations  was  given  by  three  cases,  each  of  which  gave 
rise  to  an  abundant  growth  within  thirty -six  hours  in  the  peptone  solu- 
tion of  exceedingly  well-defined  spirilla,  while  in  the  rest  of  the  cases 
several  days  (ten  to  twenty)  passed  before  these  forms  appeared. 

The  temperature  and  the  reaction  of  the  media  are  also  factors  in- 
fluencing the  individual  appearance  of  the  germs.  Gelatin  cultures 
kept  at  the  ordinary  temperature  of  22°  C.  constantly  produced  well 
defined  curved  rods.  If  the  temperature  is  lowered,  the  curvature  in 
each  individual  germ  is  much  more  evident.  Contrary  to  this,  bouillon, 
and  agar  cultures  kept  in  the  incubator  at  37°  to  38°  C.  present  short, 
stumpy,  straight  rods,  which  greatly  resemble  at  times  the  colon  bacillus 
in  appearance. 

Colonies  obtained  in  plate  or  tube  cultures  also  vary,  and  should  be 
duly  studied  by  the  sanitarian,  as  their  appearance  may  lead  to  regret- 
table errors.  I  refer  only  to  young  colonies  in  gelatin  when  liquefaction 
has  not  taken  place.  I  have  observed  at  least  five  well  defined  varieties 
of  colonies  either  occurring  contemporaneously  in  a  plate  or  separately 
in  different  plates.     These  are — 

1.  Colonies  almost  transparent,  finely  granular,  with  a  well  defined 
circular  edge. 

2.  Colonies  small,  yellowish,  thick,  coarsely  granular,  circular,  with 
jagged  or  undulated  edges,  which  appear  like  little  heaps  of  ground  glass. 
These  are  the  classical  colonies  described  by  Koch. 

3.  Colonies  of  elliptical  shape,  very  finely  granular,  dark  brown, 
non-transparent,  with  well  defined  edges  of  a  lighter  hue. 

4.  Colonies  round,  light  yellow,  with  granular  centres  surrounded 
by  a  dark  circular  edge. 

5.  Colonies  round,  dark,  with  coarsely  granular  centres  surrounded 
by  a  yellowish  ring  with  wavy  edges,  from  which  irradiations  are  sent 
into  the  surrounding  gelatin. 

After  the  gelatin  begins  to  melt  all  these  colonies  gradually  lose  their 
characters,  giving  rise  to  the  well  known  funnel-shaped  depressions  on 
the  gelatin,  at  the  bottom  of  which  lie  the  colonies  surrounded  by  the 
melted  gelatin. 

On  agar  plates  kept  at  brooding  temperature  I  have  observed  but 
two  varieties  of  colonies — the  deep  ones,  which  appear  under  the  micro- 
scope as  small  dark,  round,  or  elliptical,  coarsely  granular  dots,  and  the 
superficial  ones,  appearing  as  large,  thin,  yellowish,  irregular  growths 
with  wavy,  finely  granular  edges,  very  much  resembling  some  colonies 
of  the  colon  bacillus. 

Cultures  in  peptone  solution  rendered  strongly  alkaline  and  kept  at 
37°  C.  present  in  a  few  hours  a  pellicle  floating  on  the  surface,  whereas 
in  slightly  alkaline  solutions  the  pellicle  does  not  form  or  takes  several 
days  to  form,  especially  if  the  colon  bacilli  are  present  in  superior 
numbers. 

The  reaction  to  coloring  solutions,  such  as  diluted  Ziehl's  carbolic 
fuchsin,  differs  somewhat  according  to  the  media  in  which  the  bacilli 


PATHOLOGICAL  ANATOMY.  311 

grow  and  the  trnipcratiuv  at  wliicli  tlu'v  arc  cultivated.  Covcr-^lass 
preparations  nuule  from  bouillon  cultures  do  not  stain  as  well  as  those 
from  o'clatin  cultures.  The  bacilli  absorb  the  dye  irrciiularly,  present- 
ing here  and  there  vacuoles  which  mioht  be  mistaken  for  s])ores. 

Althouii'h  stained  s[)ecimcns  of  dejecta  present  a  variety  of  bacteria 
in  cultures,  J  found  but  two  other  germs  which  were  associated  with  the 
comma  bacillus.  In  all  cases  excepting  three  the  comma  was  associated 
with  the  colon  bacillus  in  pure  cultures,  and  in  two  cases  comma  bacil- 
lus, colon  bacillus,  and  proteus  vulgaris  were  associated.  It  should  be 
noticed  that  in  the  tirst  diarrhwal  discharges  the  colon  bacillus  is  moi'e 
abnndant  than  the  commas,  whereas  during  the  prevalence  of  rice- 
water  discharges  the  commas  are  in  the  majority ;  and  then,  again,  the 
colon  bacillus  begins  to  increase  as  the  disease  advances. 

The  indol  reaction  was  tested  in  every  case  by  adding  a  few  drops 
of  c.  p.  sulphuric  acid  to  a  peptone  solution  kept  in  the  in(!ubator  for 
twenty-foiu-  hours.  The  acid  reaction  prevented  differences  in  the  hue. 
I  have  also  obtained  quite  an  evident  indol  reaction  by  adding  to  the 
diluted  and  filtered  rice-water  dejections  a  few  drops  of  sulphuric  acid. 
Lately  I  have  observed  that  by  adding  a  few  drops  of  a  1  :  10,000 
aqueous  solution  of  nitrate  of  potash  the  indol  reaction  appears  with 
greater  intensity. 

Patholgical  Anatomy. — The  lesions  produced  by  the  cholera 
infection,  although  the  localization  of  the  germ  in  the  intestines  is 
well  established,  are  so  far  from  being  constant  that  but  little  can  be 
obtained  from  an  autopsy  to  aid  the  diagnosis.  These  lesions,  which 
from  time  to  time  occur,  bear  little  or  no  definite  relation  to  the  inten- 
sity of  the  symptoms.  A  disease  which  may  terminate  fatally  in  three 
or  four  hours  from  its  onset  gives  no  time  for  extensive  pathological 
lesions  to  develop.  Visceral  congestions  and  hemorrhages,  with  great 
emaciation  and  dryness  of  the  tissues,  are  perhaps  the  most  character- 
istic findings. 

Rigor  mortis  is  present  early  and  is  well  marked,  but  I  have  failed 
to  note  the  unusual  positions  of  the  body  described  by  some  pathologists. 
There  may  be  slight  contractures  of  the  flexor  muscles  of  the  hands  and 
arms,  but  there  is  nothing  unwonted  in  that. 

The  skin  becomes  actually  warmer  than  during  life,  owing  to  the 
cessation  of  previous  excessive  perspiration.  It  is  pale  and  wrinkled, 
and  the  purple  hue  of  asphyxia  is  absent,  excepting  perhaps  on  the 
cheeks  and  backs  of  the  hands. 

The  eyeballs  are  deeply  sunken,  the  orbital  fat  has  disappeared, 
and  the  eyes  have  a  lack-lustre  look  beyond  that  of  the  ordinary 
cadaver. 

Putrefaction  sets  in  very  slowly,  even  in  hot  weather.  This  is 
probably  due  to  the  fact  that  so  much  water  has  been  drained  from 
the  tissues. 

The  brain  itself  appears  normal,  but  the  ventricles  are  dry  and 
viscid ;  so  also  is  the  surface  of  the  pia  mater.  The  meningeal  vessels 
are  injected. 

The  heart  is  dark  ;  the  left  ventricle  alone  is  in  systole,  the  other 
chambers  being  usually  dilated  and  filled  with  dark,  fluid,  viscid  blood. 
I  have  observed  cardiac  thrombosis.     The  pericardium  is  usually  dry, 


312  CHOLERA. 

but  it  may  contain  a  little  serum.  Sometimes  numerous  hemorrhages, 
varying  in  size  from  a  pinhead  to  an  inch  in  diameter,  are  found  on  the 
surface  and  in  the  parenchyma  of  the  heart.  The  aorta  is  filled  with 
fluid  blood. 

The  langs  are  highly  congested,  of  a  dark  purple  hue,  and  cedematous. 
In  some  cases  lobar  pneumonia  is  found.  In  others  numerous  hemor- 
rhages, varying  in  size  like  those  in  the  heart,  are  present  all  over  the 
pulmonary  surfaces  and  in  the  parenchyma.  The  pleurae  are  dry,  coated 
with  viscid  fluid. 

The  per  it  onev/ a  is  dry  and  resembles  ground  glass.  It  is  coated,  like 
the  other  serous  membranes,  with  glairy,  viscid  fluid. 

The  liver  is  sometimes  small,  and  light  yellow  in  color,  or  it  may  be 
of  a  dark  purple  hue  or  present  hemorrhagic  spots.  I  have  observed 
perihepatitis.  The  gall  bladder  is  usually  distended  with  viscid  yellow- 
ish mucous  fluid,  from  which  cultures  of  comma  bacilli  are  obtainable. 

The  spleen  is  of  normal  size,  somewhat  hard  and  purple  or  hemor- 
rhagic.    There  is  sometimes  perisplenitis. 

The  stomach  appears  small,  with  venous  congestion  in  the  larger 
vessels,  but  the  mucous  membrane  is  usually  normal  and  covered  with  a 
thick,  tenacious  layer  of  creamy  mucus.  Sometimes  the  natural  folds 
of  the  mucosa  are  much  exaggerated  by  contraction,  and  exhibit  conges- 
tion and  punctate  hemorrhage. 

The  kidneys  are  sometimes  normal,  sometimes  large  and  yellowish, 
but  if  the  disease  has  lasted  for  several  days  they  usually  present  the 
appearance  of  acute  parenchymatoas  nephritis.  The  so-called  "  cholera 
kidney"  does  not  differ  from  that  of  all  severe  acute  infectious  diseases, 
and  is  therefore  not  diagnostic.  The  bladder  may  be  distended  with 
all)uminous  urine,  but  in  the  majority'  of  cases  it  is  contracted  and 
empty. 

Xone  of  the  above  described  lesions  are  constant  or  characteristic, 
nor  are  they  all  observed  in  any  one  case.  AVhen  present  they  bear  no 
definite  relation  to  the  iutensits^  of  the  symptoms.  In  children  in 
general  the  lesions  are  all  less  distinct. 

The  Intestines. — At  times  the  intestinal  tract  is  found  normal,  but 
2)rofound  lesions  are  discovered  in  many  cases. 

The  small  intestine  is  contracted,  and  presents  venous  and  capillary 
congestion,  particularly  in  the  ileum.  The  contents  may  be  copious, 
rice-water  exudation  or  viscid  greenish-yellow  mucus  tenaciously  adher- 
ing to  a  normal  or  hemorrhagic  mucous  membrane.  Both  the  solitary 
and  agminated  glands  are  considerably  enlarged. 

The  mucous  membrane  is  often  found  denuded  of  epithelium  where 
the  germs  have  been  most  active,  the  follicles  being  choked  with  gran- 
ular and  epithelial  debris  and  masses  of  bacilli.  The  germs  are  also 
found  in  the  subepithelial  layer  of  the  intestinal  mucosa,  into  which  they 
penetrate  by  their  own  motion. 

The  Large  Intestine. — The  contents  of  the  large  intestine  consists  of 
large  quantities  of  rice-water  fluid,  excepting  after  intestinal  irrigation, 
when  creamy,  tenacious,  or  blood-stained  mucus  is  found  clinging  to 
the  mucosa. 

A  lesion  with  which  I  have  constantly  met,  and  which  I  think  is  of 
great  diagnostic  importance,  is  the  condition  of  the  large  intestine.     It 


PATUULOCICAL    AXATOMY.  313 

seonis  that  the  choh-ra  poison  f'onned  in  the  small  intestine  passes  into 
the  large  intestine,  where  abs()rj)tion  takes  place,  u:iving  rise  at  the  same 
time  to  intianimatory  symptoms  which  I  have  never  I'onnd  al)sent  in 
these  antopsies.  The  condition  of  the  large  intestine  is  that  of  dysen- 
tery ;  the  mucous  membrane  is  swollen,  and  presents  here  and  there 
large  patches  of  g-angrene  or  hemorrhages  which  at  times  involve  all  the 
coats  of  the  gut.  C'ruveilhier  was  the  first  to  call  attention  to  the  import- 
ance of  this  condition  during  the  last  ej)idemic  of  cholera  in  P'urope. 

Identical  observations  are  reported  by  Guttnian,'  Fiirbringer,^ 
Kirchner,^  Ceci  and  Klebs/  and  others.  AVe  should,  however,  acknow- 
ledge that  we  are  far  from  knowing  the  biological  changes  that  take 
place  in  the  diseased  intestine  in  the  different  stages  of  Asiatic  cholera, 
and  the  influence  such  changes  may  have  upon  the  vitality  of  the  comma 
bacillus.  In  fact,  it  is  a  matter  of  common  occurrence  to  find  few 
commas  during  the  prodromic  stage,  whereas  they  are  present  in  almost 
pure  cultures  in  the  evacuating  stage,  and  again  disappear  or  are  rarely 
found  in  the  typhoid  stage. 

Although  no  anatomical  lesion  is  pathognomonic  of  cholera,  if  the 
series  of  lesions  above  mentioned  are  observed  in  a  suspected  case 
where  no  other  cause  of  death  can  be  discovered,  then  one  is  justified 
in  making  at  least  a  conditional  diagnosis  of  Asiatic  cholera. 

The  following  report  of  an  autopsy  which  I  performed  ten  hours 
after  death  gives  a  fair  idea  of  the  lesions  of  a  typical  case  : 

Autopsy. — Female,  aged  thirty  years. 

Appearance  of  Body.  —  Moderately  emaciated;  rigor  mortis  well 
marked ;  features  pinched. 

Thorax. — A  few  pleuritic  adhesions,  indicating  a  previous  plastic 
pleurisy.  The  right  pleura  presents  evidences  of  an  acute  pleurisy ; 
left  pleura  normal.  Lungs  emphysematous  in  their  antero-lateral  sur- 
face ;  both  lungs  present  extensive  areas  of  broncho-pneimionia  in  the 
upper  lobes ;  inferior  lobes  hypostatic  pneumonia  and  o?dema,  also 
puuctiform  hemorrhages  throughout  the  parenchyma  and  subj)leural 
space.  Large  bronchi  and  trachea  very  much  congested.  Pericardial 
sac  contains  about  two  drachms  of  thick,  creamy  pus  and  other  evi- 
dences of  acute  prevalent  pericarditis.  The  heart,  normal  in  volume, 
presents  the  left  ventricle  in  systole,  the  other  cavities  filled  with  dark 
Huid  blood  ;  valves  normal  and  competent.     Aorta  normal. 

Abdomen. — All  organs  in  proper  relation.  Upper  surface  of  liver 
covered  by  recent  fibrous  exudation  ;  the  rest  of  peritoneum  appears 
dry,  and  of  a  peculiar  "  ground-glass  "  hue.  Liver  of  normal  volume  ; 
npon  section  presents  a  slight  nutmeg  and  fatt^"  appearance  ;  gall  blad- 
<ler  filled  by  a  mixture  of  bile  and  mucus  ;  spleen  small  and  consist- 
ence increased ;  kidneys  large  and  yellowish  ;  on  section  present  the 
signs  of  acute  parenchymatous  nephritis,  also  slight  chronic  interstitial 
nephritis.     Suprarenal  capsules  normal. 

^  "Todtlicher  Ablauf  eines  Falles  von  Cholera  nostras,"  Berl.  kUn.  Wock.,  1892. 

^  "Todtlicher  Cholera  verdachtiger  Fall  in  Krankenhause  Fredrichshain,"  Deutsch. 
med.    WocL,  1892. 

^  "  Bacteriologische  Untersuchungen  bei  Cholera  nostras  und  Cholera  Asiatica,"  Berl. 
Mm.  Woch.,  1892. 

*  "  Ueber  Cholera  Asiatica  nach  Beobachtungen  in  Cenna,"  Correspondenzbl.f.  Schweizer 
Aerzte,  1884. 


314  CHOLERA. 

Alimentary  Canal. — Stomach  normal  in  dimensions ;  on  section  its 
mucous  membrane  is  seen  covered  by  a  thick,  creamy  deposit  of  mucus, 
underlying  which  can  be  noted  extensive  and  intense  hypersemia,  with 
large  patches  of  extravasated  blood.  These  hemorrhages  are  specially 
noticeable  in  the  fundus  and  pylorus ;  the  duodenum  and  rest  of  the 
small  intestines  present  evidences  here  and  there  of  acute  enteritis. 
There  are  hemorrhagic  areas,  principally  in  the  lower  portions  of  the 
ileum.  Large  intestine  from  caecum  to  descending  colon  very  much 
congested,  and  at  intervals  hemorrhagic.  Intestinal  surface  (large  and 
small)  presents  the  characteristic  staining  due  to  tannic  acid  (from  en- 
teroclysis),  and  the  contents  are  fluid  and  of  a  brownish  color. 

Pelvic  Organs. — Ovaries  normal.  Bladder  empty.  Rectum  presents 
the  signs  of  acute  proctitis.  Uterus  pregnant ;  contains  a  female  foetus 
about  twenty-eight  weeks  old,  well  nourished,  on  which  an  autopsy  was 
performed,  and  all  organs  found  apparently  in  normal  condition  except 
the  bladder,  which  was  enormously  distended  with  urine. 

Adipose  tissue  very  scanty  ;  muscles  of  a  dark  reddish  color  ;  dry. 

Diagnosis  of  Asiatic  cholera  confirmed  by  bacteriological  cultures. 

Symptoms. — The  symptoms  of  cholera  are  exceeding  acute,  typical, 
and  constant.  They  are  produced,  it  is  believed,  on  the  one  hand,  by 
the  absorption  of  toxic  material  and  its  effect  on  the  system,  and,  upon 
the  other  hand,  by  the  rapid  and  unwonted  drainage  of  fluid  from  the 
blood  and  lymphatic  vessels.  It  is  not  easy,  however,  to  differentiate 
clinically  the  various  symptoms  in  relation  to  the  special  cause  which 
has  produced  them,  and,  although  a  matter  of  considerable  scientific 
interest,  it  is  of  no  practical  importance  to  do  so.  For  purposes  of 
clinical  description  it  is  convenient  to  subdivide  the  course  of  the  dis- 
ease into  four  stages,  which  merge  into  one  another,  however,  without 
decided  demarcation.  These  stages  are  as  follows  : 
I.  Premonitory  stage ; 
II.  Stage  of  serous  diarrhoea  ; 

III.  Stage  of  asphyxia  and  collapse,  known  also  as  the  algid  stage  ; 

IV.  Reaction. 

The  first  stage  is  occasionally  omitted,  especially  in  the  more  severe 
epidemics,  when  persons  are  attacked  with  great  suddenness  and  vio- 
lence by  the  disease.  Many  patients  die  in  the  third  stage  without  ever 
reaching  the  fourth.  Very  mild  cases  may  occur  in  connection  with  an 
epidemic,  especially  at  the  commencement  and  end  of  it,  in  which  the 
third  stage,  or  even  the  second  stage,  is  absent.  In  some  cases,  although 
they  are  in  the  decided  minority,  there  is  an  undefined  prodromal  stage 
of  a  day  or  two,  during  which  the  patient  complains  of  malaise,  exhaus- 
tion, loss  of  appetite,  and  flatulent  dyspepsia,  with  possibly  vertigo. 

I.  The  PREMONITORY  STAGE  is  characterized  by  more  or  less  lassi- 
tude and  diarrhoea,  which,  at  first  mild,  soon  increases,  the  stools  becom- 
ing more  and  more  frequent,  watery,  and  abundant.  They  are  usually 
passed  without  pain,  are  alkaline  in  reaction,  and  have  a  pale  yellowish 
color.  They  may  occur  as  often  as  once  every  two  hours,  even  once  an 
hour.  There  are  more  or  less  intestinal  indigestion,  frequent  vomiting, 
and  considerable  flatulence.  There  is  headache  and  the  patient  is 
nervous,  and,  if  aAvare  of  the  prevalence  of  an  epidemic,  is  apt  to  be 
filled  with  fear  and  apprehension.     The  tongue  is  not  coated,  but  is 


SYMPTOMS.  315 

pale,  tliiii,  and  moist.  It  soon  bccoiucs  dry,  however,  and  thirst  is 
early  eoinplainetl  oi",  whieh  afterward  becomes  excessive.  The  voice  is 
usually  taint  and  the  })atient  experiences  threat  muscular  huit^uor. 
Exceptint>-  the  headache  there  is  no  decided  pain  anywhere.  The  ex- 
pression becomes  unnatural,  evidencing  dread,  and  the  complexion  is 
pallid.  The  pulse  may  be  slightly  quickened,  but  there  is  nothing  dis- 
tinctive in  the  character  of  either  pulse,  respiration,  or  temperature  in 
this  stage. 

The  premonitory  stage  may  last  for  one  or  two  days,  and  if  promptly 
treated  may  end  in  immediate  recovery.  Otherwise  it  will  merge  into 
the  second  stage  of  serous  diarrhoea,  and,  as  stated  before,  it  may  be 
abbreviated  even  to  a  few  hours  or  it  may  be  absent  altogether. 

II.  The  SECOND  STAGE  presents  one  of  the  most  alarming  condi- 
tions ever  recognized  in  any  of  the  infectious  diseases,  excepting,  per- 
haps, yellow  fever.  The  stools  become  more  and  more  frequent,  finally 
almost  continuous.  They  are  still  alkaline,  and  they  become  more  and 
more  watery  until  they  finally  consist  only  of  water,  in  which  flakes  of 
w^hitish  mucus  and  epithelium  float  about,  giving  rise  to  the  character- 
istic appearance  familiarly  known  as  "  rice  water."  The  bowels  having 
been  thoroughly  evacuated  of  all  fecal  matter  and  bile  by  previous  pas- 
sages, the  stools  become  purely  sero-mucous  and  odorless,  though  there 
is  a  distinct  meaty  smell.  They  are  frothy  and  exceedingly  copious  ;  as 
much  as  two  quarts  of  fluid  may  be  almost  instantaneously  evacuated 
with  considerable  force.  If  left  standing,  a  sediment  is  deposited 
which,  when  examined^  is  found  to  consist  principally  of  desquamated 
intestinal  epithelium,  granular  debris,  bacteria,  and  possibly  a  little 
mucus.  The  stools,  although  described  as  resembling  rice  water,  are 
in  reality  much  more  transparent  (Milles).  In  some  cases  they  are 
stained  with  blood  pigment,  and,  according  to  Flint,  the  specific  gravity 
of  the  evacuation  is  1005  to  1013.  They  contain  sodium  chloride  and 
also  ammonium  carbonate,  which  latter  imparts  the  alkaline  reaction. 
There  is  at  first  a  notable  absence  of  tormina  and  tenesmus  ;  in  fact, 
patients  are  often  temporarily  relieved  by  the  evacuations.  When  the 
stools  become  typical  they  are  found  to  contain  fewer  varieties  of  bac- 
teria than  are  present  normally,  and,  in  fact,  the  comma  bacillus  may 
be  the  only  one  present.  This  germ,  however,  is  not  found  in  any  con- 
siderable quantity  until  the  evacuations  are  thoroughly  watery. 

The  quantity  of  fluid  drained  from  the  system  by  this  means  is 
enormous,  and  far  exceeds  that  which  is  ingested.  It  should  be  remem- 
bered that  about  70  per  cent,  of  the  normal  body  weight  is  composed 
of  water,  and  while  the  evacuations  continue  much  of  this  Avater  is 
drained  from  the  more  fluid  tissues,  such  as  the  muscles  and  viscera, 
and  is  withheld  from  the  digestive  organs,  and  is  reabsorbed  from  the 
serous  surfaces.  Hence  all  the  latter  become  dry  or  coated  with  a 
sticky,  thick,  slimy  secretion,  and  the  soft  tissues  generally  diminish  in 
volume.  Brunton  considers  the  transudation  of  serum  into  the  intes- 
tine as  due  to  paralysis  of  the  intestinal  nerves.  The  facies  are  typical 
in  this  stage.  The  rapid  emaciation,  showing  prominently  in  the  face, 
gives  the  individual  a  wizened  aspect.  The  conjunctivae  are  red  and 
congested,  the  pupils  are  contracted,  and  the  orbits  are  hollow  and  are 
generally  surrounded  by  dusky  rings.     The  eyes  have  a  vacant,  staring, 


316  CHOLERA. 

cadaveric,  expressionless  look.  The  face  is  flushed,  the  nose  is  pinched, 
the  mouth  is  drawn,  the  cheeks  are  sunken,  the  abdomen  is  depressed 
and  "  boat-shaped,"  the  skin  becomes  inelastic,  loose,  and  wrinkled, 
and  the  muscles  lose  in  volume.  A  few  hours  will  make  a  previously 
healthy-looking  young  adult  appear  like  a  withered  octogenarian. 

The  tongue  is  dry,  covered  with  a  thick,  yellowish  white  coat  in  the 
centre,  but  red  at  the  edges  and  tip,  somewhat  resembling  the  tongue 
of  typhoid  fever,  but  with  less  prominent  papillae.  The  whole  mouth 
is  very  dry  and  thirst  is  extreme.  The  desire  for  fresh  water  and  for 
acidulated  drinks  is  insatiable.  Patients  drink  eagerly,  and  never  seem 
to  get  enough  water.  Among  other  subjective  sensations  complained 
of  are  headache  and  a  feeling  of  oppression  or  of  suffocation  in  the 
chest.     Restlessness  gives  way  to  quiet  and  apathy. 

The  mental  condition  of  the  patient  is  characteristic.  The  mind  is 
dull,  listless,  apathetic,  but  consciousness  may  remain  until  death  super- 
venes, and  the  patient  can  often  be  aroused  to  answer  questions  intelli- 
gently, although  he  volunteers  nothing,  but  moans  and  rests  with  the 
eyes  half  closed.  When  aroused  from  this  semi-conscious  condition  the 
voice  is  feeble,  cerebration  is  slow,  and  speech  is  difficult.  If  asked 
how  he  feels,  the  patient  may  reply  that  he  is  well,  but  asks  at  once  for 
more  water. 

Vomiting  usually  characterizes  this  stage,  and  it  comes  on  suddenly 
or  is  preceded  by  nausea.  It  is  difficult  to  control,  and  is  often  accom- 
panied by  considerable  straining  and  consequent  epigastric  pain  and 
soreness.  The  stomach  is  at  first  emptied  of  whatever  food  it  may  con- 
tain ;  then  bile  is  vomited,  and  finally  the  ejecta  consist  of  watery  fluid, 
become  colorless,  almost  odorless,  alkaline  in  reaction,  and  resemble  the 
choleraic  stools.  The  urine,  like  the  other  secretions  in  the  body,  is 
withheld,  and  suppression  may  become  complete,  or,  if  this  is  not  the 
case,  it  is  dark-colored,  of  high  specific  gravity,  containing  an  exces- 
sive percentage  of  urea,  some  albumin,  and  hyaline,  granular,  and  fatty 
casts. 

The  anuria  is  not  wholly  due  to  lack  of  water  in  the  blood,  but  in 
great  part  to  inability  of  the  kidneys  to  perform  their  functions.  The 
scrotum  is  retracted.  The  pulse,  owing  to  the  small  volume  of  blood 
contained  in  the  arteries  and  the  feeble  heart  action,  becomes  very 
thread-like  and  compressible.  It  is  quickened,  at  first  to  100,  later 
it  may  rise  to  115  or  120.  Arterial  tension  is  diminished.  The  respi- 
ration becomes  feeble  and  shallow.  It  is  mainly  thoracic,  and  may  be 
irregular  in  rhythm.  It  may  be  increased  to  30  or  40.  The  perspira- 
tion is  often  profuse,  being  the  only  secretion  which  is  not  checked. 
The  surface  of  the  body  becomes  livid,  and  feels  cold  and  cadaveric  to 
the  touch,  although  the  internal  temperature  may  register  one  or  two 
degrees  above  the  normal  when  carefully  taken  by  a  long-stemmed 
thermometer  placed  in  the  rectum.  It  is  often  stated  that  cholera  is  a 
disease  of  subnormal  temperature,  but  this  is  not  strictly  correct,  as 
pointed  out  by  De  Renzi,  Guterbock,  and  others.  Although  the  tem- 
perature in  the  mouth  has  been  recorded  as  low  as  79°  F.  and  that  in 
the  axilla  at  75°  F.,  the  internal  temperature  is  elevated,  and  the  patient 
complains  of  a  subjective  sensation  of  fever.  The  fever  is  described  as 
being  of  a  remittent  type  with  exacerbations.      This  temperature  is 


SYMPTOMS.  317 

commonly  overlooked  on  account  of  the  frequency  of  the  stools  and  the 
difficulty  of  takings  the  temperature  correctly  in  any  other  place  than 
the  rectum.  The  freshly  voided  urine  may  show  an  elevation  of  tem- 
perature. The  muscular  cram])s  may  aifeet  the  dia])hrao;m,  giving  rise 
to  more  and  more  tlitticult  respiration,  or,  occurring  s[)asmodically,  cause 
hiccough. 

The  stage  of  serous  diarrhoea  lasts  from  one  to  two  or  three  hours  or 
more,  and  the  patient  usually  passes  into  the  stage  of  collapse.  More 
rarely  recovery  takes  place  at  the  end  of  the  second  stage.  Naturally, 
the  more  violent  the  symptoms  of  this  stage  the  briefer  it  becomes. 

One  important  fact  should  be  borne  in  mind — namely,  that  tlie 
quantity  of  the  evacuations  is  not  an  infallible  guide  for  prognosis. 
A  very  fatal  form  of  cholera  is  sometimes  observed  in  which  diarrhoea 
is  slight,  although  the  other  symptoms  are  all  present.  This  is  described 
as  "  drv  cholera,"  or  "  cholera  sicca."  Such  are  often  cases  in  whicli 
the  patient  is  suddenly  seized  with  great  prostration  and  faintness  with- 
out any  premonitory  symptoms.  Death  occurs  in  two  or  three  hours, 
and  examination  of  the  intestines  shows  them  to  be  enormously  dis- 
tended with  serous  fluid  which  failed  to  escape  in  diarrhoeal  stools, 
apparently  because  intestinal  paralysis  has  been  complete. 

The  stage  of  collapse  cannot  be  distinctly  separated  from  the 
stage  of  serous  diarrhoea,  for  they  gradually  merge  one  into  the  other. 
In  this  algid  stage  the  heart  action  becomes  so  feeble  on  account  of  the 
lack  of  blood  pressure,  the  difficulty  of  propelling  the  thickened  blood 
through  the  capillaries,  and  the  lack  of  nutrition  of  the  organ  itself, 
that  stimulation  is  urgently  needed. 

Owing  to  the  excessive  loss  of  water  by  osmosis  into  the  intestine 
the  blood  becomes  thick  and  tarry.  The  bloodvessels  are  comparatively 
empty,  and  the  velocity  of  the  blood  stream  is  reduced  by  the  weakness 
of  the  heart.  The  red  corpuscles  do  not  circulate  readily  through  the 
pulmonarv  capillaries,  and  the  normal  respiratory  function  is  greatly 
impeded.  There  is  deficient  oxidation,  and  carbonic  acid  accumulates 
in  the  blood.  Cyanosis  results,  and  this  becomes  especially  marked 
about  the  nose,  lips,  and  in  the  extremities. 

As  a  further  consequence  of  the  rapid  loss  of  fluid  from  the  system 
the  muscles  become  dry  and  pass  into  tonic  spasms,  in  which  they  are 
hard  and  board-like.  Severe  and  frequent  cramps  ensue  in  them.  The 
abdominal  recti  are  usually  first  affected,  and  subsequently  the  calves 
of  the  legs,  and  finally  nearly  all  the  larger  muscles  of  the  extremities 
and  trunk,  may  be  involved,  including  those  of  the  arms  and  neck. 
The  cramps  are  persistent,  and  give  rise  to  intense,  agonizing  pain, 
especially  in  the  abdomen  and  legs.  The  arms  and  legs  are  distorted. 
Pain  is  also  referred  to  the  sternum  and  other  parts  of  the  chest. 

The  patient's  general  condition  is  pitiful.  The  skin  is  dry,  pinched, 
and  wrinkled,  the  face  is  expressionless,  the  half-closed  eyes  have  a 
vacant  stare  ;  the  mouth  is  drawn  and  set ;  the  cheek-bones  protrude  as 
if  they  would  burst  through  the  skin  ;  there  is  sudden  increase  in  vom- 
iting and  diarrhoea,  which  is  followed  by  further  fall  in  the  surface  tem- 
perature (Shakespeare),  although  the  deep  internal  temperature  may 
continue  elevated  by  one  or  two  degrees.  The  patient's  mouth  is  so 
diy  and  he  is  so  feeble  that  he  is  unable  to  articulate,  although  he  can 


318  CHOLERA. 

be  aroused  to  evident  consciousness.  The  muscular  cramps  continue, 
and  the  abdominal  walls  are  sunken,  but  rigid.  The  emaciated  fingers 
and  toes  are  flexed  or  drawn  into  unusual  positions  by  the  contractures. 
The  respirations  become  more  and  more  feeble  and  irregular,  and  the 
exhaled  breath  is  cold.  The  patient  often  suffers  greatly  from  a  sense 
of  suifocation.  The  tears,  saliva,  and  bile  are  all  suppressed,  and  so  is 
the  menstrual  function.  The  conjunctivae  become  so  dry  that  exposure 
to  the  air  may  make  them  inflamed  (Stille),  The  urine  continues  highly 
albuminous  or  else  is  totally  suppressed.  It  sometimes  contains  sugar. 
The  rapidity  of  the  pulse  is  not  excessive.  It  often  remains  between 
100  and  120,  and  it  finally  becomes  imperceptible  at  the  wrist.  The 
second  sound  of  the  heart  is  quite  inaudible.  The  duration  of  this 
stage  varies  from  a  few  hours  to  as  much  as  one  or  two  days,  ending 
either  in  the  stage  of  reaction  or  in  a  typhoid  state  in  which  the  patient 
may  linger  for  a  week  or  more  before  death,  or,  as  is  frequently  the 
case,  it  terminates  early  and  the  patient  dies  of  asthenia.  Death 
sometimes  occurs  from  sudden  heart  failure,  and  the  patients  who  have 
not  presented  the  most  severe  symptoms  have  been  known  to  escape 
from  bed,  take  a  few  steps,  and  drop  dead.  Usually,  however,  death 
occurs  so  gradually  that  it  may  be  difficult  to  fix  the  exact  moment  at 
which  the  heart  action  finally  ceases.  Just  before  death  and  for  some 
time  thereafter  the  temperature  begins  to  rise,  and  within  an  hour  or 
two  after  death  it  may  reach  106°  F.  In  the  asphyxiated  cases,  caused 
by  stagnation  in  the  flow  of  the  thickened  blood,  the  temperature  may 
even  reach  as  high  as  108°  F.  Not  infrequently  rigor  mortis  sets  in 
while  the  patient's  facial  muscles  and  those  of  the  extremities  are  so 
contracted  as  to  produce  fixed  grimaces  and  contortions,  which  add  much 
to  the  horror  of  the  disease. 

TV.  Stage  of  reactiOjS^. — This  stage  follows  gradually  upon  that 
of  collapse.  The  diarrhoea  and  vomiting,  which  have  ceased  toward  the 
end  of  the  previous  stage,  either  from  exhaustion  or  from  lack  of  fluid 
to  be  voided,  do  not  return.  By  slow  degrees  the  pulse  becomes  again 
perceptible,  and  the  internal  temperature  begins  to  rise,  in  the  majority 
of  cases  for  two  or  three  or  more  degrees.  The  patient's  expression 
becomes  more  intelligent,  and  muscular  contractures  cease.  The  res- 
piration becomes  deeper  and  more  regular,  and  slowly  the  external 
warmth  of  the  body  is  restored.  The  patient  ceases  to  experience  thirst, 
and  there  is  gradual  evidence  of  the  recovery  of  the  different  secretory 
functions  which  have  been  suppressed.  The  urine  increases  in  volume 
and  improves  in  character,  and  the  stools,  which  are  now  infrequent, 
by  slow  degrees  take  on  a  solid  character  (after  nourishment  has  been 
given),  and  show  some  evidence  of  bile  pigmentation,  although  if  there 
has  been  excessive  denuding  of  the  epithelial  surface  of  the  intestine 
they  may  continue  to  have  a  hemorrhagic  character. 

Recovery  is  sometimes  prompt,  but,  as  might  be  expected  from  such 
a  severe  disease,  it  is  often  protracted  by  continued  anaemia  and  pro- 
nounced irritability  and  feebleness  of  the  stomach,  bowels,  and  nervous 
system  in  general.  Such  symptoms  as  severe  frontal  headache,  dizzi- 
ness, and  fainting  may  recur  from  time  to  time.  In  other  cases  septic 
material  is  apparently  absorbed  from  the  denuded  intestinal  surfaces, 
and  the  patient  passes  into  a  condition  of  septicaemia  or  a  typhoid  state. 


COMPLICATIONS  AND  SEQVELjK.  319 

in  which  he  may  linger  for  a  week  or  two  before  deatli.  Tliis  condition 
is  characterized  bv  continued  liit>h  fever  (104°  to  105°  F.),  a  dry  fissured 
tongue,  continued  diarrhioa,  delirium,  and  coma.  Sometimes  there  are 
cutaneous  eruptions  of  differeut  kinds,  luiviuij::  no  constant  type,  how- 
ever. Other  cases,  again,  owing  to  the  continued  sup])ression  of  urine, 
pass  into  a  unomic  condition,  with  a  preponderance  of  nervous  symp- 
toms, such  as  delirium  and  convulsions.  In  still  other  cases  the  intes- 
tines have  been  so  much  weakened  that  they  are  long  in  regaining  their 
natural  tone,  and  protracted  diarrhoea  maintains  the  exhaustion  of  the 
patient.  Relapses  sometimes  result  from  overexertion,  too  hasty 
resumption  of  normal  diet,  or  occasionally  without  any  assignable 
cause. 

In  the  disease  called  "  cholerine,"  which  has  been  mentioned  as  often 
preceding  or  accompanying  widespread  epidemics  of  cholera,  and  which 
some  Avriters  regard  as  a  mild  form  of  the  latter  disease,  the  symptoms 
are  much  less  severe,  and,  although  the  diarrhoea  is  exhaustive,  asphyxia, 
muscular  cramps,  and  total  suppression  of  the  urine  are  not  common. 
This  disease,  however,  is  often  fatal. 

DuEATiox. — The  cases  which  are  fatal  commonly  terminate  in  two 
or  three  days.  Death  has  been  known  to  take  place  within  two  hours 
after  the  passage  of  the  first  typical  stools,  the  patient  going  into  the 
algid  state  at  once.  Ordinary  cases,  ending  in  recovery,  may  last  from 
a  week  to  several  weeks  according  to  the  severity  of  the  disease  and  the 
supervention  of  complications.  Epidemics  do  not  long  prevail  in  any 
one  locality.  They  do  not  often  remain  longer  than  three  or  four  weeks 
in  one  place,  but,  being  migratory,  pass  on  to  new  localities,  and  are 
thus  sometimes  prolonged  throughout  an  entire  season.  They  may  be 
temporarily  checked  by  cold  weather  and  be  resumed  in  the   sj^ring. 

Complications  axd  Sequelae. — Owing  to  the  conditions  under 
which  cholera  develops,  especially  those  of  the  presence  of  a  damp  soil, 
putrefying  organic  material,  and  bad  water,  other  diseases  are  apt  to 
prevail  in  the  same  locality  and  at  the  same  time  in  which  cholera  is 
active.  Such  diseases  are  simple  diarrhoea,  gastro-enteritis,  dysentery, 
and  the  more  severe  forms  of  malarial  fevers. 

A  variety  of  symptoms  have  been  recorded  in  different  epidemics  as 
complicating  or  following  cholera,  but  none  of  them  are  distinctive  or 
constant.  Such  are  the  different  exanthemata,  as  roseola,  urticaria,  etc. 
The  emaciation  predisposes  to  bedsores,  ulceration,  and  furunculosis. 
Perspiration  may  continue  and  become  excessive,  the  sweat  containing 
urea.  Painful  swelling  of  the  parotid  glands  has  been  recorded.  Occa- 
sionally a  condition  resembling  tetanus  obtains,  and  the  muscles  remain 
rigid  and  contracted  for  several  days.  Still  rarer  sequelae  are  gangrene, 
peritonitis,  and  ulcer  of  the  cornea.  Very  commonly  considerable  irri- 
tation of  the  gastro-intestinal  tract  persists  after  many  days  or  weeks, 
which  naturally  postpones  convalescence.  The  circulation  may  remain 
feeble  for  a  long  time,  so  that  the  patient  suffers  from  coldness  of  the 
extremities,  wakefulness,  dizziness,  and  other  symptoms.  Persistent 
albmuinuria  may  remain,  and  there  is  sometimes  cerebral  congestion. 
In  many  cases,  and  in  children  especially,  broncho-pneumonia  is  a 
somewhat  common  complication. 

Diagnosis. — The  immense  importance  of  an  early  diagnosis  of  Asi- 


320  CHOLERA. 

atic  cholera  is  self-evident,  for  not  only  is  the  clinician  materially  aided 
by  being  thus  enabled  to  apply  the  proper  treatment  at  the  onset,  but 
the  sanitarian  can  more  easily  control  an  impending  epidemic  by  prompt 
recognition  of  the  first  cases.  The  diagnosis  is,  however,  beset  with 
difficulties  even  during  the  prevalence  of  an  epidemic,  for,  on  the  one 
hand,  a  number  of  very  mild  cases  escape  detection — which  for  this 
reason  are  apt  to  spread  the  scourge  in  its  worst  form — and,  on  the  other, 
there  are  undoubtedly  many  cases  of  severe  acute  gastro-intestinal  dis- 
ease which  so  closely  simulate  Asiatic  cholera  as  to  be  neither  clinically 
nor  anatomically  distinguishable  from  it.  These  cases  are  due  to  other 
bacteria  than  the  comma  bacillus,  which  are  endowed  with  either  per- 
manent or  temporary  specific  virulence.  Fortunately,  in  the  recognition 
of  the  spirillum  of  Asiatic  cholera  discovered  by  Koch  we  have  a  means 
of  diagnosis  which  is  today  admitted  by  the  great  majority  of  author- 
ities to  be  absolute.  Hence  in  all  suspected  cases  early  bacteriological 
examination  is  imperative,  and  whenever  the  spirillum  is  found  the  case 
is  at  once  to  be  regarded  as  one  of  true  Asiatic  cholera.  Upon  the 
negative  side  it  must  be  admitted  that  there  are  cases  of  true  cholera  in 
which  the  spirillum  cannot  be  found,  but  these  are  far  fewer  of  late 
years  since  the  bacteriological  technique  has  made  such  rapid  advances 
and  the  examinations  are  made  more  promptly.  The  causes  of  failure 
to  find  the  bacillus  in  such  cases  are  chiefly  the  following :  1.  Imper- 
fect technique.  2.  Examination  conducted  after  the  intestines  have  been 
already  irrigated  with  acid  injections.  3.  Examination  made  at  the 
wrong  stage  of  the  disease,  when  the  bacilli  are  absent  or  greatly  reduced 
in  number.  4.  Some  few  extremely  virulent  cases,  occurring  especially 
in  young  children,  in  which  death  results  before  there  has  been  time  for 
the  development  of  many  germs. 

The  panic  caused  by  Asiatic  cholera,  no  matter  in  what  community 
or  class  of  people  it  may  appear,  is  only  to  be  judged  by  those  who  have 
an  opportunity  of  being  witness  to  such  scenes.  The  most  formidable 
barrier  the  sanitarian  meets  with  in  his  endeavors  to  check  an  epidemic 
is  the  fear  possessed  by  the  masses.  People  imagine  that  the  authorities 
are  hunting  for  the  sick,  not  to  help  them  in  their  distress,  but  to  exter- 
minate them  by  any  means.  When  a  patient  is  taken  to  a  lazaretto  his 
relatives  and  friends  are  often  convinced  that  he  will  be  poisoned  at 
once  and  hurried  into  an  unknown  grave.  Consequently  in  hospitals 
one  very  seldom  sees  cases  of  cholera  in  the  first  stages  of  the  disease. 
This  experience  was  repeated  during  my  stay  in  the  New  York  Quaran- 
tine in  1892  and  1893. 

There  are  three  symptoms  which  are  present  at  the  outset  of  the 
disease,  the  observation  of  which  has  aided  me  and  others  connected 
with  the  quarantine  in  diagnosing  suspected  cases  at  a  very  early  stage. 
These  symptoms  are  as  follows  : 

1.  Expression  of  the  face.  The  face  appears  pale,  with  slightly  flushed 
cheeks,  a  bluish  hue  of  the  lips,  slight  congestion  of  the  conjunctivae, 
and  a  peculiar,  rather  stupid  look  in  the  eyes. 

2.  Moderate  rapidity  of  the  pulse.  This  symptom  is  most  important, 
and  is  one  of  the  earliest  to  appear.  The  pulse  is  compressible,  and 
beats  about  108  to  120  a  minute  without  accompanying  elevation  of 
temperature. 


DIAGNOSIS.  321 

3.  Appearance  of  the  toiufue.  This  is  thickly  coated  in  the  centre 
and  red  at  the  edges,  sometimes  moist,  in  otiier  cases  drv. 

The  sul)iective  symptoms  cannot  he  (Icpciidcd  upon  :it  all  in  the  pro- 
dromal staye. 

It  is  oidy  in  the  jjrenionltory  stage  or  before  the  recognition  of  an 
epidemic  of  cholera  that  the  disease  is  apt  to  be  mistaken  for  any  other. 
Typical  cases  are  absolutely  unique,  and  the  diagnosis  is  easily  estab- 
lished by  the  rice-water  stools,  the  rapid  emaciation,  suppression  of 
secretions,  prostration,  and  algid  condition.  Nevertheless,  errors  have 
been  made,  and  those  diseases  and  conditions  which  have  from  time  to 
time  been  mistaken  for  cholera,  or  for  which  cholera  has  been  mistaken, 
are  septicaemia,  cholera  morbus  or  cholera  nostras,  severe  gastro-enteric 
fever,  typhoid  fever,  pernicious  malarial  fever  wdth  gastro-intestinal 
symptoms,  and  ptomaine  or  other  forms  of  poisoning.  Asphyxia  from 
coal-gas  (CO)  poisoning  may  resemble  the  stage  of  choleraic  asphyxia, 
but  the  absence  of  the  rice-water  stools  will  not  long  leave  the  diagnosis 
in  doubt. 

In  the  typhoid  or  septic  condition  into  which  cholera  patients  some- 
times pass  during  the  reaction  stage  the  disease  sometimes  resembles 
typhoid  fever,  but  the  latter  can  be  differentiated  by  the  type  of  the 
fever,  the  abdominal  eruption,  the  less  rapid  emaciation,  and  the  fact 
that  the  stools,  if  diarrhoeal,  are  much  less  watery  than  in  cholera.  In 
cases  of  severe  septicsemia  the  invasion  is  less  acute,  the  temperature  is 
higher,  there  may  be  chills  and  sweating,  and  the  history  of  the  case  is 
wholly  different.  Exceptionally,  intensely  acute  cases  of  cholera  mor- 
bus prove  fatal  in  a  day  or  two,  and  very  closely  resemble  Asiatic 
cholera,  although  usually  complete  suppression  of  urine,  cyanosis,  and 
prolonged  muscular  cramps  are  wanting  in  the  former  disease.  The 
bacterial  diagnosis  can  be  made  within  a  few  hours.  The  stools,  while 
loose  and  watery,  are  not  so  clear  as  the  t^'pical  rice-water  evacuations 
of  Asiatic  cholera.  The  cases  are  almost  always  isolated,  non-epidemic, 
and  recovery  is  more  frequent.  In  pernicious  malarial  fever  of  the 
gastro-enteric  t}^e  the  onset  of  the  disease  is  often  acute,  and  for  a  few 
hours  it  may  resemble  cholera,  but  the  temperature  is  much  higher, 
reaching  106°  or  107°  ;  free  pigment  is  found  in  the  blood,  with  some- 
times malarial  organisms. 

Ptomaine  poisoning  produces  great  prostration,  violent  watery  diar- 
rhoea, cramps,  thirst,  etc.,  but  the  histoiy  of  the  case  and  the  non- 
appearance of  typical  rice-w^ater  stools  will  enable  the  diagnosis  to  be 
made.  There  are  some  cases  of  acute  arsenical  poisoning  which  may 
resemble  the  first  stage  of  cholera  from  the  collapse,  cramps,  suppression 
of  urine,  and  thirst  which  may  occur  ;  but  in  these  cases  there  is  decided 
epigastric  pain  and  burning,  with  constriction  in  the  throat  and  oesoph- 
agus. In  all  doubtful  cases  thorough  bacteriological  examination  should 
be  at  once  made. 

Peognosis. — The  prognosis  of  cholera  depends  mainly  upon  the 
severity  of  a  given  epidemic  and  the  promptness  with  which  individual 
patients  are  treated.  Other  conditions  which  affect  it  are  the  general 
sanitary  condition  of  environment  and  the  patient's  previous  state  of 
health.  The  prognosis  is  worse  along  the  sea-coast  than  inland,  and 
is  always  bad  in  overcrowded  camps  and  tenements.     In  Asia,  such  are 

Vol.  I.— 21 


322  CHOLERA. 

the  habits  of  the  people,  so  largely  influenced  by  ignorance,  supersti- 
tion, and  certain  religious  customs,  that  no  progress  has  of  late  years 
been  made  in  reducing  the  mortality  from  cholera,  excepting  where  the 
British  government  has  been  able  to  improve  the  water  supply  and 
drainage  in  some  localities,  notably  in  Calcutta.  By  these  means  the 
mortality  of  foreign  soldiers  serving  in  India  has  been  reduced  to  one 
sixth  of  the  rate  of  thirty  years  ago,  when  it  varied  between  18  and  20 
per  1000.  In  various  epidemics  the  mortality  has  varied  chiefly  between 
20  and  80  per  cent.,  and  it  has  sometimes  been  as  high  as  90  per  cent. 
The  mortality  is  greatest  at  the  extremes  of  age  when  individuals  are 
regarded,  but  in  general  the  total  mortality  is  greater  in  early  adult  or 
middle  life,  because  more  victims  are  taken  during  this  period.  Some 
extensive  epidemics  have  had  comparatively  slight  mortality,  while 
others,  less  widespread,  have  been  exceedingly  fatal. 

From  21  cases  of  cholera  diagnosed  by  myself  bacteriologically,  and 
1  clinically,  only  4  deaths  resulted :  3  died  directly  from  the  effects  of 
the  disease ;  the  fourth,  after  becoming  convalescent,  contracted  lobar 
pneumonia,  to  which  he  succumbed.  Judging  from  these  results,  in 
which  there  is  a  mortality  of  less  than  14  per  cent.,  Asiatic  cholera 
should  not  be  considered  such  an  excessively  dangerous  disease ;  in 
fact,  it  is  an  easy  enemy  to  vanquish  if  one  is  well  prepared  for  it  and 
is  forewarned  of  its  presence. 

Prophylaxis. — Unquestionably,  the  greatest  drawback  to  the 
total  extirpation  of  cholera,  which  is  theoretically  quite  possible  if  a 
sanitary  millennium  could  be  attained,  is  the  ignorance,  superstition, 
and  fanaticism  prevailing  among  different  races  and  tribes  of  semi- 
civilized  Eastern  people.  In  the  past  few  years  many  lives  have  been 
lost  through  riots  originating  in  efforts  on  behalf  of  the  people  to  pre- 
vent the  enforcement  of  ordinary  commonsense  hygienic  rules.  Officers 
in  authority  in  their  attempts  to  use  disinfectants,  and  even  physicians 
making  humane  efforts  to  treat  the  disease,  have  been  brutally  mobbed. 
It  will  be  long  before  this  condition  can  be  overcome,  and  such  is  the 
religious  superstition  prevailing  in  India  in  regard  to  bathing  in  the 
sacred  pools  and  other  religious  rites,  that  it  is  doubtful  whether  the 
disease  can  ever  be  wholly  controlled  as  it  should  be.  It  is  possible, 
however,  for  civilized  countries  to  protect  themselves  against  invasion 
by  the  adoption  and  enforcement  of  simple  sanitary  regulations  which 
have  been  thoroughly  proven  abundantly  adequate  to  check  absolutely 
the  further  spread  of  the  disease. 

Cleanliness. — In  all  epidemics  of  cholera  a  careful  study  of  the 
modes  of  transmission  of  the  disease  emphasizes  the  fact  that  personal 
cleanliness  and  absolute  cleanliness  of  all  clothing  are  distinctly  pro- 
phylactic. Upon  guarded  steamships,  unless  they  have  contracted  the 
disease  from  foul  water  on  shore,  it  never  spreads  among  the  well  cared- 
for  cabin  passengers,  but  affects  particularly  emigrants  of  the  low  classes, 
whose  filthy  habits,  combined  with  overcrowding,  make  them  ready  sub- 
jects to  the  infection. 

Among  other  prophylactic  agencies  are  the  examination  and  disin- 
fection of  all  emigrants  coming  from  a  region  infected  with  cholera, 
their  detention,  by  suitable  quarantine  regulations,  on  their  arrival  at  a 
new  port,  their  promjjt  treatment,  isolation^  and  disinfection  when  sus- 


rnoriiYLAxis.  323 

picious  cases  oociir,  and  liiially  tlic  eiiliiilitcimu'iit  of"  the  fj:eneral  ])ul)li{r 
as  to  the  real  nature  of  the  disease  and  tlie  iinjjossihility  of  infection  by 
any  other  means  than  throtiiih  the  agency  of  the  mouth,  because  eitlier 
contaminated  food  or  drink  is  the  agent  necessary  to  originate  an  epi- 
demic. 

When  an  invasion  of  chok'ra  is  threatened,  all  cities  liable  to  be 
invaded,  especially  seaboard  towns,  should  l)e  put  in  the  best  ])ossible 
sanitary  conditit)n.  The  streets  shonld  be  thoroughly  cleaned  ;  all  sew- 
ers, cesspools,  or  receptacles  for  excreta  or  manure  should  undergo  a 
most  thorough  cleansing  and  disinfecting.  The  water  snpply  shonld  be 
immediately  investigated,  and  every  source  of  contamination  with  it 
."^ihould  be  guarded,  if  necessary,  by  sanitary  police.  Through  printed 
circulars  and  the  public  press  the  public  should  be  warned  to  use  no 
water  for  either  cooking,  drinking,  or  washing  purposes  (or  brushing 
the  teeth)  which  has  not  been  iirst  subjected  to  thorough  and  prolonged 
boiling,  Avhicli  will  render  it  absolutely  innocuous. 

The  local  government  should  appoint  special  medical  inspectors 
whose  duty  shall  be  to  allay  the  fears  of  the  people  and  disseminate 
knowledge  in  regard  to  the  importance  of  obeying  sanitary  rules  and 
caring  for  personal  hygiene.  They  should  make  house-to-house  visits 
iind  see  that  all  cases  of  diarrhoea  or  dyspepsia  from  any  cause  are 
promptly  treated.  Large  assemblies  of  people  should  be  forbidden, 
especially  at  public  funerals  of  those  who  have  died  from  the  disease. 

Baw  Food. — The  eating  of  all  forms  of  raw  food  shonld  be  discour- 
aged, for  undoubted  cases  of  infection  from  this  source  are  numerous. 
If  necessary,  the  civic  authorities  of  the  town  should  take  measures  to 
prevent  temporarily  the  sale  of  all  fruits  and  such  vegetables  as  are  apt 
to  be  eaten  raw.  This  was  done  in  Hamburg  during  the  last  epidemic 
there.  The  reason  for  such  action  is  obvious.  The  fruits  and  vegeta- 
bles are  often  cleansed  by  w^ashing  them  in  foul  water,  and  undoubtedly' 
not  only  cholera,  but  typhoid  fever  germs,  may  be  conveyed  into  the 
human  body  by  eating  raw  food  which  has  been  thus  contaminated. 
Moreover,  it  has  been  clearly  proved  that  flies  are  active  agents  in 
spreading  cholera  bacilli  abroad.  Their  filthy  habits,  in  the  exercise 
of  which  they  alight  on  decomposing  offal  and  excreta,  cause  the  con- 
tamination of  their  feet  and  bodies  with  the  germs  of  disease,  Avhich  are 
thus  easily  conveyed  by  them  to  any  articles  of  raw  food,  such  as  sweet, 
overripe  fruits,  etc.,  which  are  exposed  on  public  sale.  This  is  not  mere 
theory,  but  the  observation  of  scientific  bacteriological  research. 

Much  discussion  has  been  occasioned  in  regard  to  the  possibility  of 
infection  from  beet  sugar  prepared  in  an  affected  locality,  the  idea  being 
that  the  coarse  sacks  in  which  the  sugar  is  shipped  for  commerce 
become  saturated  with  saccharine  material,  affording  a  good  culture 
medium  for  cholera  germs  ;  but  Sternberg  has  proved  that  cholera  bacilli 
do  not  grow  in  a  moist  beet  sugar  medium  in  the  absence  of  nitrogenous 
material,  and  beet  sugar  alone  does  not  nourish  the  spirillum. 

Disinfection  of  Stools,  Clothing,  etc. — Physicians,  nurses,  and  attend- 
ants are  no  more  liable  to  contract  cholera  than  they  are  in  attend- 
ing cases  of  typhoid  fever  to  acquire  that  disease,  and  identical 
precautions  must  be  observed.  In  both  cases  infection  is  con- 
A'eyed    through   the  stools,    and    absolute   personal    cleanliness    after 


324  CHOLERA. 

handling  the  patients  or  their  evacuations  cannot  be  too  strictly- 
insisted  upon.  In  cholera  the  stools  are  so  copious,  and  occur 
with  such  frequency  and  violence,  that  it  is  often  difficult  to  keep 
the  patients  and  their  bedding  clean,  and  the  hands  of  the  attend- 
ants must  necessarily  come  more  or  less  in  contact  with  the  evac- 
uations. Unless  they  thoroughly  disinfect  themselves  by  washing  the 
hands  in  soap  and  water,  alcohol,  and  finally  corrosive  sublimate,  a, 
1  :  500  solution,  or  1  :  20  carbolic  acid  solution,  they  may  convey  the 
germs  to  their  own  food  at  their  next  meal,  and  thus  become  infected. 
Great  care  should  be  exercised  by  such  attendants  not  to  spatter  any 
fluid  into  their  own  mouths  while  bathing  cholera  patients  or  washing 
utensils,  bed-pans,  etc.  All  clothing  and  bed-clothing  of  patients,  if  they 
cannot  be  burned,  should  be  placed  in  disinfecting  solutions  before  they 
are  washed  ;  otherwise  there  is  the  same  danger  of  infection  for  those  who- 
handle  them  by  spattering  the  contaminated  water  about  or  immersing 
their  hands  in  it.  It  is  claimed  that  greatly  debilitated  patients  wha 
have  been  crowded  in  rooms  or  hospital  wards  with  cholera  patients,  and 
who  have  been  obliged  to  inhale  effluvia  from  their  evacuations,  have 
contracted  the  disease,  but  under  these  conditions  it  is  difficult  to  dis- 
prove the  possibility  of  other  sources  of  infection,  such  as  those  before 
described,  and  the  poison  must  certainly  be  very  concentrated  to  enter 
the  system  in  any  such  manner. 

All  dejections  must  be  received  in  china  bed-pans  containing  either 
a  1  :  500  corrosive  sublimate  solution  or  a  5  :  100  carbolic  acid  solution. 
The  volume  of  solution  should  be  at  least  half  of  that  of  the  stool  to 
secure  thorough  disinfection,  and  it  should  remain  in  contact  with  it  for 
an  hour  or  two  before  being  thrown  away.  Schauz  and  others  advise 
the  addition  to  the  disinfectant  of  a  solution  prepared  by  adding  lOO- 
grammes  of  crude  sulphuric  acid  to  a  litre  of  water.  This  is  to  be 
'added  to  the  stool  in  the  proportion  of  one  sixth  of  its  volume.  Other 
disinfectants  are  made  more  efficacious  by  the  addition  of  this  acid. 
The  practical  objection  to  this  method  is  that  the  acid  is  ruinous  ta 
metallic  drain-pipes,  and  to  overcome  this  difficulty  Stills  suggests  that 
the  dejecta  after  disinfection  be  either  mixed  with  sawdust  and  burned 
or  buried  in  a  trench. 

Quarantine. — When  a  vessel  sails  from  a  port  in  which  cholera  pre- 
vails or  in  which,  during  an  ejiidemic  elsewhere,  suspicious  cases  of 
gastro-intestinal  disorders  have  been  reported,  she  should,  on  arrival,, 
be  held  at  quarantine  until  thorough  bacteriological  examination  can  be 
made,  which  is  possible  within  twenty-four  hours.  If  the  result  of  the 
examination  establishes  the  presence  of  cholera  infection  on  board,  all 
the  passengers  should  be  removed  at  once,  and  carefully  separated  into 
groups  of  the  sick,  the  well,  and  suspected  cases.  Authorities  differ  as 
to  the  length  of  time  which  they  should  be  detained,  and  many  eminent 
sanitarians  (especially  in  England)  are  disposed  to  ignore  the  necessity 
of  quarantine  for  the  well,  believing  that  the  disease  can  be  readily 
stamped  out  in  any  situation  in  which  it  may  occur.  Others  claim 
that  all  persons  from  the  infected  vessel  should  be  held  for  from  seven 
to  ten  days.  In  any  event,  their  baggage  should  be  disinfected  by 
steam,  and  the  vessel  must  undergo  thorough  disinfection  by  being- 
flooded  Avith  steam  and  washed  down  with  a  1  :  500  solution  of  bi- 


TREATMENT.  325 

t'hloi'idc  of  mercury.  Elmiiirants  who  are  susjHH'tcd  should  he  f^ivon 
au  autisoptic  bath,  and  their  personal  elothinti;  and  l)a<^^age  should  be 
disinfected  in  steam  sterilizers  under  pressure.  Since  the  disease  is 
often  s})read  bv  foul  clothino-,  the  importation  of  raj>;s  from  infected 
ports  should  be  absolutely  prohibited  durino;  the  prevalence  of  the 
disease. 

The  International  Sanitary  Conference,  which  met  at  Konie  in  1885, 
adopted  the  view  that  a  disinfection  of  the  mails  and  of  clean  dry  mer- 
chandise was  M'holly  unnecessary. 

During:  the  prevalence  of  cholera  epidemics  on  board  ship  it  is 
impossible  for  the  ship's  surgeon  to  take  the  time  or  sup])ly  the  facil- 
ities for  bacteriological  research,  even  were  he  competent  to  do  the  work 
of  an  expert.  There  is  a  strong  tendency  on  the  part  of  shipowners  to 
conceal,  for  obvious  reasons,  the  possibility  of  deaths  from  cholera  occur- 
ring upon  their  vessels ;  hence  it  is  that  the  doubtful  cases  are  usually 
recorded  as  "  gastro-enteritis."  The  fatal  cases  are  promptly  buried  at 
sea,  and  all  their  effects  are  thrown  overbroad.  This  greatly  embar- 
rasses the  health  officers  in  their  work  at  quarantine,  for  it  is  often 
impossible  upon  the  ship's  entry  into  port  to  obtain  a  single  article  of 
personal  clothing  or  of  bedding  which  belonged  to  a  fatal  case,  much 
less  to  obtain  any  of  the  excreta,  for  examination.  It  should  be  the 
duty  of  the  ship's  surgeon  to  preserve  specimens  of  the  dejecta  in  sealed 
receptacles  for  bacteriological  examination,  for  it  would  thus  be  possible 
for  the  health  officers  to  determine  with  greater  certainty  whether  or  not 
the  ship  has  been  infected  with  cholera.  During  the  last  epidemic  of 
cholera  in  this  country  much  time  and  anxiety  might  have  been  saved 
upon  the  ship's  entering  New  York  harbor  had  this  precaution  been 
taken. 

Treatment. — There  is  as  yet  no  specific  treatment  for  cholera, 
although  it  is  not  impossible  that  an  antitoxin  or  an  immunizing  serum 
may  be  before  long  discovered  which  will  affi^rd  a  means  of  checking 
this  much-dreaded  plague.^ 

The  rational  treatment  of  the  disease  is  based  upon  the  principles 
now  established  which  govern  the  treatment  of  similar  infectious 
diseases  having   a  definite  focus  of  operation  for  the  activity  of  the 

^  The  prophecy  here  made  by  Dr.  Byron  is  possibly  approaching  verification  since 
his  untimely  death.  Dr.  Haffkine,  a  former  pupil  of  Pasteur,  has  for  several  years 
been  experimenting  with  preventive  inoculations  against  cholera.  The  inoculations 
are  first  made  witli  a  mild  culture  of  cholera  germs,  and  five  days  later  with  a  stronger 
one.  Five  days  later,  still,  immunity  is  reported  to  follow.  Dr.  Simpson,  health  officer 
of  Calcutta,  was  authorized  in  the  spring  of  1894  to  expend  20,000  rupees  (approximately 
§5000)  in  research  with  the  inoculations.  His  report  to  the  Municipal  Commissioners 
of  tliat  city,  lately  issued,  covers  a  series  of  7690  persons,  chiefly  Hindoos,  who  received 
the  treatment.  Of  this  number  many  were  exposed  to  the  disease  before  the  lapse  of 
five  days  after  the  second  inoculation,  but  some  of  these  escaped  infection,  or,  being 
infected,  escaped  death.  Of  a  smaller  series  of  269  persons  inoculated  five  days  or  more 
before  exposure,  a  few — Dr.  Simpson  does  not  give  the  exact  number — became  infected, 
but  only  1  died.  He  claims  that  the  chances  of  death  among  inoculated  subjects  are 
"22.62  times  smaller"  than  they  otherwise  would  be.  Dr.  Haffkine  himself,  experi- 
menting in  India,  claims  similarly  favorable  results.  Judgment  of  the  value  of  this 
treatment  must  be  suspended  until  more  extensive  reports  are  received.  As  in  the  early 
days  of  the  diphtheria  antitoxine  inoculations,  much  opposition  is  being  made  by  some 
of  the  British  physicians  in  India  to  the  treatment,  but  it  is  to  be  hoped,  as  Dr.  Bvron 
has  said,  that  success  in  this  or  a  similar  method  may  be  attained  when  the  technique 
of  its  application  is  fully  understood. — Editor. 


326  CHOLERA. 

pathogenic  germs,  from  which  poisonous  materials  or  toxalbumins  are 
developed  to  be  absorbed  by  the  agency  of  the  lymphatic  or  blood- 
vessels, and  thus  cause  general  systemic  intoxication.  In  the  case  of 
cholera  the  focus  of  the  disease  is  a  single  one,  very  definitely  located  in 
the  intestines.  The  appearance  and  nature  of  the  germ  is  definitely 
known,  as  are  also  those  remedies  which  are  capable  of  destroying  it. 
The  problem  of  treatment  is,  then,  a  twofold  one  :  first,  to  either  destroy 
or  limit  the  development  and  activity  of  the  germs  in  loco,  and,  second, 
to  combat  the  eifects  on  the  system  of  the  highly  poisonous  substances 
which  may  have  been  already  absorbed,  and  aid  the  process  of  elimina- 
tion and  reparation.  Such  is  the  extraordinary  virulence  of  this  disease 
that  the  former  method  offers  more  hope  of  successful  accomplishment 
than  the  latter,  although  both  methods  are  to  be  simultaneously  em- 
ployed. The  treatment  above  outlined  will  be  conveniently  described 
under  the  headings  of 

1.  Internal  antiseptic  treatment; 

2.  Systematic  treatment. 

1.  Internal  Antiseptic  Treatment. — Many  remedies  have,  in  times  past^ 
been  strongly  advocated  for  the  purpose  of  limiting  the  local  action  of 
the  cholera  bacilli,  and  such  remedies  were,  in  fact,  employed  before  the 
germ  theory  was  established,  but  modern  research  and  experience  have 
reduced  this  number  to  a  very  restricted  basis. 

Calomel  is  strongly  recommended  by  Von  Ziemssen  and  others.  It 
is  distinctly  serviceable  in  the  premonitory  stage  and  in  mild  cases  as 
an  evacuant  of  the  poison  from  the  intestine,  and  its  probable  partial 
conversion  in  the  alimentary  canal  into  a  more  strongly  antiseptic  form 
of  mercury  no  doubt  enables  it  to  exert  some  slight  disinfectant  or 
germicidal  action.  I  have,  however,  found  it  worse  than  useless  in 
severe  cases.  Mercuric  bichloride  is  used  by  Ivert  and  others.  He 
employed  it  in  Tonquin,  and  claims  a  reduction  in  mortality  from  66 
to  20  per  cent.  Iodoform  has  been  recommended  by  Bouchard,-  and 
other  remedies  of  the  so-called  intestinal  antiseptic  series  which  have 
been  extensively  tried  are  naphthol,  naphthalin,  salicylate  of  bismuth, 
salol,  etc.  All  the  above  remedies  possess  the  common  disadvantage 
of  being  administered  per  os.  There  is  usually  persistent  vomiting, 
which  is  intensified  by  all  stomach  medication.  Moreover,  most  of  these 
remedies  are  so  altered  in  their  transit  to  the  real  focus  of  the  disease 
that  they  cannot  be  depended  upon.  Owing  to  their  poisonous  nature 
in  large  doses,  it  is  unjustifiable  to  give  them  in  strength  sufficient  to 
prove  effective  germicides  against  so  active  a  bacillus  as  that  of  cholera. 

2,  Systematic  Treatment. — The  systematic  treatment  which  follows 
is  most  strongly  recommended  from  the  results  of  my  personal  experi- 
ence with  cholera  at  quarantine.  It  will  be  conveniently  divided  to 
correspond  with  the  natural  stages  of  the  disease. 

(a)  Premonitory  Stage.  —  In  the  premonitory  stage  the  patient  should 
be  kept  in  bed  after  receiving  a  warm  bath,  and  must  be  carefully 
protected  from  cold.  Ten  grains  of  calomel  may  be  administered, 
and  intestinal  irrigation  should  be  at  once  begun  after  the  manner  de- 
scribed below  (Enteroclysis,  p.  329). 

The  food  must  be  very  simple,  and  it  is  best  given  in  small  doses  at 
two-hour  intervals.     Such  articles  as  boiled  milk,  thoroughly  cooked 


TREATMENT.  327 

rice,  milk  tOcast,  and  plain  broths  sIiduUI  be  given.  It  is  often  best  to 
pancrcatinize  the  milk,  and,  as  the  gastric  juice  is  feeble  and  intestinal 
digestion  is  disordered,  it  is  well  to  give  fifteen  or  twenty  minims  of 
dilute  hydrochloric  acid  with  five  grains  of  pepsin  after  taking  animal 
food.  The  acid  destroys  the  cholera  bacillus  and  ])rcvcnts  the  develop- 
ment of  its  |)oison,  besides  being  the  natm-al  acid  of  the  gastric  juice. 
It  has  the  further  effect  of  tending  to  slightly  diminish  the  i)atient's 
thirst.  These  are  the  ordinary  precautions  to  be  taken  in  dealing  with 
the  premonitory  stage,  but  every  case  of  cholera,  in  whatever  stage  it 
may  be  first  seen,  should  be  subjected  at  once  to  intestinal  irrigation. 

The  premonitory  stage  is  often  very  brief,  and  is  often  unre(;ognized 
by  either  patient  or  physician,  and  in  a  majority  of  cases  the  physician 
is  not  called  or  does  not  reach  the  patient  until  the  evacuant  or  collapse 
stage  has  developed.  Those  cases  seen  at  Swinburne  Island  were  of 
such  an  exceedingly  virulent  type  that  the  premonitory  diarrhoea  was 
very  slight  and  often  passed  unnoticed. 

The  administration  of  preparations  of  opium  in  the  early  stage  of 
cholera  to  control  the  diarrhoea  is  to  be  condemned,  for  it  may  cause  re- 
tention of  the  intestinal  contents,  and  thereby  counteract  nature's  only 
method  of  eliminating  the  poison  of  the  disease  by  watery  evacuations. 
Given  later,  it  is  usually  ineffectual  in  controlling  the  discharges  from 
the  bowels,  and  it  merely  adds  a  dangerous  narcotic  to  the  system. 
Morphine  may  be  required  hypodermically,  however,  to  relieve  the 
cramps  when  in  the  later  stages   they  become  intolerable. 

The  treatment  of  the  second  stage,  or  stage  of  serous  diarrhoea,  does 
not  differ  essentially  from  that  of  the  stage  of  collapse,  and  it  will  there- 
fore be  detailed  under  that  heading. 

(b)  Stage  of  Collapse. — In  this  stage  the  most  active  and  prompt  treat- 
ment is  an  absolute  necessity  if  the  patient's  life  is  to  be  saved.  The 
main  indication  for  treatment  in  this  stage  is  to  restore  by  every  possible 
means  the  water  which  has  been  drawn  from  the  blood  in  copious  alvine 
evacuations. 

During  two  epidemics  I  have  obtained  the  most  encouraging  results 
from  what  I  may  call  the  surgical  treatment  of  this  stage — /.  e.  the  injec- 
tion of  fluids  into  the  body  through  the  skin  and  rectum,  as  descriljed 
below  (Hypodermoclysis,  Enteroclysis,  p.  329).  This  method  of  treat- 
ment, resorted  to  at  Swinburne  Island,  differs  from  all  others,  inasmuch 
as  the  internal  administration  of  drugs  is  avoided.  I  first  used  this 
treatment  in  1892,  and,  encouraged  by  the  results  obtained,  I  again  used 
it  in  1893  with  still  better  effect,  though  it  should  be  stated  that  the  last 
epidemic  was  not  of  such  a  virulent  character  as  that  of  1892,  and  that 
most  cases  were  treated  at  an  earlier  stage  of  the  disease. 

In  former  epidemics  the  attempt  has  been  made  to  transfuse  salt 
solution,  defibrinated  blood,  etc.  into  the  veins  as  a  means  of  restoring 
the  balance  of  circulation  more  promptly  than  in  any  other  way,  but 
the  practical  difficulties  in  the  way  of  this  procedure  are  considerable, 
owing  to  the  fact  that  all  the  veins  are  collapsed,  and  are,  consequently, 
difficult  to  find.  It  is  often  impossible  to  secure  one  large  enough  for 
transfusion  without  performing  a  formal  operation  to  reach  a  deep- 
seated  vein.  Especially  is  this  true  in  children,  and  the  time  lost  in 
the  procedure  may  be  even  greater  than  that  required  for  the  absorption 


328  CHOLERA. 

of  fluids  administered  in  other  ways,  and  the  operation  adds  to  the  dis- 
comfort, if  not  the  terror,  of  the  patient.  Practically,  the  method  has 
proved  an  emphatic  disappointment,  and  it  is  now  rarely  practised. 

Hypodermoclysis. — This  name  is  applied  to  the  simple  process  of  the 
free  subcutaneous  injection  of  a  normal  salt  solution ;  that  is,  0.6  per 
cent,  of  sodium  chloride  in  distilled  water,  or,  practically,  two  small 
teaspoonfuls  of  pure  common  salt  to  the  quart  of  warm  water,  distilled 
and  sterilized.  It  is  often  well  to  add  an  ounce  of  brandy,  as  stimula- 
tion is  much  needed.  The  operation  of  injecting  this  fluid  was  first 
suggested  and  used  by  Cantani  of  Naples  in  the  cholera  epidemic  of 
1865,  and  he  has  since  then  employed  it  repeatedly  ^\\i\\  great  success. 
Its  recommendations  are  its  simplicity  and  the  promptness  with  which 
it  can  be  performed.  To  give  the  injections  an  ordinary  rubber  douche- 
bag  is  utilized,  such  as  that  commonly  employed  for  vaginal  irrigation. 
To  the  rubber  tube  leading  from  this  bag  a  small-sized  aspirating  needle 
is  attached.  The  bag  is  filled  with  the  salt  solution  at  a  temperature  of 
110°  F.,  which  is  reduced  to  105°  F.  in  its  passage  through  the  appa- 
ratus. A  large  fold  of  skin  is  grasped  between  the  thumb  and  fore- 
finger, and  lifted  so  that  the  needle  can  be  introduced  deeply  into  the 
loose  cellular  tissue  of  the  subcutaneous  space.  The  skin,  as  well  as 
the  hands  of  the  operator  and  needle,  should  all  be  first  sterilized.  The 
skin  should  be  first  washed  with  soap  and  water,  and  afterward  cleansed 
with  alcohol  and  ether  and  a  1  :  500  solution  of  bichloride  of  mercury. 
The  needle  should  be  boiled  for  at  least  half  an  hour.  The  point  of 
selection  for  administering  the  injection  should  be  preferably  on  either 
side  of  the  abdominal  wall  between  the  inferior  ribs  and  the  iliac  crest. 
In  extreme  cases  the  injection  can  be  made  into  the  peritoneal  cavity. 
The  inner  surface  of  the  thighs  can  also  be  utilized,  but  the  region  of 
the  neck  should  be  avoided,  as  two  cases  of  laryngeal  oedema  are  known 
to  have  occurred  after  the  injections.  When  all  these  precautions  are 
conscientiously  observed  no  untoward  results  occur.  I  have  known  of 
but  one  accident — the  development  of  an  abscess — which  was  distinctly 
due  to  a  careless  observation  of  the  above  rules.  The  quantity  of  fluid 
injected  for  the  first  time  by  hypodermoclvsis  should  be,  for  an  adult, 
from  one  to  two  quarts ;  for  an  adolescent,  one  or  two  pints  ;  and  for  an 
infant,  one  half  pint.  In  critical  cases  the  injection  should  be  pushed 
as  much  as  possible,  and  repeated  again  in  an  hour  or  two.  The  liquid 
enters  by  hydrostatic  pressure,  and  the  reservoir  may  be  gradually 
raised  or  lowered  to  regulate  it.  i^bout  half  an  hour  should  be  con- 
sumed in  injecting  a  quart  of  fluid.  The  injections  are  not  so  painful 
as  might  be  supposed.  At  all  events,  the  patients  are  so  ill  that  they 
submit  to  the  treatment  without  much  complaint,  and,  as  the  saving  of 
time  is  an  important  object,  the  use  of  cocaine  is  not  desirable,  espe- 
cially as  it  is  decidedly  depressant  to  the  heart  action  in  the  doses  which 
would  be  required  to  cover  the  ground  of  the  injection.  As  an  imme- 
diate result  of  the  entrance  of  the  fluid  a  large  tumor  forms  which  may 
reach  the  size  of  an  orange,  but  it  is  not  advisable  to  attempt  to  dispel 
it  by  massage.  If  the  hypodermoclysis  is  successful,  the  tumor  will 
soon  be  naturally  absorbed,  and  in  favorable  cases  its  disappearance  will 
be  complete  in  from  twenty  to  forty-five  minutes.  I  regard  the  rate 
of  absorption  as  of  considerable  prognostic  value,  for  if  absorption  is 


TREATMENT.  329 

delayed  for  three  or  ioiir  lioiii's,  it  is  an  indication  that  the  lymphatic 
and  liioniic  circulations  are  botii  very  feeble  and  that  death  is  likely  to 
soon  occur.  More  ]'aj)id  al)sorption,  on  the  other  iiand,  with  iniprove- 
nient  in  the  volume  of  the  pulse,  is  an  ex(H'e(liii<;ly  favorable  sign.  The 
introduction  of  the  salt  solution  has  a  twofold  l)eneticial  action  :  First, 
by  restoring;  the  proper  volume  and  normal  density  of  the  blood  the 
i'irculation  is  benefited  and  the  inhibited  renal  function  is  re-estab- 
lished ;  secondly,  it  acts  favorably  as  a  diluent  of  the  ])tomaines  which 
have  been  absorbed  from  the  intestines,  and  aids  in  their  elimination 
from  the  system. 

In  favorable  cases  the  effects  of  the  injections  are  truly  astonishing 
in  their  rapidity  of  action  and  in  the  change  in  the  appearance  of  the 
patient.  This  method  of  treatment  is  indicated  just  as  soon  as  there  is 
the  slightest  appearance  of  the  approaching  stage  of  collapse,  and  it 
should  be  repeated  according  to  symptoms  until  permanent  restoration 
of  the  balance  of  the  circulation  and  respiration  has  been  established. 
Among  those  who  commend  this  treatment  as  a  result  of  personal  trial 
are,  notably,  Cantani,  Nothnagel,  Kaeler,  Rumpf,  Von  Ziemssen,  and 
Stofella. 

E)it('rocIysis. — To  fulfil  the  second  important  indication  for  treat- 
ment it  is  necessary  to  reach  the  focus  of  the  disease  by  intestinal  irri- 
gation. There  is  the  more  hope  of  benefit  from  this  procedure  from 
the  fact  that  comma  bacilli  affect  the  superficial  layers  of  the  intestinal 
mucous  membrane,  and  are,  consequently,  within  reach.  The  difficulty 
or  impossibility  of  oral  medication  has  been  already  discussed,  and  it 
remains  to  be  proven  that  fluids  introduced  in  large  volume  per  rectum 
<.'an  be  made  to  flood  the  whole  intestine.  This  fact  is  often  denied,  for 
it  is  claimed  that  the  anatomical  structure  of  the  ileo-csecal  valve  com- 
pletely prevents  regurgitation  from  the  large  into  the  small  intestine. 
That  this  is  ordinarily  true  under  normal  conditions  there  can  be  no 
doubt,  but  it  is,  nevertheless,  also  true  that  under  moderate  hydrostatic 
pressure  fluids  may  be  made  to  pass  this  valve.  The  conditions  for  its 
successful  passage  are  the  use  of  a  long  and  properly  introduced  rectal 
tube,  a  large  volume  of  fluid,  a  hydrostatic  pressure  of  about  five  feet, 
a  horizontal  or  partially  inverted  position  of  the  patient,  and  the  per- 
formance of  gentle  massage,  commencing  in  the  right  iliac  region  and 
passing  in  the  direction  of  the  ascending  colon.  To  test  the  possibility 
of  the  passage  of  the  fluid  beyond  the  ileo-csecal  valve  I  have  made 
experiments  on  a  number  of  cadavers,  and  have  been  able  to  fill  not 
only  the  entire  intestine,  but  even  the  stomach,  in  the  manner  described. 
These  results  are  confirmed  by  Cantani,  Simon,  Hofmolk,  and  Hegar, 
and  they  are  further  confirmed  by  the  fact  that  in  several  instances 
where  I  have  used  tannic  acid  injections  for  cholera  patients  some  of 
the  acid  has  been  ejected  by  vomiting.  In  some  experiments  upon 
cadavers  I  have  even  succeeded  in  forcing  the  passage  of  liquids  from 
the  rectum  out  through  the  mouth  and  nose  by  means  of  no  harder 
pressure  than  that  which  is  justifiable  in  the  clinical  treatment  of 
cholera.  There  are  undoubtedly  some  cases  in  which,  owing  to  a  twist 
in  the  large  intestine,  old  adhesions,  disproportion  in  the  size  of  the 
valve,  or  other  conditions,  it  may  be  impossible  to  reach  the  small  intes- 
tine, but  even  in  these  cases  the  large  intestine  can  almost  always  be 


330  CHOLERA. 

completely  flooded.  The  rapid  emaciation  of  the  patient  and  the  con- 
sequent thinness  of  the  boat-shaped  abdominal  walls  makes  it  compara- 
tively easy  to  manipulate  the  intestine  by  massage. 

Method  of  Giving  the  Injections. — The  ordinary  fountain  rubber 
douche-bag  is  employed,  or,  in  an  emergency,  a  quart  bottle  may  be 
fitted  with  a  piece  of  rubber  tubing,  and  when  the  bottom  is  knocked 
oiF  it  may  be  suspended  inverted  and  used  as  a  reservoir.  The  rubber 
tubing  is  connected  with  a  long  rectal  tube  which  should  have  a  blunt 
extremity  and  one  or  two  large  perforations  situated  from  one  to  two 
inches  behind  the  blind  end.  Such  tubes  as  those  employed  for  stomach 
washing  are  of  suitable  size  and  stiffness.  If  too  stiff,  they  do  not 
readily  follow  the  curves  of  the  rectum,  and  if  too  limp,  they  bend  or 
twist,  which  makes  their  introduction  difficult.  Such  a  tube  can  always 
be  passed  in  for  a  distance  of  seven  or  eight  inches,  and  occasionally^ 
with  good  luck,  it  can  be  made  to  pass  beyond  the  sigmoid  flexure. 
All  the  apparatus  employed  is  to  be  sterilized,  and  the  water  used  for 
the  injection  should  be  distilled  and  sterilized.  The  tube  is  well  oiled 
and  carefully  passed  into  the  rectum.  Sometimes  its  further  passage 
can  be  facilitated  by  allowing  some  of  the  fluid  to  flow  while  the  tube  is 
pressed  inward. 

The  object  of  the  injections  is  a  threefold  one  :  First,  to  flush  the 
intestine  and  wash  out  such  poisonous  material  as  may  be  within  reach  ; 
secondly,  to  supply  a  medium  fatal  to  the  comma  bacillus  ;  thirdly,  the 
fluid  being  hot,  local  warmth  is  applied  to  the  deeper  portions  of  the 
body,  which  is  serviceable  in  arousing  the  patient  from  collapse.  These 
indications  are  met  by  the  use  of  a  2  per  cent,  solution  of  tannic  acid 
in  water,  heated  in  the  reservoir  to  110°  F.  A  lowering  of  about  five 
degrees  in  this  temperature  occurs  as  the  fluid  flows  through  the  rubber 
tubing-.  It  is  well  to  warm  the  rectal  tube  in  hot  water  before  its  inser- 
tion.  When  the  tube  is  in  place  the  injection  should  be  allowed  to  flow 
at  first  very  slowly,  and  fully  ten  or  fifteen  minutes  should  be  occupied 
in  giving  a  quart  or  more  of  fluid.  After  the  fluid  has  been  injected, 
several  minutes  more  should  elapse  before  the  withdrawal  of  the  tube, 
while  gentle  pressure  is  maintained  on  the  perineum,  and  the  patient 
is  to  be  encouraged  to  make  every  effort  to  retain  the  injection.  The 
tube  is  then  very  slowly  and  carefully  withdrawn.  By  means  of  these 
precautions  it  may  be  possible  to  secure  the  retention  of  the  injection 
for  some  time.  This  will  check  the  growth  of  the  bacillus,  and  much 
of  the  fluid  may  be  absorbed  by  the  lymphatics.  The  quantity  of  fluid 
to  be  employed  should  be  from  one  to  two  quarts,  and  in  severe  cases  it 
is  to  be  used  as  often  as  once  every  hour. 

Other  remedies  which  have  been  used  by  rectal  injection  are  solu- 
tions of  subacetate  of  lead,  solutions  of  creolin  (2  per  cent.),  and  diluted 
laudanum. 

With  regard  to  the  efficacy  of  the  treatment  by  hypodermoclysis  and 
enteroclysis  the  following  data  are  instructive,  but  it  should  be  borne 
in  mind  that  the  patients  treated  at  Swinburne  Island  were  many  of 
them  brought  off  the  vessel  in  an  almost  moribund  state.  There  were 
in  all  72  cases  treated  in  the  epidemic  of  1892  at  Swinburne  Island,  with 
20  deaths,  giving  a  mortality  of  27  per  cent. ;  or,  if  46  suspects  are  in- 
cluded who  had  distinct  prodromic  symptoms  of  cholera,  the  mortality 


TREATMENT.  331 

is  rcdiu'od  to  17  per  cent.  On  the  other  hand,  amont^  the  patients 
attacked  at  sea  upon  the  vessels  which  reached  our  quarantine  the  mor- 
tality varied  from  50  to  98  per  cent.,  and  the  general  mortality  of  this 
epidemic  in  liamlnirii"  ^vas  hetween  50  and  60  per  cent.  I'ndouhtedlv, 
the  mortality  at  Swiuhurue  Island  Wduld  have  been  even  lower  l)ut  for 
the  fact  that  uiany  of  the  patients  attacked  were  under-fed  Russian  emi- 
grants, already  anannic  or  diseased.  Many  of  them  were  marasmic 
young  children,  so  that  the  premonitory  stage  of  the  disease  was  often 
absent. 

Application  of  Wannfli. — In  the  stage  of  collapse  the  external  surface 
of  the  body  is  always  cold,  and  the  external  temperature  may  be  six  or 
eight  degrees  below  the  normal.  To  restore  the  natural  warmth  and  aid 
in  the  re-establishment  of  the  normal  circulatory  functions  external  heat 
must  be  energetically  applied.  In  many  cases  this  is  best  accomplished 
by  the  use  of  a  hot  plunge  bath,  which  has  the  further  advantage  of 
diminishing  the  tendency  to  cramps.  While  in  bed  the  patient  should 
be  kept  warm  by  the  use  of  hot  water  bags,  hot  sand  bags,  or  hot  bricks 
packed  about  the  extremities,  or  hot  air  may  be  applied  beneath  the  bed- 
clothes. The  latter  should  consist  of  two  woollen  blankets  and  a  coun- 
terpane. As  before  indicated,  heat  is  also  supplied  in  some  degree  by  the 
warm  subcutaneous  and  rectal  injections  given.  If  perspiration  occurs, 
the  sweat  should  be  immediately  dried. 

Belief  of  Pain  and  Cramp. — "When  the  cramps  are  unbearable  they 
should  be  relieved  by  inhalation  of  chloroform  to  the  point  of  primary 
anaesthesia.  Moderate  cramps  are  sometimes  relieved  by  the  rubbing 
of  the  muscles  with  mustard  water,  by  the  application  to  the  abdomen 
and  legs  of  hot  water  bottles  or  of  turpentine  stupes.  Placing  the 
patient  in  a  bath  of  108°  F.  for  twenty  minutes  will  sometimes  give 
great  relief.  Care  is  of  course  to  be  exercised  in  moving  the  patient, 
and  he  should  be  lifted  so  as  to  be  subjected  to  as  little  exertion  as  possible. 

When  the  patient's  general  condition  is  one  of  great  suifering,  small 
hypodermic  injections  of  morphine  (one  sixth  of  a  grain),  combined 
with  one  one-hundreth  of  a  grain  of  atropine,  should  be  given  locally 
in  the  muscles  chiefly  aifected.  It  is  noticeable  that  in  cases  of  cholera 
treated  by  subcutaneous  and  rectal  injections  the  frequency  of  pains  and 
muscular  cramps  is  greatly  diminished.  This  is  a  further  proof  of  the 
belief  that  the  cramps  are  directly  due  to  the  drying  of  the  muscles  and 
nerves  which  follows  the  loss  of  water  from  the  intestines. 

Relief  of  Vomiting. — When  the  vomiting  is  excessive  it  may  be  some- 
times relieved  by  hypodermic  injections  of  morphine,  and  h\  a  mustard 
paste  or  turpentine  stupes  applied  over  the  region  of  the  stomach.  The 
aerated  waters,  small  doses  of  iced  champagne,  or  iced  fresh  lime  juice 
are  sometimes  grateful  for  relieving  thirst  and  to  some  extent  controlling 
the  vomiting ;  but,  as  a  rule,  throughout  the  entire  stage  of  collapse, 
if  there  is  any  nausea  or  tendency  to  vomiting,  it  is  best  to  make  no 
attempt  to  give  anything  at  all  by  the  mouth.  The  mechanism  of 
vomiting  only  excites  further  intestinal  movements  in  a  reflex  manner, 
and  is  weakening  and  injurious.  When  vomiting  is  persistent  and  the 
ejecta  are  copious,  it  is  desirable  to  wash  out  the  stomach  by  lavage. 
For  this  purpose  a  hot  2  per  cent,  tannic  acid  solution  is  to  be  employed, 
like  that  recommended  for  enteroclvsis.     The  removal  of  the  cholera 


332  CHOLEBA. 

liquid  from  the  stomach  will  check  further  vomiting  and  straining,  and 
will  add  much  to  the  patient's  comfort. 

Stimulation. — While  the  stomach  remains  irritable  stimulation  is 
to  be  given  in  connection  with  the  hypodermoclysis  or  by  separate  hypo- 
dermic injections  of  brandy.  The  ordinary  hypodermic  syringe,  holding 
half  a  drachm,  may  be  filled  with  good  brandy,  which  is  to  be  deeply 
injected  in  the  outer  side  of  the  arms  or  thighs.  Several  such  injections 
should  be  given,  at  least  once  an  hour.  For  an  infant  five  or  ten  minims 
may  be  used. 

The  entire  stage  of  collapse  is  to  be  combated  by  vigorous  hypoder- 
mic stimulation,  for  which  purpose  such  remedies  are  to  be  used,  in 
addition  to  brandy,  as  sulphuric  ether,  strychnine,  gr.  one  thirtieth, 
citrated  caifeine,  gr.  j,  and  morphine,  gr.  one  sixth.  Efforts  to  stimu- 
late by  the  mouth  do  more  harm  than  good.  In  this  stage,  especially 
when  dyspnoea  is  prominent,  the  free  inhalation  of  oxygen  gas  is  often 
beneficial,  or  at  least  it  relieves  the  subjective  sensations  of  the  patient. 
Nitrite  of  amyl  inhalation  is  also  of  occasional  benefit. 

(c)  Stage  of  Reaction. — Should  the  suppression  of  the  urine  continue 
into  this  stage,  the  rectal  and  subcutaneous  injections  should  be  con- 
tinued two  or  three  times  a  day,  but  it  is  undesirable  to  use  tannic  acid. 
If  the  temperature  becomes  normal,  the  external  application  of  heat  is 
discontinued,  and  should  a  reactionary  fever  occur  the  patient's  woollen 
undergarments  and  heavy  bedclothes  should  be  removed. 

As  the  symptoms  begin  to  abate  and  slight  improvement  is  mani- 
fested, a  little  fluid  nourishment  may  be  cautiously  given  per  os. 
Aerated  waters  may  be  freely  given.  For  this  purpose  may  be  used 
one  of  the  meat  extracts,  pancreatinized  milk,  or  koumyss.  The  milk 
is  often  better  borne  if  diluted  with  equal  parts  of  Vichy  or  carbonic 
water.  Iced  champagne  in  tablespoonful  doses  is  also  to  be  recom- 
mended. 

Throughout  convalescence  the  patient  must  be  carefully  watched, 
and  the  return  to  solid  food  must  be  very  gradually  made,  attention 
being  given  to  the  condition  of  the  bowels  and  gastric  digestion.  The 
stomach  often  remains  very  weak  for  many  days,  and  the  patient  must 
be  kept  upon  a  diet  of  predigested  milk,  beef  peptonoids,  nutritious 
broths,  and  gruels,  egg  albumen  with  sherry,  milk  punch,  or  egg-nog. 

Later,  such  articles  may  be  given  as  cream  toast,  junket,  well  boiled 
rice,  lightly  cooked  eggs,  custards,  meat  broths  thickened  with  rice  or 
macaroni,  etc. 

As  soon  as  more  food  is  given,  it  is  best  to  resume  the  administration 
of  dilute  hydrochloric  acid  and  pepsin,  which  may  be  given  every  three 
or  four  hours. 

Strychnine  may  be  given  as  a  tonic,  at  first  hypodermically  two  or 
three  times  a  day,  and  then  by  the  stomach  in  doses  of  one  fiftieth  of  a 
grain.  Later  the  simple  bitters  and  preparations  of  malt  may  be  useful, 
and  three  grains  of  quinine  may  be  given  as  a  tonic  after  each  meal. 

The  urine  should  be  frequently  examined  until  all  albuminuria  has 
disappeared.  If  the  kidneys  are  slow  in  resuming  their  normal  activity, 
mild  saline  diuretics  and  effervescing  mineral  waters  are  to  be  prescribed. 

The  patients  at  Swinburne  Island  were  compelled  to  take  a  daily 
sun  bath,  which  proved  of  great  benefit. 


TREATMEyT.  333 

I  (][Uot(>  in  full  tlie  details  of  three  eases  from  my  eoiitrihiition  to  the 
livport  of  ILcdlih  Ofiiccr,  Port  of  New  York,  18i)3,  whieii  are  seleeted 
from  the  cliiiieal  notes  of  Dr.  Jndson  Daland,  who  volunteered  us  assist- 
ant during  the  late  ej)idemie  at  Swinburne  Island.  They  will  be  found 
to  present  an  instruetive  elinieal  })ieture  of  the  symptoms  and  a  resume 
of  the  treatment  eni[)loyed  : 

Ca8E  J. — "  Male,  twenty-nine  years  ;  passeng'er  on  boai'd  S.  S.  Kara- 
mania ;  in  perfect  health  until  the  3d  of  Auj»;ust,  1893,  when  he  beiran 
to  have  a  moderate  diarrluea  and  nausea.  Not  considering  his  illness 
serious,  he  did  not  report  his  condition  until  the  afternoon  of  the  6th, 
when  his  symptoms  became  alarming.  When  examined  by  me  the  same 
day  I  found  him  in  collapse,  with  the  following-  sym])t()ms  :  Pulse  rapid, 
filiform,  and  compressible ;  temperature  subnormal,  features  pinched, 
eyes  sunken,  injected,  and  expressionless  ;  lips,  eyelids,  and  extremities 
cyanosed ;  cold,  clammy  perspiration ;  husky  voice ;  complete  indiffer- 
ence to  all  surroundings  ;  intelligence  unimpaired.  Patient  complains 
of  excessive  thirst  and  a  choking  sensation,  which  he  describes  as  if 
having  a  heavy  weight  upon  the  chest.  Vomiting  and  rice-water  dis- 
charges abundant  and  repeated  at  short  intervals. 

"  Examination  of  dejecta  showed  comma  forms  mixed  with  other 
bacteria ;  cultures  on  bouillon  and  gelatin  revealed  the  bacilli  of  Asiatic 
cholera.  Patient  was  transferred  to  the  hospital  and  subjected  to  the 
following  treatment  :  Hourly  rectal  injections  of  the  hot  2  per  cent, 
tannic  acid  solution  ;  subcutaneous  injections  of  brandy,  preceded  by  a 
single  injection  of  y^  grain  of  nitroglycerin.  The  condition  of  the 
patient  grew  rapidly  worse.  At  midnight  his  temperature  (rectal)  was 
96°  F. ;  pulse  only  perceptible  at  the  brachial  artery  ;  profound  collapse. 
Three  quarts  of  sterilized  salt  solution  (salt  1  part,  water  1000)  were 
injected  into  the  peritoneal  cavity  after  proper  disinfection  of  the  skin 
and  instruments.  Rectal  injections  were  also  continued.  From  this 
time  symptoms  began  to  improve.  Six  hours  later  all  the  fluid  had  been 
.absorbed  from  the  peritoneal  cavity,  the  radial  pulse  could  be  perceived, 
the  respiration  was  easier.  A  second  intraperitoneal  injection  of  two 
quarts  of  warm  salt  solution  was  injected,  and  the  rest  of  the  treatment 
continued. 

"  August  7. — Improvement  continued.  As  vomiting  had  ceased,  the 
patient  was  allowed  to  take  some  beef  tea  and  milk  and  seltzer.  Rectal 
injections  continued ;  hypodermic  stimulation  suspended.  Diet  care- 
fully increased  until  the  morning  of  August  10th,  when  all  treatment 
was  suspended  and  the  patient  was  taken  out  for  a  sun  bath.  Recovery. 
Duration  of  disease  from  first  symptoms  to  convalescence,  six  days." 

Case  II. — "  The  second  case  well  illustrates  an  ordinary  attack  of 
Asiatic  cholera.  A  Russian,  aged  seven  years,  was  admitted  from  the 
steamship  Bohemia,  September  26,  1892,  at  8  p.m.,  with  a  temperature 
of  96.2°  F.,  pulse  106,  respirations  22,  and  the  surface  of  the  body 
extremely  cold  and  cyanotic.  The  face  was  pinched,  especially  in  the 
nasal  region  ;  it  was  markedly  cyanotic,  and  the  eyes  were  deeply  sunken 
and  surrounded  by  dark  circles.  The  pulse  was  feeble  and  small,  and 
was  counted  witli  difficulty.  She  at  once  received  a  w^arm  plunge 
bath,  and  her  stomach  was  then  washed  out  with  one  pint  of  a  1  per 
cent,  solution  of  tannic  acid  at  the  temperature  of  the  body.     Shortly 


334  CHOLERA. 

afterward  she  vomited  twenty-three  ounces  of  fluid.  She  remained  in 
about  the  same  condition  during  the  night,  but  the  passage  of  a  moderate 
amount  of  urine  encouraged  us  to  hope  for  a  favorable  issue.  On  Sep- 
tember 27th  her  pulse  was  104,  temperature  97.4°  F.,  and  respirations 
18.  The  cyanosis  persisted ;  there  was  no  further  vomiting,  but  she  had 
frequent  copious  discharges  from  the  bowels,  composed  chiefly  of  the 
tannic  acid  solution  which  had  been  injected  j^er  anum.  Later  in  the 
day  improvement  began ;  the  temperature  varied  between  100.2°  and 
100.4°  F. ;  a  large  semi-solid  stool  was  passed.  She  slept  moderately 
well  during  the  night,  but  complained  greatly  of  thirst.  A  sufficient 
quantity  of  urine  was  excreted,  and  the  liquid  from  the  bowels  was 
composed  chiefly  of  the  tannic  acid  solution  that  had  been  given  by 
injection.  She  became  very  restless,  but  the  following  day  was  much 
brighter  and  began  to  notice  her  surroundings.  The  dejecta  changed  in 
character,  becoming  greenish  in  color  and  somewhat  frothy.  On  Sep- 
tember 29th  she  slept  well ;  her  bowels  were  moved  only  after  giving 
the  intestinal  injection  of  tannic  acid  solution.  In  the  afternoon  her 
improvement  was  so  marked  that  it  was  decided  to  suspend  these  injec- 
tions. Her  temperature  varied  from  97.8°  to  99.4°  F.,  the  pulse  be- 
tween 96  and  120,  and  the  respiration  from  22  to  24.  On  September 
30th  she  was  able  to  take  nourishment  and  stimulants  by  the  mouth, 
but  the  stools  continued  brownish  and  thin,  and  when  an  attempt  was 
made  to  administer  beef  tea  or  any  food  by  the  mouth  vomiting  occurred. 
The  cyanosis  disappeared,  but  she  was  still  shrunken  and  emaciated. 
She  continued  to  improve,  and  on  the  fourth  day  after  admission  was 
carried  into  the  open  air,  where  she  received  a  sun  bath  for  two  hours. 

"  The  following  is  a  summary  of  the  treatment :  Upon  admission 
she  received  a  hot  plunge  bath.  The  first  enteroclysis  or  intestinal  in- 
jection was  retained  for  three  minutes,  and  afterward  these  injections 
were  repeated  every  two  hours.  A  subcutaneous  injection  of  one  pint 
of  a  0.6  per  cent,  solution  of  sodium  chloride  was  given  the  day  after 
admission.  At  first  whiskey  was  administered  by  the  mouth,  but  after- 
ward 10  minims  were  given  hypodermically  every  four  hours.  The  total 
duration  of  the  patient's  illness  was  five  days,  and  her  convalescence 
was  extremely  rapid  and  uninterrupted." 

Case  III. — "  I  will  narrate  the  history  of  a  third  case,  the  most  in- 
teresting of  all  observed,  in  which  we  were  fortunately  able  to  note 
minutely  every  change  that  took  place  from  the  beginning  to  the  end. 
This  patient  exhibited  nearly  all  the  symptoms  of  a  typical  malignant 
case  of  Asiatic  cholera,  illustrating  also,  in  an  equally  striking  manner, 
the  results  obtained  by  treatment. 

"  This  patient,  a  male,  aged  twenty-four  years,  a  native  of  Germany, 
was  admitted  to  the  Swinburne  Island  Hospital  on  September  27, 
1892,  at  11  A.  M.  His  muscular  and  osseous  systems  Avere  unusually 
well  developed,  and  it  was  reported  that  he  was  perfectly  well  on  the 
morning  of  September  27th  until  4  a.  m.,  when  he  first  complained  of 
pain  in  the  abdomen,  which  was  followed  by  two  loose  stools.  He  con- 
tinued feeling  well  until  we  saw  him  at  10  A.  m.,  when,  in'view  of  the 
diarrhoea,  it  was  deemed  wisest  to  remove  him  to  the  hospital,  although 
his  general  condition  did  not  indicate  that  he  was  suffering  from 
cholera.     He  objected  strongly  to  his  removal,  and  said  that  he  felt 


TREA  TMENT.  335 

pertbotly  well,  lie  walked  i'roni  hi.^  brrtli  to  the  side  ui"  the  .ship  and 
down  a  rope  ladder  to  the  quarantine  tug-boat.  He  arrived  at  Swin- 
burne Island,  and  reiterated  his  statement  that  he  felt  perfeetlv  well, 
and  walked  iVoni  the  (juarantine  boat  to  the  door  of  the  hcjspital,  when 
suddenly  lie  eoni])lained  of  weakness  in  the  knees  and  fell  to  the  oroimd 
in  a  state  of  eolh'.pse.  He  was  earried  to  the  ward  in  a  condition  of 
partial  stupor,  from  wliieh  he  w'as  easily  aroused.  He  responded  to  all 
<piestions  in  a  manner  showing  that  his  consciousness  was  perfectly  pre- 
served. Soon  he  comj^lained  of  agonizing  cramp-like  pains  in  the 
jirms,  feet,  and  knees,  which  recurred  more  or  less  regularly  at  intervals 
of  thirty  minutes.  Innnediately  after  his  admission  his  countenance 
presented  the  typical  appearance  of  cholera.  The  eyes  were  deeply 
.sunken  and  surrounded  by  dark  circles ;  the  pupils  were  contracted  to 
the  size  of  a  pin  point.  The  lips,  cheeks,  arms,  hands,  legs,  and  feet 
•were  cyanotic,  and  the  entire  skin  surface  was  dry,  and  when  the  skin 
was  pinched  it  remained  elevated  and  compressed  for  several  minutes. 
There  was  no  pulse  at  the  wrist.  The  temperature  was  98.5°  F.,  the 
respirations  shallow  and  18  per  minute,  and  the  voice  whispering.  I 
Avas  unable  to  detect  any  special  coldness  in  the  expired  breath. 

"  The  man  was  at  once  placed  in  a  hot  plunge  bath  having  a  tem- 
perature of  104°  F.,  and  was  given  four  pints  of  a  1  per  cent,  solution 
of  tannic  acid  at  a  temperature  of  104°  F. ;  also  two  pints  of  distilled 
water  at  a  temperature  of  100°  F.,  containing  0.6  per  cent,  of  sodium 
chloride  and  1  per  cent,  of  whiskey.  He  responded  but  slightly  to  this 
treatment ;  the  pulse  was  scarcely  perceptible,  was  filiform  in  charac- 
ter, and  about  100  per  minute.  At  11.30,  or  thirty  minutes  after  his 
admission,  he  complained  of  intense  agonizing  pains  in  the  legs,  feet, 
iind  hands.  These  cramps  forced  the  feet  into  extreme  extension  and 
twisted  and  distorted  the  fingers.  The  pain  was  so  great  that  it  became 
necessary  to  administer  a  hypodermic  injection  of  \  grain  of  morphine. 
The  hypodermoclysis  and  enteroclysis  were  repeated.  Camphor  was 
given  h^iiodermically.  Oxygen  was  inhaled  constantly,  hot  bottles 
were  applied  to  the  extremities,  and  hot  air  was  conducted  under  the 
l)edclothing  from  a  large  steam  radiator.  The  patient  now  vomited  a 
large  quantity  of  a  clear  liquid,  and  passed  several  copious  rice-water 
<lischarges  from  the  bowels.  His  collapse  deepened ;  the  pulse  became 
slow,  feeble,  and  almost  imperceptible,  and  his  respirations  shallow. 
His  intellect  was  clear,  and  his  condition  is  best  described  by  the  word 
*  terror.'  At  2.30  p.  m.,  or  three  hours  and  thirty  minutes  after  admis- 
sion, he  was  extremely  restless  and  anxious,  and  the  choleraic  intestinal 
discharges  continued.  He  moved  from  side  to  side,  tossing  the  arms 
about  wildly  and  calling  aloud  for  air.  The  hypodermoclysis  was  re- 
peated, and  hydrochloric  acid  and  brandy  were  administered  by  the 
mouth.  At  5  p.  M.  he  was  pulseless,  and  complained  most  bitterly  of 
intense  pain,  produced  by  the  tonic  spasm  of  the  muscles.  The  cramps 
were  so  violent  that  the  muscles  were  knotted  and  felt  board-like.  At 
6  P.  M.  the  hypodermoclysis  was  repeated ;  the  pulse  was  scarcely  to  be 
felt,  and  thirty  minims  of  whiskey  were  given  hypodermically  and 
repeated  for  five  doses,  but  with  no  effect.  He  now  passed  two  copious 
liquid  stools  containing  whitish  shreds  composed  of  intestinal  epithe- 
lium, giving  the  discharges  their  rice-water  like  appearance.     At  6.30 


336  CHOLERA. 

P.  M.  he  passed  three  more  stools,  and  at  this  time  we  were  unanimously 
of  the  belief  that  he  must  speedily  die.  At  7  p.  m.  he  showed  slight 
reaction ;  his  extremities  became  a  trifle  warmer  and  the  pulse  more 
easily  counted.  At  10  p.  m.  hypodermoclysis  and  enteroclysis  were 
repeated,  and  a  hypodermic  injection  of  twenty  minims  of  whiskey  was 
given  every  thirty  minutes  until  1  p.  m.  At  11  P.  m.  the  intellect  was 
clear ;  the  eyes  were  horribly  sunken  and  surrounded  by  dark  circles ; 
the  nose  pinched ;  the  face  shrunken ;  the  voice  whispering,  and  so 
feeble  that  the  man  was  compelled  to  rest  between  words  in  replying  to 
questions.  He  now  complained  of  pain  in  the  chest  and  renal  region. 
His  extremities  grew  warmer,  and  perspiration  was  visible  on  the  trunk. 
This  symptom  was  peculiar  and  rare,  as  in  none  of  our  other  cases  was 
perspiration  visible  in  this  stage.  The  mental  condition — terror — per- 
sisted. At  this  time  he  ejected  large  quantities  of  rice-water  liquid  by 
five  acts  of  emesis.  A  1  p.  m.,  September  28th,  the  slight  improvement 
continued,  and  the  hypodermoclysis  and  enteroclysis  and  hypodermic 
injections  of  whiskey  were  repeated.  At  this  time  he  had  three  move- 
ments of  the  bowels,  which  were  composed  of  the  tannic  acid  solution 
given  by  injection.  At  5  a.  m.  hypodermoclysis  and  subcutaneous  injec- 
tions of  whiskey  were  repeated,  the  improvement  became  quite  marked, 
and  he  slept  quietly  for  a  few  hours.  At  8.30  A.  M.  the  enteroclysis 
was  repeated  and  the  whiskey  was  suspended. 

"  At  9  A.  M.  his  physiognomy  underwent  a  truly  remarkable  change 
for  the  better ;  the  face  became  slightly  flushed,  the  ghastly,  death-like 
pallor  disappeared,  the  expression  about  the  eyes  became  more  natural, 
and  the  entire  skin  surface,  especially  that  of  the  extremities,  was  warm, 
and  the  pulse  was  of  full  volume,  soft  in  quality,  regular,  beating  100 
per  minute.  At  11  a.m.  it  seemed  incredible  that  such  wonderful 
changes  could  have  occurred  in  the  twenty-four  hours  which  had  just 
elapsed.  At  10.30  a.  m.  the  enteroclysis  was  repeated,  and  at  10.50  a.  m. 
the  pulse  was  full,  regular,  soft,  and  88  per  minute ;  the  respirations 
were  normal,  and  the  expression  good.  He  responded  intelligently  to 
questions  and  improvement  continued. 

"  In  both  flanks,  where  the  needle  had  been  inserted  repeatedly  for 
the  subcutaneous  injection  of  the  sodium  chloride  solution,  the  tissues 
were  hypersemic  and  sensitive  to  the  slightest  touch.  No  extravasation 
of  blood  occurred,  and  in  three  days  these  symptoms  disappeared.  At 
no  time  was  a  single  drop  of  urine  excreted.  In  ordinary  cases  the  rate 
of  absorption,  after  the  hypodermoclysis,  varies  between  forty  and  sixty 
minutes,  whereas  in  this  case  three  hours  were  required,  thus  showing 
that  the  power  of  absorption  had  been  almost  abolished.  So  soon  as 
the  liquid  was  absorbed  a  second  enteroclysis  was  given.  Hypodermic 
injections  of  twenty  minims  of  whiskey  were  repeated  almost  hourly 
until  midnight.  The  man  passed  a  good  night,  vomiting  but  twice,  and 
had  dark-colored  stools.  His  general  condition  remained  unchanged. 
On  September  29th  he  received  champagne,  and  now  recognized  that 
he  was  convalescent.  He  was  given  whiskey  and  seltzer  water,  equal 
parts,  every  three  hours,  and  at  10.45  A.  ]\[.,  for  the  first  time,  precisely 
forty-eight  hours  after  admission,  he  passed  one  pint  of  urine.  The 
examination  of  this  urine  showed  a  distinct  trace  of  albumin  ;  no  sugar  ; 
specific  gravity  1024  ;  acid  reaction,  and  the  sediment  contained  numer- 


TREATMENT.  337 

oils  p;ranular  tuho-oasts.  The  liiiuid  niovomciit.s  oontinuod  every  two 
hours,  and  aoaiu  he  passed  a  iioriual  quantity  of  urine.  On  September 
30th  the  diarrhoea  continued  to  average  one  stool  every  two  hours  ;  the 
quantity  passed  was  small  and  the  color  had  become  dark.  The  patient 
was  excessively  irritable  and  nervous.  He  improved  slowly  for  two 
days,  and  then  sank  into  a  typhoid  state.  There  was  no  enlargement 
of  the  spleen  or  elevation  of  the  temperature. 

"  As  was  feared,  but  little  improvement  occurred,  and  the  typhoid 
state  continued  until  death,  which  took  place  on  October  5th,  or  eight 
days  after  admission  to  the  hospital. 

"  The  post-mortem  examination  revealed  the  ordinary  changes  that 
are  found  in  cholera  ;  the  kidneys  showed  a  severe  grade  of  acute 
parenchymatous  nephritis." 

Vol.  I.— 22 


DYSENTERY. 

By  HAMILTON  A.  WEST,  M.  D. 


Definition. — Under  the  term  dysentery  is  embraced  a  group  of 
morbid  conditions  affecting  chiefly  the  large  intestine,  characterized 
by  similar  symptoms,  but  differing  essentially  in  etiology,  clinical  course, 
and  pathological  results. 

In  attempting  to  give  a  definition  of  dysentery  which  would  include 
the  various  forms,  one  meets  with  the  same  difficulty  he  would  encoun- 
ter in  the  effort  to  define  under  one  category  the  different  types  of  pneu- 
monia. 

Woodward,  in  his  exhaustive  study  of  diarrhoea  and  dysentery,  de- 
spairing of  improving  upon  any  of  the  old  definitions,  does  not  offer  a 
new  one,  but,  following  Trousseau,  "  embraces  under  the  designation 
acute  dysentery  all  the  various  forms  of  acute  alvine  flux,  whether  mild 
or  severe,  in  which  tenesmus  is  a  prominent  symptom."  While  this 
event  is  important  as  indicative  of  an  inflammation  of  the  colon  and 
rectum  of  sufficient  intensity  to  make  expulsive  efforts  painful,  and  may 
serve,  in  many  instances,  to  differentiate  diarrhoea  and  dysentery,  it  is 
important  not  to  misinterpret  its  diagnostic  significance.  There  is 
abundant  evidence  to  show  that  tormina  and  tenesmus  may  be  entirely 
absent  in  cases  which  are  proven  to  be  dysentery  by  the  autopsy,  and, 
on  the  other  hand,  that  various  local  causes,  as  piles,  ascarides,  intussus- 
ception, ulcers  of  the  rectum,  fissures,  vesical  calculi,  tumors,  and  in- 
flammatory conditions  in  and  around  the  uterus,  may  be  productive  of 
tenesmus  in  the  absence  of  dysentery.  The  presence  of  any  symptom, 
however  important,  is  insufficient  to  characterize  the  disease. 

The  following  will  serve  as  an  illustration  of  the  prevalent  concep- 
tion of  dysentery  as  given  by  recent  writers  : 

"  By  dysentery  is  meant  a  disease  of  the  colon  which  appears  sporadi- 
cally, but  more  often  in  epidemics ;  it  is  excited  by  infection  with  an 
organized  pathogenic  poison  about  which  we  have  as  yet  no  further 
knowledge  "  (Striimpell). 

The  fundamental  error  in  such  definitions  has  been  well  pointed  out 
by  Ball,  in  that  dysentery  is  regarded  "  as  a  morbid  entity,  an  infec- 
tious disease  expressing  itself  by  an  inflammation  of  the  large  intestine, 
essentially  the  same  in  its  sporadic,  endemic,  and  epidemic  forms,  in 
tropical  climates  and  northern  latitudes,  and  varying  in  its  symptom- 
atology and  pathology  in  different  cases  only  in  accordance  with  climatic 
and  other  modifying  conditions." 

It  comports  better  with  our  present  knowledge  to  broaden  the  term 
for  a  group  of  inflammations  of  the  colon  chiefly,  which  may  be  of 
specific  infectious  or  non-specific  origin,  which,  differing  however  widely 

339 


340  DYSENTERY. 

in  causation,  pathology,  and  results,  are  nevertheless  characterized  by  a 
similarity  in  symptoms. 

The  following  classification  is  here  adopted  in  conformity  with  recent 
usage,  and,  though  objectionable  from  the  fact  that  it  is  based  both  upon 
the  nature  of  the  lesions  and  the  causes,  it  is  practical,  for  the  reason 
that  the  forms  described  can  usually  be  diiferentiated  during  life  :  viz. 
(1)  acute  catarrhal  sporadic  or  non-specific  dysentery,  including  those 
cases  where  the  rectum  is  chiefly  involved ;  (2)  diphtheritic  dysentery ; 
(3)  amoebic  or  tropical  dysentery ;  and  (4)  secondary  dysentery. 

Etiology. — This  constitutes  one  of  the  most  important  divisions  in 
the  study  of  dysentery,  for  from  a  knowledge  of  the  causes  only  can 
there  be  developed  an  intelligent  and  successful  system  of  prophylaxis. 
It  is  difficult  to  realize  in  northern  latitudes,  where  this  disease  prevails 
usually  in  mild  and  sporadic  forms,  that  it  takes  rank  in  malignancy 
and  mortality  with  yellow  fever,  smallpox,  and  cholera  as  one  of  the 
four  great  epidemic  diseases  of  the  world.  It  is  the  scourge  of  armies, 
causing  more  sickness  and  death  than  any  other  disease,  patients  with 
dysentery  and  diarrhoea  rivalling  the  wounded  in  multitude,  and  consti- 
tuting a  large  proportion  of  those  discharged  for  disability. 

Climate. — While  dysentery  may  occur  in  temperate  regions  in  epi- 
demic form  at  times,  it  is  notoriously  prevalent  in  tropical  and  semi- 
tropical  regions,  as  in  the  East  and  West  Indies,  China,  Africa,  South 
America,  Mexico,  and  southern  portions  of  the  United  States  of 
America. 

Season. — In  these  regions  the  effect  of  heat  as  a  predisposing  factor 
is  shown  by  the  increased  number  of  cases  occurring  during  the  hot 
months.  It  has  been  supposed  that  heat  acts  by  producing  an  injurious 
operation  upon  the  alimentary  canal,  leading  to  increased  excitability 
and  disordered  secretion,  but  it  is  more  probable  that  its  effects  are  pro- 
duced by  aiding  in  the  development  of  the  special  pathogenic  organism, 
as  it  does  in  paludal  fever,  and  explaining  the  fact,  as  mentioned  by 
Aitken,  that  in  every  country  where  that  disease  exists  dysentery  is  an 
endemic  and  prevailing  disease. 

Age. — No  age  is  exempt  from  dysentery.  Adults  are  more  liable  to 
the  diphtheritic  and  amoebic  forms  than  children,  simply  because  of 
greater  exposure  to  the  exciting  causes ;  but  if  we  regard  inflammatory 
diarrhoea  or  entero-colitis  as  synonymous  with  dysentery,  then  it  is  a 
disease  of  great  frequency  and  mortality  in  children.  Unquestionably 
when  this  disorder  in  children  has  lasted  any  considerable  length  of  time, 
we  find  similar  lesions  to  those  found  in  the  dysentery  of  adults,  even  in 
the  absence  of  the  ordinary  dysenteric  symptoms. 

Sex. — The  male  sex  is  more  liable  to  contract  this  disease  than  the 
female,  simply  from  greater  exposure  to  the  exciting  causes.  Thus,  out 
of  15  cases  of  the  amoebic  form  reported  by  Councilman  and  Lafleur, 
only  1  was  a  woman ;  of  the  7  cases  reported  by  the  writer,  all  were 
men.  When  we  consider  the  extent  from  which  men  suffer  the  evils 
incident  to  the  insanitary  conditions  of  camp,  army,  and  prison  life, 
which  have  so  much  to  do  with  dysentery,  we  can  appreciate  the  pre- 
ponderance of  its  prevalence  in  this  sex. 

Geological  Conditions. — Various  circumstances  concerning  the  soil 
may  predispose  to  dysentery  by  favoring  contamination  of  drinking 


ETIOLOGY.  341 

water,  but  as  reference  will  be  madf  to  this  subject  farther  on,  it  is 
unnecessary  to  enlarge  upon  it  here. 

Meti'orol(>(/ic((l  Injiuvnce^. — Changes  in  the  weather  and  temperature 
undoubtedly  act  as  predisponents  with  regard  to  dysentery.  Thus,  it 
has  been  observed  tliat  sudden  reduction  of  the  temperature  in  the 
night,  as  is  of  common  occurrence  in  the  autumn  season,  or  exposure 
to  rain  or  heavy  dews,  will  be  followed  by  an  increase  in  tlie  number 
of  dysentery  cases. 

Unhygienic  infuence.s,  such  as  have  heretofore  prevailed  in  armies, 
fleets,  and  prisons.  Dysentery  has  followed  the  track  of  all  the  great 
armies  which  have  traversed  Europe  during  the  continental  wars  of  the 
past  two  hundred  years.  It  helped  to  destroy  the  British  army  in  Hol- 
land in  1748.  It  decimated  the  French,  Prussian,  and  Austrian  armies 
in  1792.  It  was  the  chief  cause  of  death  in  the  ill-fated  Walcheren 
expedition  in  1809.  It  cut  down  the  garrison  of  Mantua  in  1811-12. 
It  was  the  most  fatal  disease  in  the  Peninsula  campaign,  and  disastrous 
to  the  British  troops  in  the  Crimea  in  1854.  It  is  the  disease  of  fam- 
ished garrisons  in  besieged  towns,  of  barren  encampments,  of  starving 
prisoners,  and  of  fleets  navigating  tropical  seas. 

Dysentery  and  diarrhoea  w-ere  of  enormous  frequency  in  the  Federal 
and  Confederate  armies  during  the  Civil  War  in  America  from  1861- 
65.  As  stated  by  Woodward  :  "  These  disorders  occurred  with  more 
frequency  and  produced  more  sickness  and  mortality  than  any  other 
form  of  disease.  They  made  their  appearance  in  the  very  beginning 
of  the  war,  not  infrequently  prevailing  in  new  regiments  before  their 
organization  Avas  complete,  and  although,  as  a  rule,  comparatively  mild 
at  first,  were  not  long  in  acquiring  a  formidable  character.  Soon  no 
army  could  move  without  leaving  behind  it  a  host  of  victims.  Thev 
crowded  the  ambulance  trains,  the  railroad  cars,  the  steamboats.  In 
the  general  hospitals  they  were  often  more  numerous  than  the  sick  from 
all  other  diseases.  They  abounded  in  the  convalescent  camps,  and 
formed  a  large  proportion  of  those  discharged  from  the  service  for  dis- 
ability. Many  of  the  prisoners  upon  both  sides  suifered  and  died  from 
dysentery.  For  many  months  after  the  war  was  over  and  most  of  the 
troops  had  returned  to  their  homes  deaths  from  chronic  diarrhoea  and 
dysentery  contracted  in  the  service  continued  to  be  of  frequent  occur- 
rence among  them."  What  explanation  can  be  given  of  this  excessive 
morbidity  and  mortality  from  intestinal  fluxes  in  army  life  ?  The  replv 
must  be  that  it  lies  in  the  infraction  of  almost  every  item  of  sanitarv 
law  which  is  incidental  to,  and  so  far  has  appeared  to  be  inevitable  in, 
times  of  war. 

The  lowering  of  vital  resistance  from  overcrowding,  irregular  habits, 
exposure  to  bad  weather,  forced  marches,  want  of  rest,  intemperate  eat- 
ing and  drinking,  bad  cooking,  and  imperfect  quality  of  the  food,  by 
producing  intestinal  catarrh  provide  a  suitable  soil  for  the  growth  and 
development  of  pathogenic  organisms,  which  in  the  opinion  of  the  writer 
are  most  apt  to  gain  an  entrance  through  contaminated  drinking  water, 
such  polluted  water  supply  being  specially  apt  to  occur  in  camps  and 
armies. 

Before  discussing  the  methods  of  water  infection  mention  should  be 
made  of  other  causes  which  are  mainly  predisposing. 


342  DYSENTERY. 

Errors  of  diet  have  been  regarded  from  time  immemorial  as  potent 
factors  in  the  production  of  dysentery.  Articles  which  have  been  con- 
sidered as  most  obnoxious  are  unripe  fruit,  decomposing  vegetables, 
tainted  meat,  canned  fish,  meat,  and  vegetables.  Such  articles  are  more 
liable  to  cause  diarrhoea,  nature  thus  getting  rid  of  the  irritant  sub- 
stances. Occasionally,  however,  such  dietetic  errors  result  in  a  catarrhal 
proctitis,  which  ra]:)idly  subsides  when  the  oifending  cause  is  removed. 
Dysentery  is  not  likely  to  result  unless  the  error  is  frequently  repeated, 
but  the  catarrhal  condition  ensuing  upon  dietary  faults  will  undoubtedly 
predispose  to  the  worst  forms  of  the  disease.  The  idea  that  fresh  fruits 
and  vegetables  are  dangerous  has  been  proven  to  be  a  mistake ;  on  the 
contrary,  army  experience  has  demonstrated  that  by  warding  off  scurvy 
and  maintaining  a  better  state  of  general  health  dysentery  is  actually 
prevented  when  such  articles  are  freely  consumed. 

Constipation,  and  Retention  in  the  Bowels  of  Fermentative  Irritant 
Compounds. — ^Virchow  and  others  have  attached  great  importance  to 
such  conditions  as  causes  of  dysentery.  Several  circumstances  show 
that  this  view  is  true  of  a  certain  class  of  cases,  or  at  least  that  such 
influences  predispose  to  dysentery — viz.  the  catarrhal  and  diphtheritic 
inflammation,  ulceration,  sloughing,  and  perforation  of  the  mucous  mem- 
brane in  contact  with  fecal  masses  which  accumulate  above  the  point  of 
obstruction  in  cases  of  stricture,  and  the  fact  that  constipation  often  pre- 
cedes the  occurrence  of  dysentery,  are  significant  in  this  direction. 

Constitutional  Condition  of  those  Exposed. — Various  writers  on  dis- 
eases of  camps  and  armies  have  called  attention  to  the  effects  of  exhaus- 
tion from  fatigue,  over-exertion,  loss  of  sleep  during  long  marches, 
sieges,  battles  of  several  days'  duration,  as  predisposing  to  dysentery. 

In  a  like  manner,  any  severe  constitutional  disorder  producing  gen- 
eral debility  favors  the  development  of  dysentery  among  those  exposed 
to  its  exciting  causes.  Thus,  Finger,  in  describing  the  Prague  epidemic, 
calls  attention  to  the  frequency  with  which  the  disease  attacks  patients 
already  the  victims  of  tuberculosis,  cancer,  typhus  fever,  syphilis,  and 
Bright's  disease.  AVoodward  confirms  these  observations,  and  adds  that 
in  the  American  Civil  War  the  diseases  in  which  dysentery  occurred 
principally  as  a  secondary  affection  were  tuberculosis,  typhoid  fever, 
malarial  fever,  and  scurvy,  and  that  in  tuberculosis  and  typhoid  fever 
there  was  not  only  the  intestinal  ulceration  peculiar  to  these  diseases, 
but  in  many  instances  acute  catarrhal  and  diphtheritic  dysentery  devel- 
oped as  the  terminal  event. 

As  regards  malaria  and  the  scorbutic  taint,  the  evidence  is  conclusive 
that  the  cachectic  condition  produced  by  these  diseases  is  especially 
favorable  for  the  development  of  dyseiiterv. 

Drinking  Wcder. — In  regard  to  contamination  of  drinking  water  as  a 
source  of  infection,  it  has  been  conclusively  proven  that  the  infectious 
micro-organisms  of  cholera  and  typhoid  fever  (intestinal  diseases)  also 
are  largely  conveyed  by  means  of  impure  water.  It  will  be  shown  that 
there  is  at  least  a  strong  probability  for  such  an  origin  in  many  cases  of 
dysentery.  When  we  consider  the  large  quantity  of  water  consumed  by 
every  individual,  the  extreme  likelihood  of  its  contamination  with  path- 
ogenic organisms,  and  that,  unlike  the  food,  it  usually  is  taken  without 
any  previous   preparation  by  which   such   infectious  agents   might  be 


ETIOLOGY.  343 

destrovod,  wc  can  appreciate  the  infliicnce  a  poisoned  water  supply 
might  have  as  an  excitant  of  tliis  disease. 

From  the  earliest  times  the  use  of  impure  drinking  water  has  been 
considered  as  a  cause  of  intestinal  fluxes.  Hippocrates  discussed  the 
question  at  length,  and  attributed  the  occurrence  of  such  disorders 
among  those  wlio  live  in  marshy  districts  to  drinking  the  stagnant  water 
of  lakes  and  ponds.  This  opinion  was  quoted  by  Galen,  who  pointed 
out  the  methods  of  purifying  water  by  filtration  and  boiling. 

It  is  unnecessary  to  discuss  at  length  the  various  ingredients  of  water 
which  have  been  supposed  to  exercise  a  causative  influence  in  the  pro- 
duction of  dysentery.  Evil  effects  have  been  ascribed  to  inorganic  sub- 
stances in  suspension  and  such  substances  in  solution  as  sulphate  and 
carbonate  of  lime,  salts  of  soda,  potash,  and  magnesia.  The  evidence 
upon  this  subject  appears  to  be  that,  while  such  waters  may  often  have 
a  purgative  effect,  especially  upon  those  unaccustomed  to  their  use,  and 
may  be  deleterious  in  other  ways,  there  is  no  proof  to  show  that  these 
chemical  ingredients  will  cause  dysentery.  Facts  appearing  to  offer 
such  demonstration — e.  g.  where  in  an  epidemic  of  dysentery  only  those 
who  drank  limestone  water  were  affected,  those  who  used  cistern  water 
being  entirely  exempt — do  not  prove  that  the  carbonate  of  lime  was  the 
morbific  agent,  but  only  that  such  water,  being  supplied  by  surface 
drainage,  was  liable  to  other  contamination. 

The  presence  of  decomposing  matters  of  vegetable  origin  in  the  water 
used  for  drink  has  been  regarded  as  a  cause  of  intestinal  flux,  but  so  far 
the  evidence  from  either  custom  or  experiment  has  been  inconclusive  as 
to  the  evil  effects  of  such  substances. 

Pathogenic  Micro-organisms  in  Drinhing  Water. — Since  the  facts  as 
regards  this  source  of  infection  have  been  established  as  to  typhoid  fever 
and  cholera,  the  probability  of  a  similar  origin  of  dysentery  has  been 
greatly  strengthened,  and  in  the  opinion  of  the  writer  ample  confirma- 
tion will  be  offered  when  similar  methods  of  investigation  have  been 
applied  to  dysentery ;  and  here,  also,  fecal  contamination  is  the  most 
probable  source  of  infection.  I  will  cite  but  a  few  of  the  facts  which 
go  to  supjDort  this  view. 

Read  relates  that  in  August  and  September,  1870,  one  of  two  regi- 
ments lodged  in  the  barracks  at  Metz  suffered  greatly  from  dysentery, 
while  the  other  had  but  few  cases.  On  inquiry  it  was  found  that  the 
former  obtained  its  drinking  water  from  two  wells  which  were  proved 
to  have  been  contaminated  with  fecal  matter  filtered  from  neighboring 
latrines,  while  the  latter  drank  from  two  wells  not  having  such  connec- 
tion.    The  impure  wells  were  closed  and  the  disease  at  once  subsided. 

Oaks  traced  an  outbreak  of  dysentery  at  Cape  Coast  Castle,  on  the 
west  coast  of  Africa,  to  the  passage  of  sewage  from  a  cesspool  into  one 
of  the  tanks  supplying  drinking  water. 

One  of  the  most  conclusive  instances  upon  record  of  water  infection 
is  that  mentioned  by  Fagge  in  regard  to  the  prevalence  of  dysentery  in 
the  Millbank  prison.  It  appears  that  this  disease  had  prevailed  ex- 
tensively and  for  a  long  time  in  this  prison.  Fagge  says  :  "  In  the 
year  1854  the  prisoners  ceased  to  be  liable  to  dysentery,  and  during  the 
next  eighteen  years  (up  to  1872)  one  death  only  occurred  from  that  dis- 
ease or  from  diarrhoea ;  indeed,  so  far  as  I  am  aware,  the  immunity  has 


344  DYSENTERY. 

continued  down  to  the  present  time.  Now  one,  and  only  one,  change  in 
its  hygienic  arrangement  has  coincided  in  time  with  this  improvement 
in  the  sanitary  state  of  the  prison.  Formerly  the  water  which  the  con- 
victs drank  was  taken  directly  from  the  Thames  as  it  ebbed  and  flowed 
beneath  the  walls.  But  on  August  10,  1854,  the  artesian  well  in  Tra- 
falgar Square  was  made  the  source  of  supply  to  the  prison  ;  this  has 
since  continued.  The  change  was  effected  in  the  midst  of  the  cholera 
epidemic ;  six  days  afterward  the  disease  suddenly  ceased.  Typhoid 
fever  too  no  longer  attacks  the  convicts,  and  the  death  rate  has  declined 
to  an  extraordinary  extent.  It  is,  I  think,  impossible  to  avoid  the  con- 
clusion that  the  exciting  cause  of  dysentery  in  Millbank  prison  was  the 
Thames  water,  and  in  all  probability  the  noxious  ingredient  was  derived 
from  the  sewage  contained  in  it."  Fecal  contamination  is  undoubtedly 
the  explanation  of  the  excessive  prevalence  of  dysentery  in  military 
camps  in  times  of  war.  The  notorious  difficulty  is  a  proper  disposal 
of  the  excrement  of  large  bodies  of  men ;  its  indiscriminate  deposit 
upon  the  ground  from  whence  it  could  be  washed  by  every  rain  into  the 
shallow  wells,  springs,  and  creeks  which  afforded  the  water  supply  fur- 
nishes the  key  to  the  situation. 

Contagium. — The  question  of  the  contagiousness  of  dysentery  is  one 
which  has  been  extensively  discussed.  It  would  be  useless  to  quote 
authorities  or  recapitulate  the  reasons  they  give  for  their  opinions  upon 
this  subject.  We  can  understand  the  wide  differences  which  prevail 
when  we  consider  the  various  standpoints  from  which  the  disease  is 
viewed,  and  the  want  of  unanimity  as  to  what  constitutes  contagious- 
ness. If  we  accept  the  modern  definition  of  contagion — that  is  to  say, 
when  the  micro-organism  which  causes  a  disease  may  under  the  ordi- 
nary conditions  of  life  be  freed  from  the  body  of  the  diseased  person 
and  by  whatever  means  conveyed  to  the  body  of  another  in  a  condition 
capable  of  lighting  up  the  disease  anew — then  we  must  conclude  that 
dysentery  is  contagious,  the  evidence  going  to  show  that  the  contagium 
is  in  the  dejecta,  and  is  likely  to  reproduce  the  disease  in  other  victims 
chiefly  through  the  drinking  water.  It  is  probable  that  in  the  future 
we  must  recognize  a  number  of  different  organisms  as  the  cause  of  the 
various  forms  of  dysentery,  for  it  is  impossible  that  conditions  so  vary- 
ing in  both  their  anatomical  and  clinical  aspects  as  are  the  various  forms 
of  dysentery  can  be  due  to  a  single  organism  or  even  a  single  group  of 
organisms. 

TJie  Amoeba  Dysenterica. — Although  earlier  observers  had  discovered 
certain  organisms  belonging  to  the  protozoa  in  the  stools,  the  first  ac- 
count given  of  the  presence  of  amoebae  in  the  intestinal  contents  was 
given  by  Lambl  in  1859.  Losch  was  the  first  author  who  gave  an  accu- 
rate description  of  a  species  of  amoebae  which  he  found  in  the  stools  of 
a  dysenteric  patient,  together  with  a  careful  clinical  history  and  account 
of  the  autopsy.  The  first  case  studied  by  L5sch  was  received  in  the 
clinic  of  Prof.  Eichwald  in  St.  Petersburg  in  November,  1873.  The 
amoebae  found  in  the  stools  were  oval,  pear-shaped  or  irregular  in  form, 
five  to  eight  times  the  size  of  a  red  blood  corpuscle.  They  were  formed 
of  an  outer  hyaline  or  faintly  granular  material  enclosing  a  more  gran- 
ular mass.  They  were  often  so  abundant  that  a  single  field  of  the 
microscope  contained  sixty  or  seventy.     They  changed  their  form  fre- 


ETIOLOGY.  345 

quently  with  j^reat  rapidity,  tlirusting  out  blunt  processes  which  were 
at  times  quickly  withdrawn  ;  at  others  the  granular  interior  slowlv 
flowed  into  thcni  and  a  change  of  place  resulted.  Tlu;  nucleus  was 
pale,  of  delicate  contour,  and  (litHcult  to  make  out.  It  alwavs  contained 
a  nucleolus  of  variable  size. 

In  the  resting  amcebte  the  nucleus  was  always  in  the  midst  of  the 
granular  interior.  Refractive  vacuoles  of  various  sizes  which  under- 
went some  change  of  form  were  very  numerous  in  the  central  mass. 
Foreign  substances,  such  as  bacteria,  fragments  of  cells,  and  red  blood 
corpuscles,  were  frequently  seen  in  the  anifjebte. 

Cunningham,  the  only  observer  who  has  rejjorted  on  the  subject  irom 
India,  states  that  he  has  found  amabas  in  the  intestinal  canal  of  healthy 
persons,  as  well  as  in  those  alfected  with  cholera  and  other  diseases.  He 
thinks  the  conditions  which  especially  favor  their  presence  are  fluidity 
of  the  stools  and  an  alkaline  reaction.  He  found  them  also  in  the  dung 
of  horses  and  cows,  and  discovered  bodies  which  he  regarded  as  their 
spores. 

In  the  cholera  report  of  Koch  an  account  is  given  of  autopsies  made 
on  5  cases  of  dysentery  in  Egypt.  In  the  colon  of  most  of  the  cases 
there  were  oedema  and  extensive  ulceration  of  the  mucous  membrane; 
amoebae  were  found  at  the  base  of  the  ulcers  and  in  the  material  cover- 
ing them  in  all  ])ut  one  case,  and  in  that  the  ulcers  were  healed. 

Amoebse  have  been  found  in  the  intestinal  contents  by  four  Italian 
observers — Grassi,  Perroncito,  Calandruccio,  and  Blanchard.  Their 
reports  have  reference  only  to  the  presence  of  the  organisms. 

Next  in  importance  to  the  paper  of  Losch  on  the  amcebae  were  the 
observations  published  in  a  series  of  papers  by  Kartulis  of  Alexandria, 
Egypt,  on  dysentery  and  abscess  of  the  liver  in  1887,  1889,  1890,  1891. 
In  his  first  publication  he  gives  a  description  of  the  amoebfe  not  diiFer- 
ing  materially  from  that  of  Losch,  except  as  to  the  size  of  the  organ- 
ism. The  second  paper,  published  in  Virchoic's  Archiv,  is  devoted  to 
the  study  of  the  relation  of  the  amcebse  to  abscess  of  the  liver,  and  of 
his  attempts  to  secure  pure  cultures.  In  another  article  he  calls  atten- 
tion to  the  wider  distribution  of  the  amcebse,  and  cites  cases  in  which 
they  were  found  in  Greece.  In  his  last  article  he  gives  details  of  his 
experiments  in  the  cultivation  of  the  amceba,  and  bespeaks  for  this 
organism  as  the  cause  of  dysentery  a  greater  recognition  among  pathol- 
ogists than  it  has  hitherto  had. 

The  culture  medium  found  most  suitable  was  an  alkaline  straw  infu- 
sion, to  which  was  added  either  contents  of  liver  abscess  or  stools  con- 
taining amoebae.  In  twenty-four  to  forty-eight  hours  a  thin  membrane 
formed  on  the  surface  which  consisted  of  bacteria  and  young  amoebae. 
Studied  in  drop  cultures,  the  amoebae  were  much  smaller  than  those  in 
the  stools  ;  their  movements  in  the  swarm  form  were  very  active,  but 
they  did  not  send  out  pseudopodia.  Among  the  actively  moving  amoebae 
were  found  round  inactive  bodies  with  a  nucleus  and  finely  granular 
protoplasm  about  the  size  of  a  white  blood  corpuscle  ;  these  were  thought 
to  be  spores. 

Pure  cultures  were  difficult  to  obtain  :  success  was  secured  only  in 
one  case,  where  the  material  was  obtained  from  a  liver  abscess  free  from 
bacteria.     With  both  pure  and  impure  cultures  inoculations  were  made 


346  DYSENTERY. 

in  cats  with  positive  results,  by  injecting  the  cultures  into  the  rectum  and 
tying  the  anus.     Feeding  the  animals  with  amoebae  gave  negative  results. 

Hlava,  in  1887,  investigated  the  dysentery  prevalent  in  Prague,  and 
found  amoebse  in  60  cases  of  partly  endemic  and  partly  sporadic  dys- 
entery. His  description  of  them  agrees  fully  with  that  of  Kartulis. 
Hlava  also  injected  stools  containing  the  organisms  into  the  rectum  of 
dogs  and  cats,  with  positive  results.  Kartulis  remarks  that  dogs  in 
Egypt  were  spontaneously  affected  with  dysentery,  and  the  same  amoebse 
were  found  in  the  stools  as  in  man. 

Osier,  in  1890,  was  the  first  in  America  to  discover  amoebse,  finding 
them  in  the  contents  of  a  liver  abscess  in  a  patient  operated  on  by  Dr. 
Tiffany  of  Baltimore.  They  were  present  in  large  numbers  in  the  pus, 
and  subsequently  faund  in  the  stools.  The  patient  had  contracted 
chronic  dysentery  in  Panama. 

The  organism,  as  described  by  Osier,  conforms  in  every  respect  to  the 
description  of  Kartulis  except  in  being  a  little  larger.  In  1890,  Mus- 
ser  and  Stengel  each  reported  3  cases  of  dysentery  in  which  amoebse 
were  found.  In  April,  1891,  Dock  gave  a  resume  of  the  subject,  and 
reported  12  cases  of  amoebic  dysentery  occurring  in  Galveston,  Texas. 
In  4  of  these  there  Avas  abscess  of  the  liver,  and  in  4  this  disease  was 
only  recognized  at  the  autopsy,  symptoms  of  dysentery  not  being  pres- 
ent during  life,  the  lesions  in  these  cases  involving  only  the  csecum. 
Dock's  description  of  the  organisms  is  in  accord  with  that  of  Kartulis 
and  others. 

In  1891  ^  Councilman  and  Lafleur  reviewed  the  literature  of  amoebic 
dysentery,  and  gave  the  results  of  a  careful  analysis  and  study  of  15 
cases  occurring  in  Baltimore,  and  a  comparison  of  the  symptoms  ob- 
served in  the  catarrhal  and  diphtheritic  forms  with  those  of  amoebic  dys- 
entery. As  more  than  half  of  these  cases  were  fatal,  they  were  able  to 
make  many  valuable  additions  to  our  knowledge  of  the  pathological 
anatomy  of  this  disease.  In  the  remarks  here  given  I  have  freely 
drawn  upon  the  excellent  summary  of  the  subject  as  presented  by  these 
authors. 

In  September,  1893,  the  writer  reported  7  cases  of  dysentery  treated 
in  the  John  Sealy  Hospital,  Galveston,  Texas,  during  the  previous 
year,  in  which  the  amoebse  were  found.  The  symptoms  in  these  cases 
were  uniform  and  characteristic  :  as  they  all  recovered  or  were  dis- 
charged uncured,  no  autopsies  were  made.  In  1  case  the  discovery  of 
amoebse  in  the  pus  from  a  liver  abscess  led  to  the  diagnosis,  the  intesti- 
nal symptoms  being  very  obscure.  The  organisms  in  these  cases  pre- 
sented the  features  as  recorded  by  other  observers. 

Baumgarten,  speaking  of  the  opinion  expressed  by  Kartulis  that  the 
amoebse  are  the  cause  of  dysentery,  says  :  "  We  regard  it  is  improbable 
that  the  amoebse  can  produce  the  entire  series  of  changes  which  con- 
stitute the  dysenteric  process.  Anatomically,  dysentery  consists  in  a 
combination  of  diphtheritic  and  purulent  inflammation,  which  rapidly 
produces  deep  ulcerations  of  the  parts  affected ;  there  is  no  analogy  to 
make  us  believe  that  amoebse  can  be  the  cause  of  the  ulceration.  We 
think  it  more  probable  that  pyogenic  micro-organisms  play  an  import- 
ant part  with  the  amoebse  in  the  production  of  tropical  dysentery." 

^  Johns  Hopkins  Hospital  Reports,  vol.  ii.  Nos.  7-9. 


ACUTE  CATARRHAL  DYSENTERY.  347 

Coimcilman  and  LatltMir,  after  an  exhaustive  study  of  the  subject, 
state,  as  a  jxirt  of  thcii-  coiichisions,  "that  the  anuebic  is  a  form  of  dys- 
entery M'hich  etiolotiically,  clinically,  and  anatondcally  should  be  re- 
garded as  a  distinct  tlisease,  and  that  the  amceba  has  been  shown  to  be 
the  causative  agent  from  its  constant  presence  in  the  stools  and  the  ana- 
tomical lesions,  and  from  the  inoculation  experiments  of  Kartulis." 

While  I  am  strongly  inclined  to  believe  in  the  (;orrectness  of  this 
conclusion,  yet,  on  account  of  the  difficulty  of  obtaining  pure  cultures 
of  the  amnebiC,  and  the  uncertainty  of  the  inoculation  ex])eriments  of 
Kartulis,  the  pathogenic  influence  of  these  organisms  must  be  considered 
as  lacking  that  complete  and  stringent  proof  requisite  to  identify  its 
positive  causative  influence. 

1.  Acute  Catarrhal  Dysentery. 

Pathological  Axatomy. — Since  acute  catarrhal  dysentery  most 
frequently  ends  in  recovery,  opportunities  for  post-mortem  examinations 
are  rare  in  uncomplicated  cases. 

The  colon,  and  more  particularly  the  csecum,  hepatic,  splenic,  and 
sigmoid  flexures,  and  rectum,  are  the  parts  chiefly  involved,  though 
sometimes  the  ileum  is  also  aifected.  Areas  of  mucous  membrane  are 
congested,  red,  swollen,  and  more  or  less  covered  with  tenacious,  yellow- 
ish or  brownish  red  mucus,  with  some  admixture  of  pus.  Punctate  or 
diifiised  extravasations  of  blood  are  usually  visible.  The  solitary  glands 
are  generally  enlarged,  and  project  as  grayish  white  elevations,  from  the 
size  of  a  pinhead  to  that  of  a  pea.  The  submucous  tissue  is  swollen 
from  congestion  and  serous  infiltration.  If  the  case  is  prolonged,  follic- 
ular ulceration  or  diphtheritic  inflammation  may  ensue. 

The  following  is  a  synopsis  of  changes  as  found  in  the  intestines  of 
a  typical  case  reported  by  Coimcilman  and  Lafleur  :  "  The  patient,  aged 
sixty-three,  had  dysentery  two  weeks  before  death.  He  had  severe  pain  : 
the  stools  were  fluid,  but  contained  no  blood.  Xumerous  ulcers  were 
found  in  the  colon,  especially  the  descending  portion,  and  the  rectum. 
The  ulcers  were  usually  superficial,  and  many  confined  to  the  mucous 
membrane  ;  others  were  deeper,  but  none  extended  to  the  muscular  coat. 
Some  of  the  ulcers  were  round ;  others  of  irregular  shaj^e  from  the 
union  of  adjacent  ones.  The  edges  were  smooth  and  were  undermined. 
The  intestine  was  not  thickened,  except  about  the  largest  and  deej^est 
ulcers.  The  mucous  membrane  generally  was  pale  and  soft.  The  tis- 
sues, after  hardening  in  alcohol  and  submission  to  microscopic  examina- 
tion, showed  decided  changes.  The  superficial  portions  of  the  mucous 
membrane  near  the  ulcers  was  broken  down  into  a  granular  looking 
mass,  in  which  only  the  remains  of  cells  were  found.  Deeper  down 
there  was  a  diffuse  infiltration  with  pus  cells,  most  .marked  just  above 
the  muscularis  mucosa.  Lieberkiihn's  glands  showed  various  stages  of 
disorganization.  In  some  instances  they  were  dilated  into  thin-walled 
cysts,  filled  with  pus  cells ;  in  others  the  cells  were  separated  from  each 
other,  forming  irregular  masses  of  epithelium  ;  the  cells  were  generally 
swollen  and  with  indistinct  outlines.  The  lymphoid  cells  were  increased 
and  the  solitary  follicles  slightly  enlarged. 

"  In  the  mucous  membrane  corresponding  to  the  wdiitish  areas  there 


DESCEIPTION   OF   PLATE   III. 

Fig.  1  :  A  transverse  section  of  colon  near  the  cfecum  in  a  case  of  secondary  diph- 
theritic dysentery  following  the  amoebic  form,  complicated  by  an  extensive  abscess  of  the 
right  lobe  of  the  liver.  Following  is  a  brief  history  of  the  case :  Aug.  Schmidt,  aged  forty- 
three,  native  of  Germany,  laborer,  admitted  to  Sealy  Hospital,  Galveston,  Oct.  23,  1895. 
Lived  in  Galveston  fifteen  years ;  previous  health  good,  with  exception  of  an  attack  of 
diarrhoea  fifteen  years  ago.  Gave  a  history  of  diarrhoea  alternating  with  constipation, 
lasting  about  three  weeks  prior  to  admission.  Stools  varied  in  number  from  four  to  ten 
daily  ;  contained  mucus,  but  no  blood.  There  had  been  some  abdominal  pain,  but  na 
tenesmus.  Condition  on  admission :  anorexia,  tongue  thickly  coated  and  brown,  slight 
tenderness  over  right  hypochondrium.  Bowels  obstinately  constipated  from  Oct.  23d 
until  Dec.  3d  ;  stools  averaged  one  daily.  Under  the  use  of  repeated  la,xatives  during  the 
succeeding  three  weeks  the  number  averaged  two  daily  ;  enemata  and  purgatives  were 
required  to  keep  the  bowels  active  during  this  time.  Dec.  27th  a  severe  uncontrollable 
diarrhoea  ensued,  the  number  of  stools  varying  from  three  to  twenty-three  daily;  the 
dejections  were  large,  thin,  and  watery,  containing  mucus,  small  particles  of  fecal  matter, 
and  undigested  food,  chiefly  casein  ;  examination  for  amoebse  negative.  Diarrhoea  lasted 
until  the  patient  died,  Jan.  8,  1895.  During  the  first  four  weeks  the  temperature  varied 
from  normal  to  100.4°  F.  ;  the  following  three  weeks  it  was  higher,  ranging  from  100°  to 
102°,  once  reaching  103°  F. ;  on  Nov.  30th  and  Dec.  3d  it  was  subnormal  (97°).  On  Dec. 
11th  there  was  a  severe  rigor,  followed  by  a  temperature  of  106.8  F.  ;  similar  rigors  and 
high  temperature  occurred  on  the  14th,  19th,  25th,  and  subsequently.  During  this  period 
the  patient  complained  of  severe  pain  in  the  hepatic  region.  Abscess  of  the  liver  was  sus- 
pected, and  an  operation  arranged  for,  but  being  postponed  for  some  reason  and  the  con- 
dition becoming  hopeless,  incision  was  abandoned.  The  autopsy  revealed  extensive 
ulceration  throughout  the  large  intestine,  as  shown  by  photograph.  The  drawing,  by 
Prof.  W.  Keiler,  made  shortly  after  death,  shows  the  dark  discoloration,  the  oval-shaped 
ulcers,  crowded  together  and  mostly  covered  by  a  closely  adherent  diphtheritic  exudation, 
extending  in  depth  to  the  muscular  coat,  and  having  their  long  diameter  across  the  gut. 
The  drawing  is  life-size  and  the  coloring  true.  The  ulcers  were  situated  mainly  upon 
the  crests  of  the  folds  of  the  mucosa,  the  grayish,  dark  green  discolorations  corresponding 
to  the  depressions  between  the  folds.  The  entire  colon  was  thickened  and  softened  ;  the 
latter  probably  was  a  post-mortem  change.  The  small  intestines  were  normal.  The 
entire  right  lobe  of  the  liver  was  occupied  by  an  abscess,  in  the  contents  of  Avhicli  amoebae 
were  found  ;  there  were  no  other  important  lesions.  The  case  is  one  of  great  interest,  as 
showing  the  insidious  nature  of  amoebic  dysentery — that  unhealed  ulcers  may  exist  with 
obstinate  constipation,  and  death  finally  occur  from  hepatic  abscess  or  the  intervention 
of  an  acute  secondary  diphtheritic  ulceration  of  the  intestine  of  such  an  extent  and 
severity  as  to  preclude  the  possibility  of  recovery. 

Fig.  2 :  a,  amoebse  coli  of  various  sizes  and  shapes ;  a',  amoeba  coli,  with  especially 
delicate  and  numerous  pseudopodia ;  b,  elastic  tissue  remnants  ;  c,  crystals  of  hsematoidin  ;: 
d,  phosphoric  crystals  ;  e,  bismuth  crystals ;  /,  crystals  of  the  fatty  acids  in  combination 
with  magnesium  and  calcium ;  g,  spiral  ducts  of  plant ;  h,  spindle  shaped  trochid  of  plant ; 
i,  red  blood  cells ;  j,  mucus  not  stained  by  bile ;  k,  various  epithelial  cells  of  a  yellow 
hue  from  bile  ;  I,  pus  corpuscles  stained  by  bile  ;  m,  various  masses  of  mucus  and  animal 
debris  stained  by  bile  ;  n,  partially  disintegrated  muscle  fibres  from  meat  diet. 

The  granular  matter  forming  the  bulk  of  the  stool  consists  of  animal  and  vegetable 
debris  and  bacteria,  oil  globules,  etc. 
348 


PLATE   III. 
Fig.  I. 


Fig.  2. 


Fig.  I.  Transverse  Section  of  Colon  near  the  Cscum,  in  a  Case  of  Secondary 
Dysentery  following  the  Amoebic  Form. 
Fig.  2.  Amoebse  Coli  of  various  sizes  and  shapes. 

(Drawing  by  Prof.  A.  J.  Smith,  University  of  Texas,  Galveston.) 


IJII'IITIIEUITKJ  DYSENTERY.  349 

was  a  (lifFiiso  suppiiraticjii  of  the  tissues.  The  grlands  were  broken  down, 
their  oontines  lost,  and  tliev  were  represented  by  irreguhir  masses  of" 
epithelium  surrounded  l)y  pus  cells.  The  ulceration  extended  througii 
the  nuiscularis  mucosa,  sometimes  in  only  very  small  areas  ;  at  others 
the  entire  ulcer  was  seated  in  the  submucosa.  In  such  instances  the 
submucous  tissue  was  somewhat  thickened,  and  the  edjje  of  the  ulcer 
marked  by  granulation  and  pus  cells.  The  pus  cells  extended  deeply 
into  the  submucous  tissue,  sometimes  diifusely  infiltrating  it,  at  others 
collecting  in  groups. 

"  Around  the  vessels  everywhere  there  were  dense  accimiulations  of 
cells,  swollen  connective  tissue  corpuscles,  and  pus  cells.  A  marked 
feature  was  the  very  great  swelling  of  the  connective  tissue  cells  near 
the  ulcers.  They  were  converted  into  large,  irregularly  shaped  masses, 
with  a  large  vesicular  nucleus.  Scattered  through  the  swollen  con- 
nective tissue  were  numerous  masses  of  fibrin.  The  vessels  showed 
an  increase  in  number  and  swelling  of  the  endothelial  cells ;  their 
walls  were  thickened  and  contained  numerous  pus  cells,  as  did  also  the 
lumen." 

As  shown  from  this  description,  the  lesions  in  catarrhal  dysentery 
consist  essentially  in  a  suppurative  inflammation  of  the  mucous  mem- 
brane, whence  it  is  liable  to  extend  into  the  deeper  tissues. 

2.  Diphtheritic  Dysentery. 

Pathological  Axatomy. — It  is  stated  by  AVoodward  that  the 
majority  of  fatal  cases  of  acute  dysentery  in  which  autopsies  were  made 
during  the  American  Civil  War  were  those  in  which  diphtheritic  in- 
flammation was  the  characteristic  morbid  process.  Similar  lesions  have 
been  described  by  English  writers  in  India,  the  French  in  Algeria,  by 
English,  German,  and  Irish  observers  in  those  countries,  as  by  Wood- 
ward and  others  in  America  (Fig.  35  and  Plate  III.  Fig.  1). 

Fig.  35. 


Photo^aph  of  colon  (description  of  Case,  page  548). 

It  appears  to  be  certain  that  the  lesions  of  most  of  the  epidemics 
of  dysentery'  are  those  of  diphtheritic  colitis,  and,  while  diphtheritic 
inflammation  may  complicate  the  catarrhal  and  amcebic  varieties,  it  is  to 


350  DYSENTERY. 

be  regarded  as  a  distinct  form.  In  fact,  most  cases  of  diphtheritic 
dysentery  are  found  to  be  associated  with  catarrhal  inflammation  of 
other  portions  of  the  intestines,  and  this  catarrhal  inflammation  is  some- 
times limited  to  the  colon,  but  more  frequently  involves  the  lower  por- 
tion of  the  ileum  or  may  appear  in  detached  patches  higher  up  in  the 
small  intestines. 

The  diphtheritic  process,  which  in  most  instances  is  to  be  regarded 
as  having  supervened  upon  the  catarrhal  inflammation,  varies  greatly 
in  extent  and  as  to  the  firmness  and  tenacity  of  the  exudation  depend- 
ing upon  the  stage  of  the  process  in  which  death  occurred.  The  exu- 
dation is  sometimes  limited  to  the  descending  colon  and  rectum,  or  to 
the  latter  alone ;  sometimes  it  involves  other  portions  of  the  large  in- 
testine, or  the  whole  of  it,  extending  in  some  instances  into  the  small 
intestine ;  the  exudation  is  in  some  cases  quite  superficial,  lying  as  a 
separable  layer  upon  the  mucous  membrane,  involving  the  outer  epi- 
thelium and  filling  the  follicles  of  Lieberkiihn.  Usually,  however,  in 
portions  of  the  affected  area  a  part  or  even  the  whole  of  the  submucosa 
is  also  involved. 

The  exudation  presents  under  the  microscope  the  characteristics  of 
any  other  croupous  exudation,  showing  a  finely  granular  or  indistinct 
fibrillated  appearance,  which  coagulates  with  various  degrees  of  firm- 
ness, and  entangles  in  the  coagulum  a  variable  number  of  white  blood 
corpuscles.  The  parts  embraced  in  the  exudation  promptly  undergo 
coagulation  necrosis,  the  depth  of  the  slough  depending  upon  the  depth 
of  the  previous  inflammation. 

The  exudation  and  resulting  sloughs  are  primarily  whitish  or  yellow- 
ish in  color,  or  are  often  reddened  by  hemorrhage  or  colored  greenish  or 
black  by  subsequent  changes  in  the  blood.  The  loss  of  substance  pro- 
duced by  separation  of  diphtheritic  sloughs  constitutes  a  form  of  dysen- 
teric ulceration.  The  ulcers  are  of  different  sizes,  and  vary  from  mere 
abrasions  to  deep  excavations  that  expose  or  even  invade  the  muscular 
coat. 

Death  often  ensues  before  sloughing  is  completed,  the  ulcers  present- 
ing no  indications  of  the  separation  process  :  when  the  area  destroyed 
is  not  too  extensive,  the  ulcers  may  cicatrize  and  recovery  take  place, 
or  more  frequently  remain  in  an  indolent  condition,  a  chronic  flux  per- 
sisting, which  after  a  variable  period  proves  ultimately  fatal. 

In  some  instances  the  ulcers  may  perforate  the  serous  coat,  death 
rapidly  resulting  from  peritonitis.  It  is  an  important  pathological  fact 
of  great  significance  in  connection  with  the  prognosis  that  very  exten- 
sive ulcers  from  diphtheritic  sloughing  may  completely  cicatrize  and 
recovery  occur.  The  cicatrices  are  more  or  less  puckered,  and  in  rare 
cases  stricture  of  the  bowel  may  result  from  this  circumstance. 

In  the  early  stages  of  the  diphtheritic  process  the  changes  observed 
in  perpendicular  sections  do  not  materially  differ  from  those  in  catarrhal 
inflammation,  except  that  the  surface  of  the  affected  part  is  coated  with 
a  thin  diphtheritic  layer.  This  layer  consists  essentially  of  the  blood 
fibrin,  which  begins  to  transude  as  soon  as  the  inflammation  is  sufficiently 
intense.  The  behavior  of  the  fibrin  varies  in  accordance  with  its  quality 
and  the  activity  with  which  it  is  poured  out.  It  may  present  almost 
any  degree  of  firmness,  from  a  jelly-like  layer  of  very  slight  cohesion 


AMLEUIC  DYSKyTERY.  351 

to  a  toiio;!!,  firmly  adlioront  mass,  wliicli  ran  be  strictly  called  a  ])scu(l<>- 
inembranc,  eiitan<;l('(l  in  the  substance  of  wliicli  are  variously  lvmj)lioi(l 
elements  (white  l)lood  corpuscles,  j)us  corpuscles,  and  red  bl<»od  cells): 
the  latter  especially  are  prone  to  accumulate  near  the  mucous  surface. 

This  fibrinous  layer  not  only  forms  a  coating  of  variable  thickness 
u])on  the  surface  of  the  mucous  membrane,  but  distends  the  glands  of 
Lieberkiilin,  and  there  is  an  increased  number  of  lymphoid  elements  in 
the  adenoid  tissue  of  the  mucosa,  the  closed  follicles,  and  the  submucous 
connective  tissue,  thus  ensuring  more  or  less  thickening  of  tlie  intestinal 
wall. 

In  the  graver  forms  of  the  diphtheritic  process  the  capillaries  of  the 
mucosa  are  distended  with  blood,  and  hemorrhagic  areas  of  considerable 
size  are  noted  upon  the  superficial  })arts  of  the  mucous  memljrane  and 
in  the  deeper  parts  of  the  diphtheritic  layer.  In  projiortion  to  the 
increasing  severity  of  the  case  the  lymphoid  elements  infiltrate  the  sub- 
mucous tissue,  and  a  granular  material  similar  to  the  surface  exudation 
makes  its  appearance  in  the  lymph  spaces.  Sooner  or  later  during  the 
progress  of  these  alterations  sloughing  sets  in,  just  as  it  does  in  diph- 
theria of  the  pharynx.  The  stage  at  which  sloughing  begins  varies  in 
different  cases  :  in  some  the  tissues  retain  their  vitality  until  the  mucous 
surface  is  coated  with  a  dense  yellow  pseudo-membrane  ;  in  others  at 
an  early  period  the  affected  parts  are  swollen  by  a  rich  albuminous 
exudation  containing  only  a  moderate  amount  of  fibrin  and  cell  elements, 
in  which  sloughing  may  occur  with  great  rapidity  and  destructiveness. 
This  necrosis  is  rapidly  followed  by  putrefactive  changes  in  the  dead 
parts,  which  condition  is  favored  by  the  moisture  and  high  temperature 
of  the  interior  of  the  body. 

Putrefaction  is  manifested  microscopically  by  a  granular  metamor- 
phosis of  all  the  tissue  elements  involved  into  an  unrecognizable  mass 
of  molecular  debris.  If  the  patient  survives"  the  occurrence  of  tissue 
necrosis,  the  sloughs  separate  by  the  ordinary  suppurative  process 
taking  place  adjacent  to  the  boundaries  of  the  necrosed  portions.  The 
depth  of  the  primary  diphtheritic  ulcer  depends  upon  the  depth  of  the 
diphtheritic  infiltration.  The  original  ulcer  may,  how^ever,  extend  both 
in  area  and  depth,  either  by  secondary  sloughing  or  a  true  ulcerative 
process,  the  cell  elements  floating  off  as  pus  corpuscles ;  thus  the 
muscular  coat  may  be  gradually  involved  and  perforation  rapidly  take 
place  by  rupture  of  the  thin  tissue  forming  the  floor  of  the  ulcer. 

3.  Amcebic  Dysentery. 

Pathological  Anatomy. — The  large  intestine  is  chiefly  involved, 
for  the  reason  that  here  the  amoebae  find  favorable  conditions  for  their 
development ;  the  small  intestine  seems  to  be  affected  only  when  there 
is  an  enormous  number  in  the  colon,  from  whence  they  pass  into  the 
ileum.  The  most  striking  characteristic  noticeable  in  all  cases  of  this 
special  anatomical  form  of  dysentery  is  the  great  thickening  of  the 
intestine.  In  some  cases  thickening  involves  all  the  coats ;  in  all  cases 
it  is  more  marked  in  the  submucous  coat,  and  in  some  confined  in  the 
latter.  There  is  not  only  a  general  thickening  due  to  oedema,  but  cir- 
cumscribed thickenings  are  present,  containing  small  ca^^ties  filled  with 


352  DYSENTERY. 

gelatinous  pus.  These  cavities  communicate  with  the  mucous  membrane 
by  a  small  opening.  There  are  also  various  tracts  communicating  with 
neighboring  cavities.  (Plates  IV.  and  V.) 

The  elevated  nodules  vary  in  size :  the  openings  often  are  no  larger 
than  a  pinhead,  or  so  large  that  the  cavity  is  freely  exposed ;  even  then 
the  surrounding  mucous  membrane  is  deeply  undermined,  and  there  are 
often  sinuses  in  the  submucosa  leading  off  from  the  ulcers.  The  latter 
contain  the  same  gelatinous  looking  material  as  the  cavities,  which,  ex- 
amined under  the  microscope  fresh,  show  numbers  of  amcebse,  large 
round  cells,  red  corpuscles,  and  pus  cells. 

Moving  amoebse  are  almost  always  found  if  the  examination  is  made 
soon  enough  after  death.  The  undermined  ulcer  in  connection  with  the 
formation  of  cavities  and  various  tracts  in  the  submucosa  appears  to  be 
the  variety  oftenest  observed,  though  other  forms  of  ulcers  may  be 
present  in  the  same  intestine — e.  g.  Avhen  the  undermined  edges  have 
sloughed  away,  leaving  the  edges  smooth  in  places  and  in  others  only 
slightly  undermined.  These  ulcers  are  most  frequently  met  with  in  the 
last  portion  of  the  transverse  and  descending  colon.  The  submucous 
coat  is  the  one  chiefly  affected ;  it  is  infiltrated  and  oedematous,  not  only 
at  the  site  of  the  ulcers,  but  elsewhere. 

The  ulcers  increase  by  gradual  infiltration  and  softening  of  the  tis- 
sues, with  subsequent  necrosis  of  the  overlying  structures.  The  roof 
covering  in  the  more  or  less  closed  ulcer,  the  softening  continues  at  the 
sides,  and  an  ulcer  with  undermined  ragged  edges  is  found.  The  base 
of  such  ulcers  is  usually  clean  and  is  formed  by  the  muscular  coat ;  the 
latter,  while  it  offers  a  barrier  to  molecular  disintegration,  may  also 
become  necrotic  by  gradual  infiltration  along  the  connective  tissue  septa 
until  the  subserous  coat  is  reached.  During  the  continuance  of  this 
process  the  peritoneum  becomes  greatly  thickened  and  involved  in  a 
similar  destruction. 

The  mucous  membrane  seems  to  suffer  least,  or  rather  the  lesions  in 
this  coat  are  secondary  to  those  of  the  submucosa,  the  process  consisting 
essentially  of  advancing  infiltration  and  softening  in  the  submucous  and 
intermuscular  tissue,  with  subsequent  necrosis  of  the  overlying  tissue. 
Reaction  on  the  part  of  the  tissue  is  shown  in  the  formation  of  granu- 
lation tissue  rather  than  of  pus.  When  suppuration  is  a  prominent  fea- 
ture in  the  process,  it  is  due  not  to  the  action  of  the  amcebse,  but  to  the 
pus  organisms  which  enter  the  tissues.  The  amoebae  can  extend  in  the 
tissue  a  considerable  distance,  which  latter  softens  and  breaks  down, 
resulting  in  the  formation  of  the  large  ulcers  with  soft  undermined 
edges.  Sometimes  there  is  great  undermining  before  breaking  down  of 
the  overlying  tissues,  large  sloughs  thus  resulting.  In  other  cases  the 
amoebse  are  cast  off  with  the  softened  tissue,  leaving  an  ulcer  with 
smooth  sides  and  base,  or  the  suppuration  of  the  tissues  produced  by 
bacteria  may  get  the  upper  hand  and  an  ordinary  suppurating  ulcer 
result,  the  amoebse  being  either  cast  out  by  the  purulent  softening  or 
possibly  destroyed  by  pus  products  or  bacteria,  there  appearing  to  be  an 
antagonism  between  the  amoebae  and  the  suppuration  process. 

Councilman  and  Lafleur  (to  whose  excellent  description  of  the  lesions 
of  this  form  of  dysentery  the  writer  is  indebted,  and  the  reader  is  re- 
ferred for  fuller  details)  state  that,  while  the  lesions  of  amoebic  dysen- 


PLATE    IV. 


^'^. 


# 


« 


^^; 


^^r^l 


'Ju:y^^ 


4. 


Dysenteric  AmoebEe. 

Figs.  1,  2,  and  3,  amccba;  from  a  section  of  intestine  hardened  in  alcohol  and  stained  with 
methyleiie-blue.  In  Figs.  1  and  2  the  granulation  is  very  distinct.  In  Fig.  a  tlie  dark  staining 
at  one  end  is  seen,  which  frequently  shows  as  a  crescent  under  a  lower  power. 

Figs.  4,  5.  G,  7,  8,  and  1.".,  amwba.-  from  sections  of  intestine  and  abscess  of  liver  hardened  in 
stron?  Muller's  fluid  and  stained  with  hamotoxylin  and  eosm.  In  Figs.  4.  6,  and  8  the  nucleus. 
V,  is  very  evident.  In  Fig.  ."i  there  is  a  large  vacuole,  possibly  resulting  from  a  rupture  of  several 
vacuoles.    Figs.  7  and  15  are  examples  of  amcebte  much  smaller  than  the  others. 

(Councilman  and  Lafieur,  Johns  Hopkins  Hospital  Reports,  vol.  ii.  Plate  VII.) 


PLATE   V. 


12 


^ 


v^\ 


10.  13. 


15. 


11.  i4. 


Dysenteric  Amoeba. 

Figs.  9,  10, 11,  12,  13,  and  14  are  from  various  tissues  hardened  in  Flemming's  solution 
In  Figs.  9,  11,  and  12  tlie  central  mass  lias  shranken  from  the  peripherv.    In  Fi<^  li  and  12 
nuclear  detritus  in  the  form  of  small  brightly  staining  rods  is  seen.    In  Fi-s  13  and  14  are  the 
radiate-like  structures  described  in  the  text.    In  Figs.  10  and  13  are  portions  of  the  nuclei  of 
included  cells.    In  Fig.  lo  there  are  included  blood-corpuscles. 

(Councilman  and  Lalieur.  Johns  Hopkins  Hospital  Reports,  vol.  ii.  Plate  VU.) 


.  1  Ma:n ic  d  \ 'setter  \ :  353 

terv  conform  most  closely  to  the  (loscri|)tion  which  lias  been  given  of 
follicular  colitis,  they  found  the  follicles  involved  in  only  one  out  of 
ei_i>;ht  cases,  and  then  it  was  a  passixc  process  and  in  no  case  originating 
in  the  follicles. 

Abscess  of  the  Liver. — As  illustrating  the  frequency  of  this  lesion 
in  amoebic  dysentery,  the  following  facts  are  significant  :  Of  the  12 
cases  reported  by  Dock,  5  tlied,  and  in  4  there  was  abscess  of  the  liver ; 
in  Councilman  and  Lafleur's  series  of  15  cases  8  died,  and  of  these  0 
were  com[)licated  by  hepatic  abscess;  of  the  7  reported  by  the  writer, 
none  of  which  were  fatal,  1  had  abscess  of  the  liver.  Thus,  out  of  34 
cases  11  were  subject  to  this  complication,  and  of  13  fatal  cases  10  had 
abscess  of  the  liver.  These  figures  are  confirmatory  of  the  opinion  that 
the  amoebic  is  the  prevalent  form  of  tropical  dysentery,  for  we  find  (not 
quoting  authorities  or  details)  that  in  India,  Cochin  China,  Algeria,  and 
Egypt  hepatic  abscess  is  discovered  in  1  out  of  about  4  fatal  cases ;  also 
that  in  Cuba,  Brazil,  Chili,  Venezuela,  and  Mexico  liver  abscess  is  of 
great  frequency  in  connection  with  dysentery. 

Not  discussing  here  the  causes  or  modus  operandi  of  liver  complica- 
tions, we  proceed  with  the  anatomical  changes  found  in  this  organ.  The 
commonest  seat  of  abscess  is  the  right  lobe  and  its  lower  border,  corre- 
sponding to  the  hepatic  flexure  of  the  colon  or  the  upper  surface  close  to 
the  suspensory  ligament.  In  the  last  situation  the  abscess  usually  ex- 
tends through  the  diaphragm  into  the  lung. 

The  forms  of  liver  abscess  can  be  divided  into  («)  the  small  very 
acute  variety,  (b)  the  larger  one  with  partially  fibrous  walls,  and  (c) 
the  chronic  abscess  with  hard,  dense  fibrous  walls.  The  microscopic 
character  of  the  abscess  contents  varies.  The  smaller  contains  a  viscid 
translucent  liquid  with  a  few  pus  or  lymphoid  cells,  fatty  granular 
material,  fragments  of  distorted  liver  cells,  a  few  red  blood  corpus- 
cles, and  numerous  amoebse  in  active  motion.  In  the  large  abscess  the 
fluid  is  not  so  clear ;  its  opacity  is  not  due  to  pus  cells,  but  to  fat,  frag- 
ments of  tissue,  and  broken-down  liver  cells.  The  fluid  cannot  properly 
be  called  pus,  as  there  is  a  remarkable  absence  of  well  preserved  cells. 
Amoebae  are  found  scattered  abundantly  through  the  contents  of  the 
abscess,  especially  at  its  periphery  and  in  the  included  portal  tissue.  At 
the  edges  they  are  found  chiefly  in  the  capillaries,  and  usually  do  not 
extend  in  the  tissues  beyond  the  area  of  necrosis. 

Some  abscesses  are  of  microscopic  size,  and  are  not  connected  with 
the  larger  ones  :  in  these  we  find  the  same  process  of  destruction  and 
extension  as  in  the  larger  ones.  Abscess  formation  is  not  the  only 
change,  for  there  is  found  also  a  more  or  less  extensive  necrosis  of  liver 
cells  around  the  centre  veins  which  does  not  appear  to  be  due  to  the 
presence  of  amoebse.  These  organisms  invade  the  already  necrotic 
tissue,  and  appear  to  influence  its  breaking  down  and  liquefaction. 
While  the  more  chronic  abscesses  differ  from  the  acute  in  many  respects, 
they  have  most  features  in  common,  and  the  differences  can  be  explained 
probably  by  the  smaller  number  and  less  intense  action  of  the  amoebae 
and  a  minor  degree  of  diffuse  necrosis  of  the  tissues. 

There  are  certain  abscesses  showing  a  combination  between  those 
with  fibrous  walls  and  the  small  ones  of  recent  formation.  In  these,  por- 
tions of  the  walls  are  distinctly  fibrous  and  other  portions  are  formed 

Vol.  I.— 23 


354  DYSENTERY. 

by  necrotic  tissue,  which  extends  also  into  the  surrounding  liver 
tissue.  Occasionally  in  the  vicinity  are  small  necrotic  foci  with  central 
softening  which  are  isolated  from  the  large  abscesses,  but  become  con- 
nected with  it  by  a  gradual  increase  in  size  and  continuation  of  the 
softening  process  in  both  directions.  Thus  the  chronic  abscesses  increase 
in  size  in  two  ways — first,  by  gradual  extension  with  a  continual  new 
formation  of  fibrous  tissues,  and  secondly,  by  formation  of  separate 
small  abscesses  which  soon  become  a  part  of  the  larger. 

The  smaller  peripheral  foci  may  meet,  and  in  this  way  cut  off  larger 
or  smaller  areas  of  tissue.  The  irregularity  in  the  walls  of  the  large 
abscesses  is  produced  in  this  way.  The  amoebae  are  not  relatively  so 
numerous  in  the  large  as  in  the  small  abscesses ;  often  in  large  sections 
they  are  not  found  at  all.  They  are  usually  to  be  seen  in  the  necrotic 
edges  of  the  abscess  and  in  the  small  foci  adjoining. 

Summing  up  the  changes  in  the  liver  it  appears  that  there  are  two 
classes  of  lesions  :  First,  extensive  necrosis  of  tissue  which  does  not 
appear  to  be  due  to  the  direct  action  of  the  amoebse,  for  the  organisms 
are  not  found  in  them,  and  they  are  too  regular  in  situation  and  extent 
for  such  production.  These  necrotic  lesions  seem  to  be  due  to  the  action 
of  the  soluble  chemical  products  of  the  amoebse  absorbed  from  the  in- 
testinal ulcers.  Second,  abscess  formations  which  we  are  justified  in 
believing  are  due  to  the  direct  action  of  the  amoebse  for  the  following 
reasons :  They  are  invariably  found  in  every  abscess ;  they  are  most 
numerous  in  the  smallest  and  most  recent,  and  in  the  situations  where 
the  abscess  was  extending ;  no  other  organisms  are  found  in  the  smaller 
abscesses  ;  the  few  bacteria  found  in  the  large  ones  do  not  appear  to  have 
any  causal  connection  ;  none  of  the  pus-producing  organisms  are  found  ; 
and,  finally,  the  lesions  are  of  a  different  character  from  those  produced 
by  bacteria. 

Abscess  of  the  Lungs. — Abscess  in  these  organs  secondary  to  ab- 
scess on  the  upper  surface  of  the  liver  was  found  in  3  out  of  6  cases 
by  Councilman  and  Lafleur,  who  observed  the  following  :  Abscesses  of 
the  lung  resembling  those  of  the  liver  in  several  particulars.  They 
were  lined  with  opaque,  ragged  necrotic  material,  which  in  places 
projected  in  large  masses  into  the  cavity.  There  were  also  projec- 
tions from  the  abscess  into  the  surrounding  pulmonary  tissues,  and  by 
union  of  these  large  masses  of  tissue  were  cut  off,  as  in  large  hepatic 
abscesses.  In  a  few  places  the  abscess  wall  was  comparatively  smooth 
and  formed  of  dense  connective  tissue.  In  other  places  there  was  no 
definite  boundary  between  the  necrotic  tissue  lining  the  abscess  and  the 
surrounding  lung  tissue.  These  abscesses  were  usually  empty.  Ex- 
amination microscopically  of  the  contents  clinging  to  the  wall  showed 
granular  detritus,  round  lymphoid  cells,  a  few  pus  cells,  numbers  of  red 
blood  corpuscles,  fat  globules,  and  amoebse ;  also  elastic  fibres  of  pul- 
monary tissue. 

The  lung  tissue  in  the  vicinity  of  the  abscess  showed  the  alveoli  to  be 
small,  and  an  enormous  increase  of  the  interstitial  connective  tissue  was 
noted.  The  bronchi  were  also  altered  :  their  walls  were  thickened,  con- 
taining great  numbers  of  round  cells  ;  some  were  filled  with  fibrin  and  pus 
cells,  while  in  nearly  all  of  them  a  similar  condition  to  that  of  the  alveoli 
was  found  in  the  projection  of  masses  of  connective  tissue  from  the  wall. 


SECONDARV  DYSENTERY.  355 

Tlio  amoeba}  varied  in  niunbers  in  different  cases  and  in  different 
parts  of  the  same  abscess ;  they  were  especially  nnmerous  in  places 
where  the  abscess  was  rapidly  advancing,  and  where  there  was  no  dis- 
tinct wall  ;  they  were  also  numerous  in  the  tissues  around  the  abscess, 
decreasinu-  as  the  distance  from  the  abscess  increased.  They  were  also 
found  in  the  wall,  epithelium,  and  lumen  of  the  bronchi  near  the  abscess. 

In  the  production  of  both  \\\w^  and  liver  abscess  the  action  of  the 
amoeba"  is  similar :  they  act  by  causing  a  necrosis  and  liquefaction  of 
the  tissue ;  the  peculiarity  of  their  action  and  the  difference  which  dis- 
tinguishes these  effects  from  those  of  bacteria  consist  in  the  general 
absence  of  acute  inflammatory  reaction  on  the  part  of  the  surrounding 
tissues.  In  all  cases,  in  the  intestines,  liver,  and  lungs,  unless  there  is 
a  complication  in  the  presence  of  pus-producing  bacteria,  there  is  an 
absence  of  suppuration.  The  extension  of  the  lung  abscess  into  the  sur- 
rounding tissue  is  probably  due  to  the  entry  of  the  amoebae  by  means  of 
bronchi  bordering  on  the  abscess. 

It  is  highly  probable  that  the  amoebae  reach  the  large  intestine 
chiefly  through  the  drinking  water  :  food  is  less  likely  to  be  the  source 
of  infection,  as  the  organisms  Avould  be  destroyed  in  the  process  of 
cooking.  No  action  is  exerted  by  them  upon  the  stomach  or  small  in- 
testine, as  they  do  not  find  here  suitable  conditions  for  their  increase, 
but  in  the  colon,  finding  a  favorable  soil,  they  multiply  rapidly,  and, 
aside  from  the  production  of  definite  ulceration,  we  have  evidence  of 
their  causing  a  superficial  necrosis  and  softening  of  the  epithelium,  an 
increased  secretion  of  mucus  from  the  epithelial  cells,  and  cysts  of  the 
mucous  membrane  from  the  dilatation  of  glands  whose  mouths  have 
been  plugged  from  the  accumulation  of  mucus. 

The  question  arises  as  to  the  routes  by  Avhich  hepatic  and  pulmonary 
metastases  take  place.  The  evidence  seems  to  show  that  in  most 
instances  the  amoebae  reach  the  liver  by  passing  through  the  intestine, 
entering  the  organ  directly  from  the  hepatic  flexure  of  the  colon,  or, 
wandering  along  the  upper  surface  of  the  liver  in  the  abdominal  cavity 
beneath  the  diaphragm  they  may  cause  peritonitis,  or,  as  is  more  likely, 
produce  no  effect  upon  the  peritoneum.  There  may  be  infection  through 
the  bloodvessels  also,  as  shown  in  cases  where  there  is  formation  of 
small  multiple  abscesses  both  on  the  surface  and  through  the  liver  tissue. 
•Abscess  of  the  lung  appears  to  result  from  a  direct  extension  through 
the  diaphragm  from  the  liver,  as  it  is  usually  found  in  that  portion  of 
the  lower  lobe  of  the  right  lung  which  is  in  contact  with  the  diaphragm. 

4.  Secondary  Dysentery. 

Pathological  Anatomy. — The  lesions  of  this  form  of  dysentery 
are  usually  those  of  diphtheritic  colitis,  previously  described.  In  some 
cases  there  may  be  only  a  thin  superficial  infiltration  of  the  upper  laver 
of  the  mucosa  in  localized  regions,  especially  along  the  ridges  and  folds 
of  the  colon,  often  extending  into  the  ileum.  In  severe  forms  the  entire 
mucosa  may  be  involved  and  necrotic,  often  having  a  rough  granular 
appearance.  In  that  form  which  occurs  in  connection  with  pneumonia 
the  exudation  may  consist  of  a  firm  white  pellicle  which  seems  to  lie 
upon,  and  not  within,  the  mucous  membrane. 


356  DYSENTERY. 

Follicular  Ulceration. — A  great  deal  has  been  written,  especially 
by  older  authorities,  upon  the  subject  of  follicular  dysentery,  A  careful 
study  of  the  results  of  autopsies  and  comparison  of  the  clinical  histories 
will'show  that  the  lesions  in  a  majority  of  these  cases  correspond  to  the 
description  of  amoebic  dysentery  as  herein  given. 

In  the  cases  cited  by  Woodward  as  acute  or  "  Chickahominy 
diarrhoea "  he  thus  describes  the  lesions  :  "  In  some  of  the  fatal  cases 
of  acute  diarrhoea  the  only  intestinal  lesion  observable  with  the  naked 
eye  was  a  reddish  discoloration  of  the  mucous  membrane,  which  for  the 
most  part  occurred  in  patches  of  various  dimensions  from  a  few  inches 
to  several  feet  in  length.  Such  patches  were  observed  in  all  parts  of 
the  intestinal  canal,  but  were  more  common  in  the  ileum  than  in  the 
jejunum,  and  were  still  more  frequent  in  the  colon,  where  they  particu- 
larly affected  the  ceecum  and  sigmoid  flexure.  Microscopical  examina- 
tions of  these  reddened  patches  showed  their  color  to  be  due  either  ta 
an  engorgement  of  the  small  vessels  with  blood,  to  transudation  of  its 
coloring  matter,  or  to  actual  hemorrhage  into  the  mucous  or  submucous 
layer,  or  to  a  combination  of  these  conditions.  In  the  majority  of  cases 
the  solitary  follicles  situated  in  the  reddened  patches  were  more  or  less 
enlarged ;  the  most  common  condition  being  that  in  which  they  had 
attained  the  size  of  pinheads  and  appeared  as  whitish  or  yellowish 
elevations  surrounded  by  a  circlet  of  increased  vascularity.  In  the 
colon  these  minute  elevations  were  generally  sessile  ;  in  the  small  intes- 
tine they  often  had  constricted  necks  and  projected  from  the  surface  of 
the  mucous  membrane. 

The  question  arises,  How  many  of  these  cases  in  which  there  is 
follicular  inflammation  proceed  to  ulceration,  and  how  many  which  have 
been  described  as  follicular  ulceration  are  really  such?  It  is  natural,, 
upon  seeing  enlarged  follicles  in  certain  cases  and  in  others  small 
nodular  ulcers,  to  regard  the  latter  as  coming  by  gradual  transition  from 
the  former.  But,  as  we  have  seen  in  the  amoebic  form,  ulceration  does 
not  begin  in  the  follicles,  and  when  they  are  afiected  it  is  only  in 
common  with  the  other  tissues  in  the  submucous  coat. 

POST-MOETEM    APPEARANCES    IN    ChRONIC    DySENTERY. — Wood- 

ward  divides  the  lesions  of  those  dying  from  chronic  fluxes  into  three 
groups,  which  may  exist  either  singly  or  variously  combined  : 

(1)  Chronic  inflammation  of  the  mucous  and  submucous  coats  of  the 
intestines,  especially  of  the  colon  without  ulceration. 

(2)  Chronic  inflammation  accompanied  by  follicular  or  other  ulcers,, 
especially  in  the  large  intestine ;  in  these  cases  the  pathological  picture 
is  often  complicated  by  the  development,  just  before  the  fatal  issue,  of 
diphtheritic  inflammation  between  the  ulcers. 

(3)  Extensive  ulceration  of  the  large  intestine,  the  result  of  slough- 
ing during  a  previous  attack  of  acute  diphtheritic  dysentery. 

To  these  three  groups  may  be  added  a  fourth — viz.  (4)  Catarrhal 
dysentery,  becoming  chronic  and  attended  by  a  form  of  ulceration- 
differing  from  the  amoebic  and  diphtheritic. 

(1)  In  the  first  group,  chronic  inflammation  without  ulceration,  we 
find  that  the  bright  red  discolorations  of  acute  inflammation  are  replaced 
by  mahogany  red,  brown,  green,  slate  color,  ash  color,  or  other  neutral 
tints  of  various  hues.     Black,  bluish,  or  brownish  deposits  of  pigment 


ACUTE  CATARRHAL   DYSESTERY.  357 

are  observed  in  llie  closed  follicles  or  in  patches  scattered  over  the 
mucous  membrane  of  both  large  and  small  intestines,  and  in  the  apices 
of  the  villi  of  the  latter,  especially  of  the  ileum.  With  these  modifica- 
tions of  color  enlargement  of  the  solitary  follich's,  and  more  or  less 
thickening  of  the  mucous  membrane  and  sul)mucous  connective  tissue, 
especially  of  the  large  intestine,  are  associated.  The  degree  of  this 
thickening  varies  witii  the  duration  and  severity  of  the  case. 

(2)  The  second  group  of  cases,  including  those  of  chronic  inflamma- 
tion accompanied  by  follicular  or  other  ulcers,  can  be  properly  classitied 
with  the  ain(el)ic  form.  Confirmatory  of  this  view,  Councilman  and 
Lafleur  stati'  that  they  examined  the  colon  specimens  in  the  Army 
Medical  Museum  at  Washington,  many  of  the  specimens  represented 
among  the  illustrations  in  Woodward's  book,  picking  out  those  which 
seemed  to  represent  the  amoeba  forms,  and  on  consulting  the  histories 
of  the  cases  found  in  each  a  clinical  history  corresponding  to  amcebic 
dysentery. 

The  writer,  who  has  had  under  observation  a  larger  or  smaller  num- 
ber of  cases  of  chronic  dysentery  for  the  past  twenty  years  in  the  hos- 
pitals of  Galveston,  is  confident  in  the  light  of  present  knowledge  that 
most  of  such  cases  belong  to  the  amoebic  variety. 

(3)  The  third  group  of  lesions  in  chronic  dysentery  are  those  where 
there  is  extensive  ulceration  of  the  large  intestine  succeedino^  an  attack 
of  the  acute  diphtheritic  form.  As  a  description  of  the  morbid  anat- 
omy of  such  cases  has  already  been  given,  it  will  be  unnecessary  to 
repeat  it  here. 

(4)  Ulceration  follo^ving  acute  catarrhal  dysentery  has  also  been 
described.  In  these  last  two  groups  the  patient  is  gradually  exhausted 
by  a  long  process  of  suppuration  taking  place  from  the  unhealed  ulcers, 
or  is  rapidly  carried  off  by  the  supervention  of  an  acute  diphtheritic  in- 
flammation of  the  large  intestine. 

1.  Acute  Catarrhal  Dysentery. 

Symptoms  axd  Clixical  CorESE. — This  form  of  dysentery  often 
occurs  during  the  progress  of  an  ordinary  acute  diarrhcea  after  the  latter 
has  lasted  a  few  days  or  weeks,  or  it  begins  as  an  independent  affection, 
frequently  coming  on  after  more  or  less  protracted  constipation.  In  the 
latter  event  it  is  usually  preceded  by  a  sense  of  malaise,  with  uneasiness 
in  the  abdomen,  resembling  the  sensations  incident  to  indigestion. 
These  are  succeeded  by  abdominal  griping,  accompanied  by  a  desire  to 
go  to  stool.  The  dejections  are  at  first  feculent  and  copious,  though  not 
infrequently  they  are  scanty,  mucous,  and  without  fecal  admixture  from 
the  beginning.  It  is  only  in  rare  cases  that  this  mild  form  of  the  dis- 
ease begins  Avith  a  rigor  followed  by  fever,  as  is  common  in  the  diph- 
theritic form.  When  catarrhal  dysentery  supervenes  upon  diarrhoea  the 
stools  sometimes  suddenly  acquire  the  dysenteric  characters ;  usually, 
however,  the  latter  ai-e  gradually  developed.  These  characteristics  are 
as  follows  :  At  intervals  griping  abdominal  pains  occur,  generally  in  the 
umbilical  region,  but  often  extending  along  the  course  of  the  ascending 
and  descending  colon,  and  accompanied  by  a  dull  pain  in  the  loins.  The 
pains  resemble  those  of  acute  diarrhoea,  but  are  usually  more  severe. 


358  DYSENTERY. 

They  are  accompanied  or  followed  by  an  urgent  desire  to  expel  the  con- 
tents of  the  bowels,  but  the  spasmodic  efforts  that  ensue  are  only  suc- 
cessful in  expelling,  after  prolonged  straining,  a  little  mucus  or  muco- 
pus,  which  may  or  may  not  be  mixed  with  blood.  This  scanty  dis- 
charge is  not  followed  by  the  sense  of  relief  which  is  noted  after  the 
discharge  in  acute  diarrhoea,  but  painful  sensations  remain  in  the  rectum 
and  anus  even  after  a  lull  has  taken  place  in  the  repeated  expulsive 
efforts.  The  term  tormina  has  been  long  in  use  to  describe  the  griping 
abdominal  pains  ;  the  painful  expulsive  efforts  are  called  tenesmus.  The 
paroxysms  of  tormina  and  tenesmus  vary  in  frequency  according  to  the 
severity  of  the  attack,  from  half-hourly,  hourly,  or  longer  intervals  to 
every  few  minutes.  In  some  instances  they  occur  so  often  that  the 
patient  is  hardly  able  to  leave  the  closet.  Notwithstanding  the  violence 
of  these  local  symptoms,  there  is  usually  at  first  but  little  constitutional 
disturbance.  The  appetite  is  fair ;  there  is  no  complaint  of  thirst ;  the 
pulse  is  but  slightly  increased  in  frequency ;  the  temperature  is  normal ; 
but  usually  there  is  a  sense  of  weakness,  causing  the  patient  to  prefer 
the  recumbent  posture.  After  a  few  days,  however,  there  is  more  or 
less  complete  anorexia,  coated  tongue,  nausea,  sometimes  vomiting  and 
slight  fever,  the  temperature  rarely  exceeding  100—101°  F.  The  par- 
oxysms of  tormina  and  tenesmus  are  usually  not  so  frequent  in  the 
morning  hours,  but  increase  in  number  during  the  afternoon  and 
through  the  night.  The  pain  and  loss  of  sleep  produce  debility,  rest- 
lessness, and  other  evidences  of  nervous  disorders.  The  disease  now 
may  take  one  of  these  directions :  (a)  The  symptoms  may  moderate 
and  convalescence  ensues ;  (6)  they  may  become  aggravated,  and  the 
case  assumes  the  character  of  diphtheritic  dysentery ;  or  (c)  they 
may  persist  with  fluctuations  of  intensity  and  gradually  pass  into  a 
chronic  flux. 

In  the  milder  cases,  which  constitute  the  majority,  convalescence 
begins  about  a  week  from  the  time  the  stools  become  distinctly  dysen- 
teric. As  the  case  progresses  toward  recovery  the  paroxysms  of  tor- 
mina and  tenesmus  become  less  frequent  and  painful :  the  surest  sign 
of  approaching  convalescence  is  the  reappearance  in  the  stools  of 
fecal  matter.  The  passage  of  hard  fecal  lumps  (scybala)  is  not  infre- 
quent in  the  early  stages,  or  they  may  occur  subsequently  from 
having  been  collected  in  the  pouches  of  the  colon  without  being  of 
favorable  import,  but  when  the  muco-purulent  and  bloody  stools  are 
replaced  by  those  of  a  semifluid  fecal  character,  we  may  expect  a 
speedy  recovery. 

In  the  American  Journal  of  the  lledical  Sciences  for  July,  1875, 
Austin  Flint  published  an  important  contribution  upon  the  natural  his- 
tory of  acute  dysentery,  consisting  of  a  report  of  10  cases  observed  with- 
out medicinal  treatment.  From  the  analysis  of  these  he  concludes  :  (1) 
"  The  disease  in  a  temperate  latitude  tends,  without  treatment,  to  recov- 
ery ;  (2)  it  is  a  self-limited  disease,  and  its  duration  is  but  little,  if  at 
all,  abridged  by  methods  of  treatment  now  and  heretofore  in  vogue ; 
(3)  convalescence  is  as  rapid  when  active  measures  of  treatment  have 
not  been  employed  as  in  cases  actively  treated  ;  (4)  relapses  do  not  occur 
in  cases  in  which  the  disease  has  been  allowed  to  pursue  its  own  course 
without  active  treatment ;  (5)  sporadic  dysentery  in  a  temperate  climate 


DIPHTHERITIC  DYSENTERY.  359 

does  not  eventuate  in  a  chronit-  I'urni  ul"  llu-  disease."  All  of  tiie  1(J 
cases  ended  in  recovery.  The  most  protracted  one  lasted  twenty-one 
days,  of  which  fourteen  were  occu])ied  by  the  prcliininary  diarrhd'a. 
The  shortest  ease  lasted  six  days,  'riic  averai>;e  duration,  excliKlin^-  the 
one  with  prcliniinaiy  diarrh(ea,  was  about  ten  days. 

While  these  observations  of  Flint  are  of  ^reat  value  as  slinwin^ 
the  course  of  the  disease  when  uninfluenced  by  treatment,  and  while 
it  is  doubtless  true,  as  stated  by  George  B.  Wood,  that  in  the  vast 
majority  of  eases  the  disease  takes  this  favorable  turn,  yet  when  a  larger 
nund)er  of  cases  are  observed  it  will  be  found  that  some,  after  run- 
ning the  course  as  above  outlined  for  one  or  two  weeks,  pass  into 
the  diphtheritic  form.  Others  without  the  latter  complication  are 
accompanied  by  severe  symptoms  of  constitutional  disturbance,  from 
impaired  digestion,  rapid  emaciation,  exhaustion,  and  possibly  death. 
Still  other  cases  mav  gradually  assume  the  characters  of  a  chronic 
flux. 

Vesical  tenesmus  and  prolapsus  ani  may  accompany  simple  catarrhal 
dysentery,  but  are  less  frequent  and  intense  than  in  the  diphtheritic 
form. 

Proctitis. — Cases  are  not  infrequent  which  present  many  of  the 
symptoms  as  above  outlined  where  the  inflammatory  process  is  limited  to 
the  rectum.  Proctitis,  as  this  condition  is  called,  may  be  acute  or  chronic, 
and  may  depend  upon  a  multitude  of  causes.  The  acute  forms,  as  pre- 
viously mentioned,  may  be  due  to  dietetic  errors.  There  are  some  persons 
in  whom  the  rectum  appears  to  be  the  pars  minoris  resistentke.  Dysen- 
teric symptoms  in  such  individuals  may  follow  the  ingestion  of  articles 
of  food  which  in  others  would  be  entirely  innocuous,  or  irritant  foods, 
which  in  most  persons  would  be  follow^ed  by  a  simple  diarrhcea,  in  them 
produces  a  proctitis.  Traumatic  influences  of  various  kinds  play  an 
important  role.  Among  the  more  common  of  such  causes  are  the  pres- 
ence of  foreign  bodies,  impaction  of  fecal  masses,  intestinal  parasites, 
abnormal  sexual  intercourse,  careless  use  of  instruments,  etc.  The  con- 
dition is  also  often  consecutive  to  other  abnormal  processes  of  the  rec- 
tum and  neighboring  organs — e.  g.  hemorrhoids,  polypoid  growths,  pro- 
lapsus, cancer,  stricture,  gonorrhoea,  uterine  and  periuterine  inflammation. 
The  long  continuance  of  any  of  these  factors  may  result  in  chronic 
inflammation  and  ulceration  of  the  rectum,  as  well  as  of  suppuration  in 
the  perirectal  tissues.  The  enumeration  of  these  causes  emphasizes  the 
necessity  in  all  cases,  when  the  symptoms  point  to  the  rectum  as  the  seat 
of  the  disease,  of  making  a  careful  physical  examination  by  touch  and 
speculum,  as  a  removal  of  the  cause  constitutes  the  most  important  indi- 
cation for  treatment,  and  is  alone  in  many  instances  sufiicient  to  eflect  a 
cure.  As  proctitis  is  fully  described  in  special  treatises,  it  is  not  neces- 
sary to  enlarge  upon  the  subject  here. 

2.  Diphtheritic  Dysentery. 

Symptoms  and  Clinical,  Course. — This  form  may  begin  in  four 
different  ways  :  1.  It  may  have  been  preceded  by  the  symptoms  as  above 
described  of  a  simple  inflammatory  dysentery.  2.  In  numerous  cases  it 
may  be  abruptly  developed  during  the  process  of  a  chronic  flux.     3.  A 


360  DYSENTERY. 

primary  diphtheritic  dysentery  may  occur  without  having  been  preceded 
by  any  preliminary  catarrhal  stages.  4.  It  may  occur  in  a  secondary 
form  after  various  acute  and  chronic  diseases,  mth  an  absence  of  bowel 
symptoms  or  a  diarrhoea  consisting  of  three  or  four  large  movements 
during  the  day  or  perhaps  the  joassage  of  a  little  blood  and  mucus. 
Those  cases  beginning  as  an  acute  catarrhal  dysentery,  instead  of  pursu- 
ing the  ordinary  course  toward  recovery,  as  above  outlined,  exhibit  a 
more  or  less  gradual  aggravation  of  all  of  the  symptoms.  The  patient 
grows  more  emaciated,  becomes  very  weak,  and  eventually  sinks  into  a 
condition  of  collapse,  with  cool  surface  and  extremities  and  greatly 
enfeebled  heart  action.  As  the  disease  progresses  the  tongue  becomes 
brown  and  dry  or  smooth,  red,  and  dry,  sometimes  fissured  ;  the  anorexia 
and  thirst  become  extreme ;  the  abdomen  tender  to  the  touch  and  often 
distended  with  flatus ;  the  skin  is  sallow  or  slightly  jaundiced ;  the 
expression  is  anxious ;  the  eyes  appear  sunken  and  acquire  a  vacant 
expression.  Pari  jmssu  with  these  symptoms  there  is  a  change  in  the 
character  of  the  stools,  which  at  first  consist  of  stringy  mucus,  more  or 
less  mingled  with  blood  and  pus,  but  now  contain  a  quantity  of  yellowish 
or  reddish  masses  of  various  sizes,  which  upon  microscopic  examination 
are  seen  to  be  necrosed  particles  of  the  diphtheritic  exudation.  The 
mucus  or  muco-pus  of  the  stools  is  now  mingled  with  a  thin  reddish 
serum,  which  sometimes  entirely  replaces  it.  In  this  fluid  the  pieces  of 
necrosed  membrane  float,  giving  the  passages  the  appearance  of  raw 
meat  minced  and  mixed  with  bloody  Avater.  The  stools  have  a  charac- 
teristic cadaveric  odor.  About  this  time  the  skin  around  the  anus  is  apt 
to  become  excoriated ;  prolapsus  ani  is  likely  to  occur  from  the  extreme 
tenesmus.  The  patient  also  complains  of  strangury  and  vesical  tenes- 
mus. The  urine  is  generally  decreased  in  amount,  is  of  high  color  and 
specific  gravity,  and  is  occasionally  albuminous. 

Notwithstanding  the  extreme  exhaustion,  the  patient  often  survives 
till  the  end  of  the  second,  third,  or  even  fourth  week  from  the  com- 
mencement of  the  dysenteric  symptoms.  Death  in  the  third  or  fourth 
week  is  apt  to  be  the  result  in  cases  presenting  the  above-mentioned 
characteristics.  Usually  a  few  days  before  the  fatal  ending  the  stools 
become  brownish  or  black  and  of  a  very  offensive  putrid  odor;  they 
also  often  contain  larger  fragments  than  before  of  necrosed  mucous 
membrane,  though  this  is  not  uniformly  the  case.  Those  cases  which 
are  not  preceded  by  diarrhoea,  but  begin  as  dysentery  from  the  first,  pur- 
sue a  similar  course  to  that  above  sketched.  Not  infrequently  they  begin 
with  a  chill,  followed  by  fever  and  the  onset  of  the  abdominal  symptoms ; 
the  temperature  is  usually  higher  than  in  the  type  just  descriljcd.  Pro- 
nounced nervous  symptoms  are  not  unusual — headache,  delirium,  flushed 
dusky  face,  and  subsultus  tendinum.  The  fever  passes  into  a  typhoid 
form,  with  sordes  upon  the  teeth,  a  rapid  weak  pulse,  110—140,  and  a 
continued  high  temperature.  Those  cases  which  begin  with  an  active 
fever  frequently  pass  into  a  condition  of  collapse,  with  slight  elevation 
of  temperature,  cool  surface,  and  a  pulse  which,  though  full,  is  but  little 
accelerated  or  slower  than  usual. 

When  diphtheritic  dysentery  is  developed  during  the  progress  of  a 
chronic  flux,  it  is  apt  to  occur  suddenly  and  prove  rapidly  fatal,  the 
patient  being  already  exhausted  from  the  chronic  disorder,  and  probably 


AMCEBIC  DYSENTERY.  361 

in  tv  state  of  excessive  cmaciiition.  After  some  exposure  to  cold,  intein- 
jHTance  in  eatinji;  or  (Irinkinj:;,  and  often  without  any  assi<rnal)le  cause, 
the  stools  suddenly  :i('(|nii'('  the  diplithci-itic  characters,  accompanied  by 
more  or  less  fever,  and  rapidly  iollowcd  by  fatal  c(>lla[)sc. 

In  the  m<n*e  j)rotracted  ceases  the  disease  ])ursues  a  less  iniiform  course. 
There  are  periods  of  improvement  succeeded  by  rela])ses  at  irregular 
intervals.  During  the  time  when  the  patient  is  better  the  stools  are 
found  to  contain  more  or  less  fecal  matter,  semi-consistent,  mixed  with 
the  blood,  pus,  and  mucus.  During  the  })eriods  of  aggravation  feculent 
matter  again  disappears.  Such  cases  may  end  in  recovery  in  from  one 
and  a  half  to  two  months,  may  prove  fatal,  or  pass  into  a  chronic  dys- 
entery of  indefinite  duration.  Convalescence  is  likely  to  be  a  tedious 
process  in  any  event,  and  more  so  in  proportion  to  the  violence  and 
<luration  of  the  disease  and  the  extent  of  exhaustion  of  the  patient's 
vitality.  The  bowels  are  left  in  a  condition  of  extreme  sensitiveness, 
Avhen  the  slightest  disturbing  cause,  as  a  trifling  imprudence  in  diet, 
•exercise,  or  changes  in  the  weather,  will  bring  on  a  relapse. 

The  clinical  picture  above  outlined  may  be  modified  by  various  com- 
plications which  are  likely  to  occur,  as  malarial  fever,  scurvy,  typhoid 
fever,  or  some  intercurrent  inflammation.  These  complications  will  be 
considered  subsequently  in  detail. 

3.  Amcebic  Dysentery. 

Symptoms  and  Clinical  Course. — This  form  of  dysentery  may 
he  divided  into  four  groups  : 

1.  Comparatively  mild  cases  ; 

2.  Grave,  gangrenous,  or  typhoid  forms  ; 

3.  Chronic  forms ; 

4.  Masked  forms. 

It  should,  however,  be  borne  in  mind  that  this  classification,  which 
is  essentially  the  same  as  propounded  by  Dutroulau  and  others,  is 
purely  arbitrary,  and  is  introduced  only  to  facilitate  description.  Cases 
will  be  observed  to  pass  from  one  grade  of  severity  to  another.  Mild 
cases  may  become  severe  or  gangrenous ;  all  forms  are  more  or  less 
disposed  to  become  chronic. 

Masked  forms  may  have  their  true  nature  exposed  by  an  explosion 
of  dysenteric  symptoms  or  be  recognized  only  at  the  autopsy. 

Amoebic  dysentery  is  characterized  by  a  variable  mode  of  onset,  an 
irregular  course,  marked  by  alternate  intermissions,  exacerbations,  and 
a  decided  tendency  to  chronicity.  The  onset  may  be  abrupt  or  gradual 
in  the  first  instance  :  without  premonition  the  patient  is  seized  with 
colicky  pains  in  the  abdomen  and  diarrhoea ;  nausea  and  vomiting  may 
or  may  not  be  present ;  in  most  cases  there  is  no  fever.  The  stools  are 
frequent  and  watery ;  blood  may  or  may  not  be  present  at  first,  but 
subsequently  blood  and  mucus  are  both  likely  to  be  found.  In  some 
■cases,  after  a  variable  period  of  slight  ill  health,  a  diarrhoea  sets  in,  the 
stools  are  watery,  contain  more  or  less  mucus ;  blood  is  either  absent  or 
only  occasionally  present. 

There  are  a  certain  number  of  cases  where  the  abdominal  symptoms 
are  either  entirely  absent   or  so  obscure  as  to  escape  attention  until 


362  DYSENTERY. 

perhaps  the  occurrence  of  hepatic  or  hepato-pulmonary  abscess  suggests 
the  probabihty  of  amoebic  dysentery.  Ilkistrative  of  the  comparative 
frequency  of  such  instances  is  the  fact  noted  by  Dock,  when  out  of  12 
cases  in  only  6  was  there  a  history  of  dysentery,  in  2  it  might  have 
been  ehcited  by  careful  examination ;  in  4  there  was  an  entire  absence 
of  such  history ;  in  2  the  autopsies  revealed  the  fact  that  the  lesions 
were  limited  to  the  caecum,  which  partly  explained  the  absence  of 
dysenteric  symptoms.  In  one  of  the  cases  reported  by  the  writer  the 
discovery  of  a  liver  abscess  containing  amoebae  first  led  to  the  suspicion 
of  dysentery.  There  are  doubtless  cases  where,  the  intestinal  lesions 
having  healed,  the  disease  can  only  be  recognized  by  its  sequelae  and 
complications. 

The  course  of  the  disease  is  characterized  in  most  instances  by  an 
irregularity  in  the  dysenteric  symptoms  irrespective  of  the  mode  of 
onset.  At  irregular  intervals  there  are  intermissions,  followed  by  ex- 
acerbations without  apparent  cause  ;  the  delusive  hope  is  often  entertained 
that  the  abatement  of  symptoms  is  the  result  of  treatment,  and  that  a 
genuine  convalescence  is  at  hand,  when  suddenly  the  stools  acquire  the 
dysenteric  characteristics  in  such  an  aggravated  way  as  to  speedily 
dispel  such  delusions. 

There  are  other  cases,  again,  remarkably  uniform  and  only  marked 
by  an  obstinate  looseness  of  the  bowels :  the  condition  hardly  deserves 
to  be  called  diarrhoea,  as  the  stools  are  semi-consistent,  perhaps  contain- 
ing no  blood  or  only  a  little  blood  and  mucus,  the  invariable  presence 
of  the  amoebae,  however,  showing  the  true  nature  of  the  disease.  Even 
the  gangrenous  cases,  while  there  are  no  actual  intermissions,  show 
periods  of  partial  abatement  followed  by  exacerbations.  The  tendency 
to  chronicity  is  well  marked  in  most  cases  ;  those  complicated  by  extreme 
sloughing  or  a  severe  typhoid  condition  are  the  exceptions,  and  are  apt 
to  terminate  by  death  in  two  or  four  weeks.  The  milder  cases  in  Coun- 
cilman and  Lafleur's  series  show  a  wide  range  of  duration,  varying  from 
six  to  thirteen  weeks.  Those  coming  under  the  writer's  observation  all 
assumed  a  chronic  character,  and  those  which  recovered  lasted  from 
three  to  four  months. 

A  clearer  idea  of  the  symptomatology  of  this  form  of  dysentery  will 
be  obtained  by  presenting  a  brief  analysis  of  its  most  important  features. 
General  Condition. — The  milder  cases  will  be  found  in  some  such 
condition  as  follows :  More  or  less  muscular  debility  and  emaciation,, 
both  varying  in  degree  according  to  duration  and  severity.  In  the 
writer's  series  the  loss  of  flesh  was  rapid  and  excessive.  The  mucous- 
membranes  are  pale,  decubitus  indifferent.  Expression  dull,  mind  clear. 
Skin  dry  and  sallow.  Tongue  pale  and  flabby,  moist,  and  slightly 
furred.  Abdomen  of  normal  appearance  or  sometimes  retracted.  Tem- 
perature normal  or  only  slightly  elevated.  Pulse  70  to  90.  Respira- 
tion 18  to  30.  More  or  less  anorexia.  Rest  disturbed  by  disposition 
to  evacuate  the  bowels.  Graver  cases  show  a  modification  of  this 
clinical  picture :  the  evidences  of  prostration  are  more  marked ;  the 
face  may  be  drawn,  slightly  cyanotic  or  flushed,  and  the  expression 
anxious.  The  anorexia  is  increased ;  intense  thirst  and  sleeplessness 
are  apt  to  occur.  The  abdomen  becomes  retracted  ;  there  may  be  free 
sweating.     The  temperature  may  become  subnormal,  the  pulse    small 


AMCEBIC  DYSEyTKRY.  363 

and  rapid,  the  respirations  proportionately  increased  in  frequency.  In 
the  chronic  cases  the  progressive  emaciation  and  ana'niia  are  notable 
features,  the  skin  in  conseciuence  heconiino;  dry,  harsh,  and  of  a  dtdl 
yellowish  color.  Aiunniit  has  been  noted  by  all  observers;  there  is  a 
deticiency  both  of  corpuscles  and  luvnioglobin,  which  is  due  to  a  com- 
bination of  causes — viz.  continuous  losses  of  blood  and  albumin,  malnu- 
trition, and  destruction  of  red  corpuscles  by  the  ama'bic.  Diarrluea  is 
the  chief  and  in  st)me  instances  the  only  feature  of  the  disease.  It 
varies  greatly  in  character  and  in  frequency  of  the  stools  according  to 
the  extent  of  the  intestinal  lesions,  and  at  different  times  in  the  same 
case.  The  occurrence  of  intermissions  and  exacerbations  as  a  special 
characteristic  has  already  been  noted.  The  exacerbations  often  begin 
suddenly  and  subside  in  the  same  way  :  they  may  last  from  one  to  ten 
davs,  becoming  progressively  worse  and  of  longer  duration  in  fatal 
cases.  The  intermissions  show  a  wide  range  of  duration,  varying 
from  one  day  to  three  weeks,  during  which  time  the  stools  are  soft  or 
even  formed,  but  with  more  or  less  adherent  mucus.  The  stool.^  vary 
greatly  in  frequency,  amount,  and  character,  not  only  in  accordance  with 
the  severity  of  the  intestinal  ulceration,  but  from  day  to  day  in  indi- 
vidual cases.  In  the  gangrenous  form  there  may  be  as  many  as  thirty 
or  forty  during  twenty-four  hours,  subsequently  declining  to  eight  or 
twelve,  and  three  or  four  toward  the  end  in  fatal  cases.  The  amount 
expelled  at  each  movement  is  at  first  small,  and  often  consists  of  clear 
or  turbid  mucus,  more  or  less  mixed  with  blood  and  sometimes  small 
fecal  masses.  As  ulceration  advances  the  dejections  become  more 
copious  and  watery  ;  blood  is  less  frequently  observed,  but  small  shreddy 
particles  of  grayish  or  light  yellow  color  appear,  mixed  with  Ijlood- 
stained  mucus.  When  extensive  sloughing  is  occurring  the  stools  are 
grayish,  greenish,  reddish-brown,  or  variegated  in  color,  quite  liquid  or 
pultaceous,  and  have  a  very  offensive  odor.  Mixed  with  finely  divided 
shreddy  mucus  and  streaks  of  dark  blood  are  seen  larger,  tough,  stringy 
masses  of  necrotic  tissue.  The  stools  are  not  distinctively  purulent, 
but  the  slimy,  gray,  liquid  dejections  contain  more  pus  cells  than  the 
others.  In  all  the  dejections  there  are  found  more  or  less  numerous 
small  opaque  or  translucent,  gelatinous  grayish  yellow  masses  from  1 
to  3  mm.  in  diameter.  In  cases  of  moderate  severity  and  abrupt  onset 
for  a  M'eek  or  ten  days  the  stools  are  similar  to  those  at  the  beginning 
of  gangrenous  dysentery.  If  the  onset  has  been  gradual,  licpiid  brown- 
ish yellow^  stools  containing  mucus,  streaks  of  blood,  and  many  of  the 
gelatinous  grayish  masses  are  the  rule.  The  number  of  such  movements 
varies  from  four  to  ten  in  twenty-four  hours,  and  a  flux  of  this  degree, 
but  more  irregular  and  A\-ithout  blood,  may  continue  for  weeks.  During 
an  exacerbation  the  stools  increase  in  frequency,  resembling  those  of  the 
second  period  of  the  gangrenous  form,  sloughs  being  occasionally  found 
and  blood  reappearing. 

The  stools  in  chronic  cases  have  a  more  uniform  and  homogeneous 
appearance.  They  are  watery  or  of  the  consistence  of  thin  gruel,  of 
an  earthy  or  dull  yellow  color,  and  contain  a  few  or  many  particles  of 
clear  mucus.  During  an  exacerbation  blood  and  pultaceous  material 
may  be  seen ;  in  intermissions  of  the  diarrhoea  the  faeces  are  soft  and  pasty 
or  partly  formed,  but  mucus  is  persistently  present.     Particles  of  undi- 


364  DYSENTERY. 

gested  milk  and  other  food  are  often  seen.  The  reaction  of  these  stools 
is  usually  alkaline. 

Microscopical  Examination  of  Stools. — In  the  small,  mucoid, 
and  bloody  stools  of  the  acute  stage  there  are  found  in  varying  propor- 
tions red  blood  cells.  The  cercomonas  intesUnalis  is  sometimes  present. 
At  a  later  period,  in  gangrenous  cases  and  those  of  moderate  severity, 
the  cellular  elements  are  less  numerous,  and  float  in  a  mixture  of  granu- 
lar detritus  and  bacteria.  Elastic  tissue  fibres  are  observed,  but  the 
necrotic  masses  are  devoid  of  structural  appearance.  In  the  liquid 
grayish  stools  of  the  chronic  forms  recognizable  elements  are  still  fewer, 
making  the  detection  of  the  amoebse  much  easier. 

Amcehce  are  found  in  all  varieties  of  these  stools  and  at  all  periods 
of  the  disease.  They  vary  in  number  in  different  cases  and  at  different 
times  in  the  same  cases  in  proportion  to  the  severity  of  the  intestinal 
ulceration.  They  are  more  numerous  in  the  severe  acute  cases  and 
during  the  exacerbations  of  cases  of  moderate  severity  than  while  there 
is  a  continuous  but  moderate  diarrhoea.  In  the  early  bloody  mucoid 
stools  they  are  numerous  and  evenly  distributed.  In  the  latter  and  less 
homogeneous  evacuations  they  are  plentiful,  but  less  evenly  distributed, 
being  found  chiefly  in  the  grayish-yellow  gelatinous  masses,  also  but  less 
abundantly  in  the  particles  of  clear  or  rose-colored  mucus ;  in  the 
shreddy  masses  of  detritus  they  are  only  occasionally  found.  In  the 
homogeneous  discharges  of  chronic  cases  they  are  less  numerous  than  in 
acute  cases,  but  are  present  in  all  portions  of  the  stools.  Even  during 
intermissions  of  the  diarrhoea,  when  the  stools  are  soft  or  formed,  they 
are  to  be  seen  in  the  particles  of  adherent  mucus.  In  the  progress 
toward  recovery  the  amoebse  gradually  disappear,  but  may  be  found  after 
the  stools  have  regained  a  normal  appearance.  Variations  in  size  and 
activity  are  frequent :  red  blood  corpuscles  are  found  more  frequently 
and  in  larger  numbers  in  the  more  active  amoebse. 

The  reaction  of  the  stool  has  a  definite  relation  to  the  presence  and 
activity  of  the  organisms.  In  the  alkaline  and  neutral  stools  they  are 
active  and  numerous ;  in  the  acid  stools  they  are  scarce  and  only  occa- 
sionally motile.  The  appearance  of  the  amoebse  is  well  shown  in  the 
accompanying  drawings.     (Plates  IV.  and  V.) 

The  fseces  should  be  examined  as  soon  after  evacuation  as  possible, 
and  at  the  body  temperature,  although  this  is  not  essential.  In  warm 
weather  the  organisms  remain  active  for  twenty-four  hours  after  removal 
from  the  body  ;  in  cold  weather  warming  the  slide  over  an  alcohol  lamp 
will  bring  out  active  motion  ;  for  continuous  observation  a  warm  stage 
is  to  be  preferred.  Those  portions  of  the  stools  which  have  been  men- 
tioned as  containing  the  greatest  number  of  amoebse  should  be  selected ; 
but  slight  pressure  should  be  made  with  the  cover-glass ;  a  magnifying 
power  of  about  400  diameters  is  sufficient.  If  not  in  motion,  the  organ- 
isms may  be  mistaken  for  degenerated  cells  or  even  starch  granules,  but 
with  a  little  experience  the  larger  ones  can  be  recognized  by  their  pecu- 
liar appearance  and  the  gradual  occurrence  of  the  characteristic  motion. 
In  size  the  amoebse  vary  greatly.  Dock  found  the  smallest  13  and  the 
largest  37  mm.  in  diameter;  the  usual  size  is  from  18  to  25  mm.  In 
all  of  them  the  fine  granular  endosarc  and  the  homogeneous  ectosarc 
can  be  made  out :  the  former  is  often  filled  with  granules  of  variable 


SECONDARY  DYSENTERY.  365 

size.  Ill  about  oin'  half"  a  spherical  highly  refracting  imcleus  can  lie 
seen  lying  in  a  clear  vesicle  ;  also  from  one  to  numerous  vacuoles.  The 
inclusion  of  red  blood  corpuscles,  leucocytes,  bacteria,  and  detritus  gran- 
ules  is  common. 

AddUiondl  Abdoininal  Si/nijAoin.^. — -Vbdominal  pain  and  tenderness, 
tejiesmus,  nausea,  vomiting,  and  singultus  occur  with  greater  or  less  fre- 
quency in  this  form  of  dysentery.  Of  these  symptoms  colic  is  the  most 
constant :  it  is  observed  oftener  in  the  early  stage  of  the  gangrenous 
form,  and  in  those  of  abrupt  onset  and  during  the  acute  exacerbations  ; 
as  the  diarrluea  subsides,  so  docs  the  pain,  which  (jften  disappears  entirely 
as  the  gangrene  progresses.  In  chronic  cases  severe  colic  is  not  promi- 
nent except  during  exacerbations,  but  a  dull  pain  usually  precedes  and 
accompanies  a  movement  of  the  bowels.  ^Iore  or  less  tenderness  is 
excited  upon  pressure  over  the  course  of  the  colon. 

Tenesmus,  to  which  such  great  importance  was  attached  Ijy  A\'ood- 
ward  and  Trousseau,  was  not  present  in  a  considerable  ])roportion  of 
cases  as  noted  by  Dutroulau  and  Councilman  and  Lafleur ;  in  the 
writer's  series  it  was  generally  observed,  though  not  so  marked  as  in 
catarrhal  and  diphtheritic  forms.  As  reported  by  the  last  mentioned 
authors,  tenesmus  was  specially  apt  to  occur  in  grave  cases  with  exten- 
sive sloughing.  Irritability  of  the  stomach  attended  by  nausea  and 
vomiting  is  most  apt  to  be  present  at.  the  onset,  but  is  likely  to  occur 
at  irregular  intervals  during  the  progress  of  the  ca.se. 

Fever  is  not  ordinarily  a  prominent  feature  in  this  form  of  dysen- 
tery, though  if  carefully  observed  a  daily  rise  of  temperature  will 
be  found  to  occur  at  some  time  during  the  twenty-four  hours  and 
extending  through  the  course  of  the  illness.  Exeepti(jns  to  this  rule 
are  the  subnormal  temperatures  of  gangrenous  forms,  the  afebrile  course 
of  chronic  cases,  and  the  cases  mentioned  l)y  Osier  of  the  typhoid 
form,  w^hen  fever  may  be  high  at  times.  Hepatic  and  pulmonary  ab- 
scess always  produces  an  elevated  temperature.  Under  such  circum- 
stances the  fever  is  of  a  continuous,  remittent  or  intermittent  type, 
ranging  from  99°  F.  in  the  morning  to  102"^  F.  in  the  evening,  and  is 
likely  to  be  accompanied  by  rigors  and  sweating. 

Circulation  and  respiration  are  affected  in  proportion  to  the  height  of 
the  fever.  The  pulse  in  cases  of  average  severity  ranges  from  80  to 
100 ;  in  chronic  cases  it  is  about  normal,  with  progressive  exhaustion  ; 
in  fatal  cases  it  becomes  feeble  and  rapid,  120  to  140.  The  respirations 
are  increased  in  frequency  in  proportion  to  the  pulse  rate. 

The  urine  is  generally  slightly  albuminous.  In  the  gangrenous  cases 
there  is  often  retention  and  decided  reduction  in  the  quantity  secreted. 

4.  Secondary  Dysentery. 

Symptoms  and  Clinical  Course. — This  form  is  likely  to  occur  as 
a  terminal  event  in  various  acute  and  chronic  diseases.  It  is  not  infre- 
quent in  heart  affections,  Bright's  disease,  tuberculosis,  measles,  small- 
pox, and  septicaemia.  Woodward  states  that  the  association  of  dipthe- 
ritic  dysentery  with  the  characteristic  t^'phoid  lesions  of  Fever's  patches 
was  by  no  means  of  rare  occurrence  in  the  cases  observed  during  the 
American  C\\\\  AVar.     The  occurrence  of  a  complicating  colitis  may  be 


366  DYSENTERY. 

manifested  by  the  ordinary  dysenteric  symptoms,  or  the  latter  may  be 
entirely  absent,  the  intestinal  affection  not  being  suspected  during  life. 
In  most  instances  there  are  only  a  few  loose  movements  daily  during 
the  terminal  stages  of  the  primary  disease.  A.  Brayton  Ball  men- 
tions an  illustrative  case  of  dysentery  following  pyelitis,  in  which  the 
patient  had  three  or  four  loose  movements  daily  for  ten  days  before 
his  death,  without  tormina  and  tenesmus,  and  with  only  occasional  traces 
of  mucus  or  blood.  At  the  autopsy  the  colon  was  found  riddled  with 
ulcers,  one  of  which  had  perforated  the  bowel  near  the  sigmoid  flexure. 
There  was  no  peritonitis  or  lesion  of  the  small  intestine. 

The  imjjortant  point  to  bear  in  mind  as  regards  the  symptomatology 
of  secondary  dysentery  is  that,  contrary  to  the  dictum  of  Woodward 
and  Trousseau,  extensive  dysenteric  lesions  not  only  may  exist  in  the 
absence  of  tenesmus  and  other  symptoms,  but  that  such  latency  is  the 
rule  in  the  secondary  form.  The  absence  of  typical  symptoms  is  some- 
times due  to  the  localization  of  the  lesions  in  the  upper  part  of  the 
colon,  but  not  always,  as  in  some  instances  the  entire  large  intestine  is 
found  to  be  aifected. 

Complications  of  Dysentery. 

AncBmia. — Reference  has  been  previously  made  to  the  frequency 
and  severity  of  angemia  as  one  of  the  symptoms  of  amoebic  dysen- 
tery. It  is  here  mentioned  as  a  complication  of  all  forms  of  the 
disease,  in  order  to  emphasize  its  importance  and  the  necessity  of 
combating  it  by  proper  measures  of  treatment.  There  is  hardly  any 
inflammatory  disease  characterized  by  such  a  rapid  developing  anaemia 
as  occurs  in  dysentery.  Niemeyer  is  authority  for  the  statement  that  a 
general  ansemic  dropsy  ensues  more  frequently  after  mild  attacks  of 
dysentery  than  after  any  other  disease  of  equally  short  duration.  Even  in 
cases  of  moderate  severity,  ending  in  recovery  in  one  or  two  weeks,  the 
disturbance  of  nutrition  is  sufficient  to  protract  the  convalescence. 

The  chief  factors  explanatory  of  the  blood  changes  of  dysentery  are 
as  follows  :  (a)  Impaired  digestive  power  depending  upon  deranged  and 
imperfect  secretion  of  all  the  digestive  fluids.  Ufi'elmann,  who  has 
investigated  the  subject,  finds  the  saliva  is  acid  and  contains  a  smaller 
number  of  salivary  corpuscles  than  usual ;  the  gastric  juice  is  deficient 
in  hydrochloric  acid,  and  is  proportionately  weak  in  peptonizing  power. 
The  secretion  of  bile  is  diminished  or  temporarily  arrested.  Similar 
derangements  doubtless  occur  with  the  pancreas  and  intestinal  glands. 
(6)  The  continuous  loss  of  blood  and  albumin  in  the  stools ;  though  the 
quantity  passed  each  time  may  be  small,  yet  frequent  repetitions  will 
effect  the  constitution  of  the  circulating  fluid,  (c)  The  destructive 
influence  of  the  amoebae  upon  the  blood  corpuscles,  these  influences 
acting  with  greater  or  less  severity  according  to  the  attack,  but,  as 
aforesaid,  being  prominent  in  all. 

Peritonitis  and  Intestinal  Perforation. — A  localized  peritonitis  from 
the  extension  of  inflammation  to  the  serous  coat  in  diptheritic  dysentery, 
or  occurring  in  the  hepatic  region  in  cases  where  that  organ  is  involved, 
is  of  common  occurrence.  This  process  may  become  chronic  and  result 
in  adhesions  or  may  result  in  general  peritonitis  with  a  fatal  issue.    The 


COMVLICATloys   OF  DYSESTKRY.  367 

condition,  however,  is  most  likely  to  ensue  as  a  consequence  of  perfora- 
tion of  the  colon  resulting  from  slou<;hing  of  a  deep  ulcer,  leading  to  a 
fecal  extravasation  and  a  rapidly  fatal  peritonitis.  Perforation  occurred 
in  about  10  per  cent,  of  cases  collected  by  Woodward.  It  is  most  apt 
to  occur  in  the  cweum,  but  may  ha})pen  in  any  p(jrtion  of  the  colon. 
In  severe  cases  there  may  be  an  encapsulating  jjroeess  ending  in  peri- 
Ciecal  abscess,  -which  may  empty  externally  or  into  the  bowel. 

Infnssusception  is  an  accident  only  in  very  rare  cases. 

Hepatic  and  Hcpato-pulmonary  Abscess. — This  complication  occurs 
but  rarelv  in  the  catarrhal  or  diphtheritic  forms,  but  in  amoebic  dysentery, 
on  account  of  the  frequency  and  the  additional  gravity  it  lends  the  case, 
it  becomes  a  matter  of  great  interest  and  importance.  Illustrative  of 
the  comparative  frequency  of  liver  abscess  in  the  different  forms  of 
dysentery,  the  following  facts  are  of  interest :  Woodward  states  that  out 
of  156  cases  of  acute  or  chronic  catarrhal  dysentery  Avithout  ulceration 
there  was  but  1  case  of  this  complication,  while  in  115  cases  of  the 
diphtheritic  form  there  were  3  of  single  abscess  and  4  of  multiple  meta- 
.static  foci.  In  chronic  intestinal  ulceration  (with  which  he  includes 
the  follicular  and  undetermined  forms),  out  of  396  cases  there  were  6 
instances  of  single  large  hepatic  abscess,  and  10  of  multiple  or  meta- 
static, or  about  4  per  cent.  Adding  together  these  figures  shows  14 
cases  of  multiple  abscesses  and  9  of  large  single  abscesses  out  of  511  cases 
in  which  the  intestine  was  ulcerated,  and  but  1  case  of  large  abscess  in 
156  cases  of  non-ulcerative  dysentery.  This  experience  corresponds 
with  that  of  medical  observers  in  Great  Britain  and  Continental  Europe, 
but  differs  very  widely  from  that  of  British  physicians  in  India  and 
Burmah,  of  the  French  in  Cochin  China  and  Egypt,  and  of  those  who 
have  studied  tropical  dysentery  in  Brazil,  Chili,  Yenzuela,  Mexico,  and 
from  recent  statistics  of  amcebic  dysentery  as  it  has  been  observed  in 
this  countrv.  Without  going  into  details,  it  appears  that  abscess  of  the 
liver  is  found  in  one  out  of  four  or  five  fatal  cases  of  tropical  dysentery. 

Showing  the  frequency  of  this  complication  in  amoebic  dysentery, 
out  of  12  cases  reported  by  Dock,  4  certainly,  and  probably  5,  had 
liver  abscess ;  6  out  of  15  in  Councilman  and  Lafleur's  series ;  and 
1  out  of  7  reported  by  the  writer.  Thus,  out  of  34  cases  there  were 
12,  or  over  one  third,  in  which  hepatic  or  hepato-pulmonary  abscess 
was  present.  These  figures  correspond  very  closely  with  those  of 
Ballingall,  Annesley,  Waring,  Eyre,  Ranking,  Moore,  Macpherson, 
Chuckurbutty  in  India,  of  Catteloup  and  Monret  in  Algiers,  of 
Bougrael  and  Gayne  in  Cochin  China,  of  De  Castro  in  Egypt,  as  to  the 
frequency  of  liver  abscess  in  tropical  dysenteri^  and  would  seem  to  con- 
firm the  identity  of  the  latter  with  the  amoebic  form.  Amoebic  dysen- 
tery as  observed  in  Europe  apjoears  to  be  an  exception  as  to  the  enor- 
mous proportion  of  hepatic  complications,  and  so  far  no  reason  can  be 
assigned  for  this  apparent  exception.  It  is  useless  to  mention  the 
various  theories  which  have  been  presented  to  account  for  the  connec- 
tion between  dysentery  and  abscess  of  the  liver,  as  the  recognition  of 
the  identity  of  the  specific  causes  of  the  intestinal  and  hepatic  lesions 
has  cleared  the  subject  of  much  of  its  former  obscurity.  Speaking 
particularly  of  the  amoebic  or  tropical  forms,  abscess  of  the  liver  may 
develop  in  any  grade  of  severity  or  at  any  period  of  the  illness.     The 


368  DYSENTERY. 

gravity  of  the  initial  attack,  instead  of  favoring,  is  prejudicial  to  the 
occurrence  of  this  event,  as  patients  are  more  likely  to  die  from  the 
severity  of  the  intestinal  lesions  before  infection  of  the  liver  has  time 
to  occur. 

The  period  when  hepatic  involvement  takes  place  varies  between 
wide  limits ;  it  commonly  develops  from  the  fourth  to  the  twelfth  week. 
The  most  frequent  site  is  the  convex  surface  of  the  right  lobe,  the  evi- 
dence going  to  show  that  in  most  cases  infection  takes  place  through  the 
peritoneum,  and  that  the  right  lung  is  involved  by  the  passage  of  the 
organisms  through  the  diaphragm. 

I  shall  not  discuss  in  detail  the  course  and  symptomatology  of 
hepatic  abscess,  as  that  subject  will  receive  attention  in  another  part 
of  this  work,  but  will  attempt  to  give  only  the  salient  points  concern- 
ing the  large  solitary  or  tropical  abscess. 

The  important  symptoms  are  pain,  irregular  fever,  and  the  develop- 
ment of  a  septic  condition.  Latent  cases  are  not  rare  ;  these  run  their 
course  without  definite  symptoms;  sudden  death  occurs  from  rupture, 
and  in  a  good  many  instances  the  abscess  is  discovered  post-mortem, 
not  having  been  suspected  during  life.  The  temperature  is  of  an  in- 
termittent type ;  it  may  be  normal  or  subnormal  for  a  few  days,  and 
then  rise  to  103°  or  higher,  being  preceded  by  a  rigor ;  the  character  of 
the  febrile  movement  often  causes  it  to  be  mistaken  for  malarial  fever. 
The  temperature  may  rise  every  afternoon  without  rigors.  Profuse 
sweating  is  common.  In  chronic  cases  there  may  be  little  or  no  fever ; 
this  is  especially  apt  to  be  the  case  where  the  abscess  has  opened.  The 
pain  is  variable,  and  is  usually  located  in  the  back  or  shoulder,  or  there 
may  be  tenderness  and  a  dull  pain  in  the  right  hypochondrium.  The 
decubitus  generally  preferred  is  upon  the  right  side.  Physical  evi- 
dences of  enlargement  are  usually  found ;  the  latter  may  be  so  great  as 
to  cause  bulging  and  projection  two  or  three  inches  below  the  costal 
margin.  Fluctuation  and  oedema  of  the  chest  wall  may  be  occasionally 
detected.  The  appearance  of  the  patient  is  suggestive  :  the  skin  has  a 
sallow  yellowish  tint,  the  face  is  pale,  the  complexion  muddy,  and  the 
conjunctivae  are  infiltrated  and  bile-tinged.  Marked  jaundice  is  rare. 
Looseness  of  the  bowels,  and  especially  the  detection  of  amoebae  in  the 
stools,  are  very  significant.  Careful  exploration  with  the  aspirating 
needle  will  usually  determine  the  diagnosis.  In  some  instances  the  re- 
sults are  negative,  even  when  exploration  is  made  with  a  long,  large-sized 
needle,  in  consequence  of  the  viscidity  of  the  abscess  contents.  Charac- 
teristic symptoms  arise  when  the  abscess  invades  the  lung,  which  event 
is  of  not  infrequent  occurrence.  Extension  may  take  place  through  the 
diaphragm  mthout  rupture,  producing  a  purulent  pleurisy  and  involve- 
ment of  the  lung.  In  such  cases  the  patients  gradually  develop  a  severe 
cough,  usually  of  an  aggravated,  convulsive  character. 

The  physical  signs  are  those  of  consolidation  at  the  base  of  the  right 
lung,  impaired  resonance,  feeble  bronchial  breathing,  increased  tactile 
fremitus,  but  the  characteristic  feature  is  the  sputum :  at  first  the 
expectoration  is  not  peculiar,  consisting  of  a  little  clear  mucus,  but  it 
soon  becomes  more  abundant,  muco-purulent,  and  streaked  with  blood. 
After  a  short  period,  during  a  paroxysm  of  coughing  the  patient  sud- 
denly expectorates  a  large  quantity  of  brick-red  or  brownish  muco-pus, 


COMJ'LICATIOyS  OF  DYSKyTERY.  369 

iiitcnnixcd  with  more  or  less  pure  blood.  Such  ('xjicftoration  is 
repeated  (hiily  witli  varying  frecpieiicy  throiii;hoiit  the  ilhu-ss.  IJudd 
and  other  aiith(»rities  declare  that  this  expectoration  is  pathognomonic 
of  abscess  of  the  liver  perforating  the  lung. 

Mlcroseopical  Charcwters. — The  cellular  elements  observed  are  red 
blood  corpuscles,  leucocytes,  round  alveolar  epitlielial  cells,  oral  epi- 
thelium, irregular  fatty  degenerated  elements  looking  like  liver  cells. 
Elastic  tissue  fibres  are  frequently  found  in  tlie  later  stages.  Am(jeb<e 
are  constantly  present ;  they  vary  in  numljcr,  size,  and  activity,  and 
are  found  in  all  parts  of  the  sputum,  but  are  not  so  abundant  as  in  the 
stools.  The  prognosis  in  these  cases  is  serious,  the  mortality  being 
over  50  per  cent. ;  the  death  rate  has,  however,  been  reduced  recently 
in  consequence  of  improved  surgical  techni<pie. 

Pneniiio)ii(i  is  not  mentioned  as  a  complication  or  secpiel  of  dysen- 
tery by  any  of  the  systematic  writers  upon  general  medicine  to  which 
I  have  access,  with  the  exception  of  Aitken,  neither  does  Ball  refer  to 
it  in  his  recent  brochure  npon  the  "  Symptoms,  Complications,  and 
Treatment  of  Dysentery."  This  is  rather  a  singular  fact  in  view  of  the 
statements  of  Woodward,  who  says  :  "  Bronchitis  and  pneumcjnia  were 
common  complications  of  acute  dysentery  during  the  war,  particularly 
of  the  diphtheritic  form.  They  were  noticed  especially  after  the  occur- 
rence of  epidemic  measles  and  after  exposure  to  cold  and  inclement 
weather,  particularly  after  marches  during  which  the  troops  were  insuf- 
ficiently sheltered  at  night."  Pneumonia  occurred  as  an  intercnrrent 
complication  during  the  advanced  stages  of  the  disease,  usually  in  the 
croupous  form,  and  was  found  in  about  one-fifth  of  all  the  autopsies  of 
acute  diphtheritic  dysentery  reported  during  the  war.  Very  similar 
facts  were  observed  with  regard  to  the  other  forms  of  dysentery.  In 
chronic  ulcerative  dysentery,  not  including  cases  complicated  with 
tuberculosis,  pneumonia  was  found  (and  often  was  the  immediate  cause 
of  death)  in  more  than  one  fifth  of  all  the  autopsies.  It  was  observed 
in  one  fourth  of  the  post-mortem  examinations  in  which  non-ulcerative 
inflammation  of  the  intestine  was  found.  The  season  of  the  year  in 
which  these  pneumonic  lesions  were  noticed  is  significant,  a  very  large 
proportion  occurring  between  the  first  of  October  and  last  of  March. 
Aitken  briefly  mentions  the  frequency  of  pulmonic  complications  in  the 
allied  armies  during  the  Crimean  War.  Griesinger  alone,  of  all  the 
w^riters  on  the  diseases  of  hot  climates,  appears  to  have  found  pneumonia 
frequently  associated  with  dysentery.  In  96  autopsies  of  primary  dys- 
entery he  found  croupous  pneumonia  7  times,  catarrhal  pneumonia  12 
times,  bronchitis  with  apoplectic  foci  4  times,  and  gangrene  7,  thus  giv- 
ing a  proportion  of  nearly  one  third  of  serious  pulmonary  lesions  and 
rivalling  the  proportion  given  by  Woodward.  It  appears  that  pneu- 
monia and  other  acute  inflammatory  diseases  of  the  lungs  do  not  occur 
Avith  such  frequency  in  tropical  dysentery  or  in  civil  life  as  in  camp  dys- 
entery, for  the  probable  reason  that  exposure  and  the  unhygienic  condi- 
tions generally  of  armies  in  times  of  war  render  the  victims  of  dysen- 
tery especially  liable  to  pulmonary  complications. 

Pulmonary  Tuberculosis. — Tubercular  disease  of  the  lungs  is  also  a 
frequent  associate  of  dysentery.  Woodward  found  it  to  exist  in  nearly 
one  sixth  of  all  the  autopsies  of  fatal  cases  of  diiferent  forms  of  flux. 

Vol.  I.— 24 


370  DYSENTERY. 

It  was  more  common  in  chronic  cases,  but  also  occurred  in  the  acute. 
In  the  first  instance  the  tubercular  trouble  developed  during  the  progress 
of  dysentery,  and  in  the  acute  form  flux  supervened  in  patients  already 
laboring  under  phthisis. 

Scurvy. — Reference  has  already  been  made  to  the  inflijence  of  the 
scorbutic  taint  as  a  predisposing  cause  of  dysentery.  This  association 
is  developed  where  the  diet  is  deficient  in  fresh  vegetables  and  where  it 
consists  chiefly  of  salted  meat.  Sir  Ronald  Martin  gives  a  terrible 
instance  of  suifering  from  this  cause  as  it  occurred  in  the  European  por- 
tion of  the  forces  employed  in  Ava  during  the  first  Burmese  War, 
where  they  were  fed  on  salt  rations  for  six  and  a  half  months :  48  per 
cent,  perished  within  ten  months,  principally  from  dysentery  compli- 
cated by  scurvy.  Such  disasters  have  since  been  surpassed  in  the 
Crimean  War  during  the  winter  of  1854-55  before  Sebastopol,  when 
the  mortality  was  even  greater  for  a  similar  combination  of  influences. 
The  testimony  of  Woodward  concerning  the  coexistence  of  scurvy  with 
intestinal  fluxes  during  the  American  Civil  War  corroborates  the  above 
experience.  He  says  :  "  While  openly  pronounced  scurvy  was  not  very 
common,  a  recognizable  but  usually  mild  scorbutic  taint  was  of  more 
frequent  occurrence,  and  whenever  this  made  its  appearance  diarrhoea 
became  prevalent,  and  showed  an  increased  tendency  to  pass  into  dysen- 
tery and  to  become  chronic."  Elsewhere  he  expresses  the  opinion 
"  that  the  scorbutic  condition  is  not  directly  the  cause  of  dysentery,  but 
that  no  cachectic  state  is  more  favorable  to  the  action  of  the  other  causes 
of  these  disorders  or  confers  upon  them  a  graver  character  when  they 
have  once  been  established."  It  is  unnecessary  to  recapitulate  any  addi- 
tional testimony  upon  this  subject.  Enough  has  been  said  to  show  that 
a  combination  of  unhygienic  conditions  with  insufficient  and  improper 
diet  predisposes  to  both  dysentery  and  scurvy,  and  will  account  for  the 
frequent  association  of  these  diseases. 

Malarial  Fever. — Closely  connected  with  scurvy  as  a  complicating 
factor  in  intestinal  fluxes  is  that  of  malarial  fever.  The  connection 
between  the  two  diseases  is  so  intimate  as  to  have  given  rise  to  the  old 
but  now  obsolete  idea  that  the  infections  of  paludal  fevers  and  of  dysen- 
tery are  identical.  Aitken,  in  referring  to  the  close  association  of  these 
affections,  illustrates  it  by  citing  the  fact  that  "  a  boat's  crew  being  sent 
ashore  in  a  tropical  climate,  the  probabilities  are  thatof  themen  return- 
ing on  board  part  will  be  seized  with  dysentery  and  part  with  intermit- 
tent fever."  Such  incidents  do  not  prove  a  unity  of  causes,  but  only 
that  the  two  etiological  factors  are  coexistent,  about  which  fact  there  is 
no  dispute.  An  excellent  opportunity  for  observing  this  connection  was 
obtained  during  the  American  Civil  War,  when  it  was  found  that  the 
great  armies  moving  suddenly  from  the  North  to  the  malarial  regions 
of  the  South  were  exposed  "^simultaneously  to  the  causes  of  dysentery 
and  malaria,  developing  a  hybrid  disease,  the  symptoms  resulting  from 
each  cause  often  appearing  together  in  the  same  individual  from  the 
beginning  of  the  case  to  its  end.  Sometimes,  however,  dysentery,  either 
of  itself  or  as  a  sequel  to  diarrhoea,  appeared  as  the  primary  disorder, 
assuming  subsequently  a  periodic  form,  either  as  to  the  flux  itself  or  as 
to  the  accompanying  fever ;  or  ague  or  remittent  fever  made  its  appear- 
ance during  convalescence  from  dysentery  or  after  it  had  become  chronic. 


COMPIJCATrOXS  OF  nVSEXTERY.  371 

In  other  cases  the  periodic  fevers  were  the  ])riiiuirv  inorliifl  condition, 
and  dysentery  set  in  only  after  the  liealth  had  been  broken  down  by 
h>ng  continned  agne  or  after  remittent  fever  had  been  first  deveh)j)ed. 
In  still  other  cases  malaria  was  manifested  by  chronic  poisoning ;  the 
resnlting  cachexia,  whether  existing  l)y  itself  or  associated  with  mild 
scorbntic  taint,  was  so  widely  spread  as  to  favor  the  development  of 
ilysentcry  as  well  as  diarrluea.  The  subjects  of  this  cachexia  seemed 
less  able  to  resist  the  causes  of  the  disease  than  healthy  men,  and,  once 
developed  in  them,  dysentery,  even  in  its  simple  or  catarrhal  form,  was 
more  a])t  to  become  chronic  and  to  prove  fatal.  Not  only  were  the  ordi- 
nary forms  of  intermittent  and  remittent  fevers  observed,  but  occasion- 
allv  paroxysms  of  pernicious  malarial  fever.  Though  the  paroxvsms 
were  otten  ol)stinate  and  prone  to  recur,  yet  quinine  was  essential  to 
control  them,  and  its  power  in  this  reg-ard  was  strong  proof  of  the 
malarial  nature  of  the  complication.  Notwithstanding  the  general  con- 
sensus of  opinion  as  furnished  by  army  surgeons  npon  this  subject,  the 
diagnosis  is  beset  with  difficulties,  and  has  doubtless  often  been  made 
upon  insufficient  grounds. 

Osier  mentions  the  fact  that  with  but  one  exception  the  cases  of 
dysentery  he  has  seen  associated  ^snth  intermittent  pyrexia  were  due  to 
suppuration.  This  observation  is  in  accord  with  the  winter's  own  expe- 
rience in  a  hospital  drawing  its  material  from  an  extensive  malarial 
country.  I  cannot  recall  a  single  instance  of  undoubted  association  of 
malarial  fever  with  dysentery.  It  would  thus  appear  that  the  malarial 
element  is  not  so  likely  to  be  associated  with  dysentery  in  civil  as  in 
army  practice.  W.  C  Maclean  gives  these  symptoms  of  malarious  dys- 
entery :  "  Such  cases  will  be  recognized  by  the  periodicity^  of  the  febrile 
paroxsyms,  the  presence  of  gastric  irritability,  such  as  we  see  in  remit- 
tent fevers,  and  by  the  peculiar  nature  of  the  evacuations,  which  from 
the  first  are  serous  and  contain  but  little  blood,  but  have  the  character- 
istic dysenteric  odor."  Other  writers  mention  the  periodicity  in  the 
frequency  of  the  stools,  while  the  occurrence  of  chills  is  regarded  as 
significant  of  malaria. 

Such  evidence  is  not  conclusive,  for  fever  of  remittent  or  intermittent 
type,  marked  gastric  symptoms,  diarrha?al  rather  than  dysenteric  stools, 
and  periodical  exacerbations  of  the  intestinal  flux  are  symptoms  recog- 
nized in  dysentery  when  malaria  can  be  excluded,  while  rigors  with 
intermittent  pyrexia  and  sweating  are  frequently  indicative  of  suppura- 
tive processes  in  the  liver  or  elsewhere.  These  facts  should  guard  us 
against  the  hasty  assumption  of  malarial  infection,  which  can  be  diag- 
nosticated with  certaintv  bv  the  discovery  in  the  blood  of  the  haematozoa 
mala  rite. 

Ti/phoid  and  Typhus  Fever. — The  combination  of  adynamic  fevers 
with  dysentery  has  been  long  recognized,  and  no  doubt  a  tendency  has 
existed  to  over-estimate  their  frequency  by  confounding  the  typhoid 
febrile  symptoms  which,  as  we  have  seen,  are  not  infrequently  developed 
in  connection  with  certain  forms  of  dysentery  with  true  typhoid  or 
typhus  fever — an  error  which  has  been  favored  by  the  peculiar  charac- 
ters assumed  by  dysentery  in  certain  epidemics.  ^Nlany  writers  of  the 
last  century  went  so  far  as  to  describe  dysentery  as  merely  one  of  the 
varieties  of  typhus,  giving  it  the  name  of  "  colotj'phus,"  and  looking 


372  DYSENTERY. 

upon  it  as  the  local  manifestation  of  the  typhus  contagium  ;  but  since 
the  anatomical  test  has  been  applied  it  was  found  that  in  many  of  the 
so-called  cases  of  typhoid  dysentery  there  was  an  entire  absence  of  the 
characteristic  lesions  of  typhoid  fever,  leading  Rokitansky  to  express  the 
belief  that  the  coexistence  of  dysentery  with  typhoid  fever  is  excessively 
rare.  But  that  this  complication  does  occur,  and  not  infrequently,  has 
since  been  shown  by  numerous  observers — first  by  Trousseau  and  Par- 
mentier  in  1826;  since  by  Parkes  in  India,  by  Baily  at  the  Millbank 
Penitentiary,  London,  by  Finger  during  an  epidemic  in  the  hospital  at 
Prague,  and  by  Lyons  during  the  Crimean  War.  These  observations 
were  confirmed  during  the  American  Civil  War,  not  merely  by  clinical 
observation,  but  by  autopsy  and  preservation  of  the  specimens  in  the 
Army  Medical  Museum.  Woodward  states  it  was  so  common  to  find 
the  characteristic  lesions  of  typhoid  fever  in  the  ileum  and  of  dysentery 
in  the  colon  that  he  was  led  to  believe  that  the  combination  was  likely 
to  occur  in  every  army  where  typhoid  was  the  prevailing  fever.  The 
complication  supervenes  much  in  the  same  way  as  in  malarial  fever ; 
that  is,  the  continued  fever  and  dysentery  run  their  course  simultane- 
ously, or  either  appears  as  the  primary  disorder,  to  which  the  other  was 
subsequently  superadded.  With  reference  to  the  coincidence  of  typhus 
fever  and  dysentery,  aside  from  the  brief  statement  that  it  does  occur 
mentioned  by  several  authorities,  I  find  no  details.  My  friend.  Dr.  C. 
Warfield,  who  has  had  an  extensive  experience  with  typhus  fever  in 
Northern  Mexico,  states  that  diarrhoea  occurred  in  about  20  per  cent,  of 
the  cases,  and  that  occasionally  dysenteric  symptoms  were  present.  The 
lesions  of  dysentery,  however,  were  not  confirmed  by  autopsies. 

Dysenteric  Arthropathies. 

Since  Sydenham  mentioned  the  occurrence  of  joint  symptoms  in  an 
epidemic  of  dysentery  in  1672,  they  have  been  met  with  in  numerous  epi- 
demics, as  that  of  1765,  described  by  Lepecq  de  la  Cloture  and  Zimmer- 
mann;  1776-77,  described  by  Stoll ;  1835,  described  by  Thomas;  and 
that  of  1854  occurring  in  the  canton  of  Montargis  in  France,  described 
by  Huette.  In  the  American  Civil  War  the  pains  in  the  limbs  and 
back  which  were  common  in  connection  with  both  acute  and  chronic 
dysentery  were  in  most  instances,  according  to  Woodward,  rather  due 
to  malarial  and  scorbutic  neuralgia  than  to  rheumatism.  Dewevre  has 
recently  made  an  interesting  report  upon  this  subject,  giving  the  results 
of  this  complication  in  65  cases,  15  of  which  occurred  among  445  cases 
of  dysentery  Under  his  care  in  the  military  hospital  at  Lyons,  France, 
during  the  summer  of  1885.  He  found  the  onset  of  articular  symptoms 
to  begin  at  variable  periods  of  the  dysenteric  attack.  Out  of  60  obser- 
vations in  which  the  date  of  invasion  was  mentioned,  in  9  it  fell  in  the 
first  week,  in  7  in  the  second,  and  44  in  the  first  days  of  convalescence 
or  several  weeks  later.  Occasionally  the  development  of  the  arthropathy 
is  preceded  by  a  sudden  arrest  of  the  intestinal  symptoms,  or  the  course 
of  the  joint  lesion  is  interrupted  by  reappearance  of  the  flux.  In  one 
case  the  alternation  of  articular  and  intestinal  symptoms  recurred  three 
times  in  the  same  individual.  The  invasion  is  always  sudden,  and  at 
first  affects  but  a  single  joint.     Of  the  63  cases,  the  attack  began  in  the 


DY^EyTERIC  rARALYSES.  373 

knees  25  times,  in  the  ankles  16  times,  in  the  shonldors  9  times,  in  the 
elbow  4  times,  in  the  hip  once,  in  the  ritrht  middle  finfrer  once,  in  the 
toe  once,  in  the  tempiu-o-niaxillary  articulation  once,  and  once  in  the 
sterno-clavicular  articulation. 

The  SYMPTOMS  are  of  slight  intensity.  There  is  bnt  little  pain,  and 
either  no  fever  or  a  slight  and  temporary  rise  of  temperature,  and  no 
other  disturbance  of  the  general  health.  The  patient  usually  first 
notices  trouble  with  the  joint  upon  making  some  slight  mo\'ement. 
The  ligamentous  attachments  are  tender,  with  some  swelling  of  the 
periarticular  tissues  ;  usually  there  is  no  effusion  into  the  joint  and  no 
redness  of  the  overlying  skiii.  Hydrarthrosis  may,  however,  occur, 
])articularly  in  the  knee,  when  it  may  distend  the  capsule  and  render 
movement  difficult.  Limitation  to  a  single  joint  is  exceptional,  occur- 
ring in  only  about  8  per  cent,  of  the  cases.  After  a  few  hours  or  days 
other  joints  are  implicated,  but  with  less  intensity,  the  last  joint  to 
recover  being  the  one  primarily  attacked.  All  the  joints  may  be 
attacked  successively,  but  usually  the  number  is  limited  to  three  or 
four.  In  cases  of  hydrarthrosis  absorption  is  slow.  Restoration  of  the 
functions  of  the  joints  involved,  although  sometimes  requiring  only  a 
week,  is  usually  protracted  to  a  month  or  several  months,  and  is  most 
obstinate  when  the  smaller  joints  are  affected. 

Neither  ill  health  producing  the  dysentery  nor  a  severe  course  of  the 
disease  seems  to  predispose  to  the  arthropathies.  On  the  contrary,  they 
are  more  frequent  in  robust  subjects,  who  have  been  but  little  weakened 
by  the  dysentery,  than  in  the  weak  and  cachectic,  and  in  the  mild 
rather  than  in  the  severe  cases.  Exposure  to  cold  or  over-exertion  was 
not  observed  as  a  possible  causal  factor. 

Various  explanations  have  been  offered  to  account  for  the  connection 
between  dysentery  and  arthritic  troubles,  but  none  of  them  are  entirely 
satisfactory.  Stoll  and  his  followers,  looking  upon  dysentery-  as  a  rheu- 
matic affection,  found  a  ready  explanation  in  a  simple  metastasis  to  the 
joints.  Others  based  the  occurrence  of  arthropathies  upon  the  exist- 
ence of  a  "  reflex  relation  "  between  the  articular  and  intestinal  lesions. 
Some  of  the  observers  regard  the  rheumatoid  symptoms  as  the  manifes- 
tation of  a  mild  pysemic  infection.  The  most  probable  solution  of  the 
question  appears  to  be  that  the  joint  affection  bears  the  same  relation  to 
dysentery  as  it  does  to  other  infectious  diseases — e.  g.  scarlet  fever, 
typhoid  fever,  cerebro-spinal  meningitis,  dengue,  etc. ;  that  is  to  say,  it 
is  not  a  genuine  rheumatism,  from  which  it  differs  in  many  essential 
particulars,  but  it  is  the  localization  of  the  infectious  agent  or  its  prod- 
ucts acting  upon  the  joints  through  the  circulation. 

Dysenteric  Paralyses. 

The  most  important  contributions  to  the  study  of  the  paralytic  com- 
plications of  dysenterv  have  been  made  during  the  latter  half  of  the 
present  century.  Cases  have  been  reported  and  the  pathology  discussed 
by  various  writers,  notably  Delioux  de  Savignac,  Leyden,  Barie,  Weir 
Mitchell,  "Woodward,  and  Pugibet.  The  latter  in  1888  gave  a  most 
valuable  resume  of  the  subject,  from  which  the  details  here  given  are 
mainly  derived.     Paralysis  may  occur  in  both  the  acute  and  chronic 


374  DYSENTERY. 

forms  of  dysentery,  sometimes  during  the  course  of  the  attack,  but 
usually  as  a  sequel.  By  far  the  most  common  form  is  paraplegia.  The 
upper  extremities  may  be  also  involved ;  hemiplegic  and  monoplegic 
cases  have  been  reported,  and  diffused  general  paralysis  has  also  been 
observed.  In  some  cases  the  onset  is  sudden,  developing  within  twenty- 
four  to  forty-eight  hours,  and  lasting  but  a  short  time — three  to  twenty- 
eight  days.  In  other  instances  the  paralysis  has  a  gradual  development, 
this  appearing  to  be  the  usual  history  of  the  paraplegic  form.  Paralysis 
of  the  vesical  and  anal  sphincters  and  girdle  sensations  are  usually  ab- 
sent. The  paralysis  is  rarely  complete  in  all  of  the  muscles  of  the 
limb  or  in  muscular  groups  elsewhere.  Among  muscles  innervated  by 
the  same  plexus  some  may  be  affected  and  others  not.  Sensory  dis- 
turbances are  usually  not  prominent,  but  in  some  cases  neuralgic  pains, 
tingling  sensations,  cramps,  and  limited  anaesthesia  were  observed.  In 
an  analysis  of  17  cases  reported  by  Pugibet,  including  his  ow^n  and 
those  of  several  other  observers,  in  13  the  paralysis  lasted  four  months, 
in  4  it  was  stationary  at  the  time  of  the  report,  in  2  death  resulted 
from  the  paralytic  lesions,  and  in  4  it  was  independent  of  them.  In 
speaking  of  the  cases  of  palsy  connected  with  dysentery.  Weir  Mitchell 
states  that  in  nearly  every  instance  there  had  been  many  possible  causes, 
as  long  marches,  bad  diet,  malapa,  or  spinal  injuries,  the  latter  being  so 
common  that  almost  any  soldier  long  in  the  service  had  some  to  relate. 
It  was  thus  difficult  to  fix  upon  any  single  factor  as  essential,  as  it  was 
likely  that  several  contributed  to  influence  the  result.  The  pathologi- 
cal condition  underlying  dysenteric  palsies  has  not  been  satisfactorily 
studied,  and  the  views  which  have  been  presented  to  explain  their 
origin  are  largely  theoretical :  some  of  the  reported  cases  were  due  to 
central  lesions,  and  others  were  cases  of  multiple  neuritis. 

Sequels  of  Dysenteey. — Among  the  more  important  sequels© 
especially  of  chronic  dysentery  are  prolapsus  ani,  anal  fistula  from  peri- 
neal abscess,  and  hemorrhoids,  these  conditions  being  largely  the  result 
of  mechanical  causes.  Indigestion,  irritability  of  the  bowels,  or  obsti- 
nate constipation  are  not  infrequent.  Intestinal  strictures  resulting 
from  cicatricial  contraction  after  the  healing  of  dysenteric  ulceration, 
according  to  Woodward,  are  exceedingly  rare.  Profuse  intestinal  hem- 
orrhage after  subsidence  of  the  dysenteric  flux  is  a  sequel  mentioned  by 
my  colleague.  Dr.  Clopton,  as  occurring  not  infrequently  in  his  expe- 
rience. It  is  not,  apparently,  due  to  ulceration,  but  rather  to  a  dis- 
eased condition  of  the  walls  of  the  intestinal  bloodvessels  and  to  the 
morbid  state  of  the  blood  itself. 

Diagnosis  of  Dysenteey. — The  recognition  of  the  catarrhal  form 
of  dysentery  is  usually  easy,  the  frequency  of  the  stools,  the  presence 
in  them  of  blood  and  mucus,  the  tormina  and  tenesmus  producing 
a  characteristic  clinical  picture.  Local  affections  of  the  rectum, 
syphilitic  and  chancroidal  ulceration,  cancer,  strictures,  the  presence 
of  foreign  bodies,  and  intussusception,  especially  in  children,  may 
produce  straining  and  the  passage  of  mucoid  and  bloody  dejections. 
A  careful  physical  examination  in  such  cases  will  generally  with- 
out difficulty  determine  the  diagnosis.  The  acute  diphtheritic  form 
with  its  rapid  and  intense  onset  and  severe  constitutional  symptoms 
may  readily  be  mistaken  for  enteric  fever.     The  higher  temperature 


PROGNOSIS.  375 

of  dysentorv,  the  aggravated  intestinal  symptoms,  the  presence  in 
the  stools  in  the  early  stages  of  blood  and  mucus,  and  later  of  di|)h- 
theritic  sloughs,  the  absence  of  enlarged  spleen,  and  the  charac- 
teristic rose  eruption  of  typhoid  fever,  shoiihl  guide  to  a  correct  dif- 
ferentiation. The  aincebic  form  can  be  recognized  by  a  careful  miero- 
seo})lc  exaniinatit)n  of  the  stools,  which  should  be  made  in  every  case 
where,  with  a  deterioration  of  the  general  health,  aiuemia,  and  impaired 
nutrition,  there  exists  a  disposition  to  looseness  of  the  bowels.  The 
irregular  and  chronic  course  of  these  cases  should  be  borne  in  mind. 
A  j)aticnt  may  not  be  bedridden,  and  even  be  in  a  fairly  good  con- 
dition, with  well  formed  stools  and  very  insignificant  intestintd  disturb- 
ance, and  yet  in  the  adherent  particles  of  mucus  in  the  fjeces  the  amcjebae 
can  be  discovered.  In  such  a  patient  an  intense  relapse  is  liable  to 
occur  at  any  time  or  a  complication  with  liver  or  lung  abscess.  Cases 
are  not  rare  in  which  the  intestinal  symptoms  are  either  entirely  in 
abeyance  or  so  slight  as  to  attract  no  attention  until  the  occurrence  of 
hepatic  abscess,  which  may  be  detected  during  life  by  the  presence  of 
the  symptoms  heretofore  detailed,  or  when  rupture  has  taken  place  into 
a  bronchus  by  finding  the  amoebse  in  the  sputum.  In  other  instances 
the  existence  of  amoebic  dysentery  and  subsequent  abscess  of  the  liver 
is  not  recognized  until  revealed  by  the  autopsy. 

With  regard  to  the  diagnosis  of  secondary  dysentery,  attention  has 
already  been  called  to  the  fact  that  the  absence  of  characteristic  dysen- 
teric symptoms  is  the  rule  in  these  cases,  and  that  the  intestinal  compli- 
cation is  but  rarely  suspected  during  life.  The  knowledge  that  an 
extensive  colitis,  and  perhaps  ulceration,  may  be  manifested  only  by  a 
slight  diarrhoea  when  it  occurs  during  the  terminal  stages  of  some  severe 
adynamic  disease  should  not  be  lost  sight  of,  as  the  prognosis  in  the 
presence  of  such  a  complication  will  be  materially  aifected.  The 
necessity  of  careful  physical  examination  by  touch  and  speculum  in 
chronic  cases,  and  where  the  rectum  appears  to  be  involved,  has  been 
previously  mentioned. 

Prognosis  of  Dysentery. — The  prognosis  in  sporadic  dysen- 
tery in  adults  is  favorable  both  as  to  the  certainty  and  speed  of 
recovery,  though  it  is  to  be  borne  in  mind  that  a  certain  propor- 
tion may  eventuate  in  the  diphtheritic  form,  ultimately  proving 
fatal,  or  others  become  chronic  and  pursue  an  indefinitely  prolonged 
course.  On  the  contrary,  there  is  hardly  any  disease  in  wliich  the 
mortality  is  more  frightful  than  epidemic  or  diphtheritic  dysentery. 
The  circumstances  upon  which  the  epidemicity  depends  contribute 
very  greatly  to  increase  the  mortality.  It  is  unnecessary  here  to 
recapitulate  these  influences  in  detail :  it  suffices  to  say  that  impair- 
ment of  constitutional  vitality  from  long  continued  infraction  of 
hygienic  laws,  over-exertion,  loss  of  sleep,  exposure,  improper  and 
badly  cooked  food,  overcrowding,  filthy  surroundings,  impure  water, 
are  the  conditions  associated  with  epidemics  of  this  disease.  When  we 
take  into  consideration  the  further  fact  that  it  frequently  attacks  those 
whose  powers  are  already  enfeebled  by  the  existence  of  some  other 
severe  disease,  and  when  we  consider  the  extent  and  severity  of  the 
intestinal  lesions,  we  can  understand  that  the  death  rate  may  vary  from 
50  to  80  per  cent.     The  outcome  of  individual  cases  can  be  judged  by 


376  DYSENTERY. 

the  severity  of  the  symptoms.  Rapid  emaciation  and  debility,  dysen- 
teric collapse,  cool  surface  and  extremities,  dry,  brown  tongue,  heart 
failure,  anorexia  and  excessive  thirst,  tenderness  of  the  abdomen, 
anxious  countenance,  shrunken  features,  sero-sanguinolent  stools  con- 
taining masses  of  necrotic  tissue  having  a  cadaveric  odor,  a  putrid  scent 
from  the  body,  and  persistent  singultus,  are  symptoms  of  extensive 
intestinal  sloughing  and  forebode  a  fatal  ending.  When  diphtheritic  dys- 
entery supervenes  during  the  progress  of  the  chronic  form,  or  occurs 
secondary  to  some  severe  acute  or  chronic  disease,  the  patient,  being 
already  exhausted  and  emaciated,  is  apt  to  succumb  in  a  few  days.  Less 
severe  cases  may  assume  a  subacute  type,  often  lasting  a  month  and  a 
half  to  two  months,  and  may  end  in  recovery  or  pass  into  a  chronic 
flux  of  indefinite  duration.  It  should  not  be  forgotten  that  even 
extensive  ulceration  is  not  incompatible  with  cicatrization  and  cure. 

The  prognosis  in  children  will  be  governed  by  the  constitution  and 
surroundings  of  the  child,  the  ability  of  parents  to  execute  proper 
measures  of  treatment,  the  season  of  the  year  when  the  attack  begins, 
and  the  occurrence  of  complications.  It  goes  without  saying  that  the 
prognosis  is  more  unfavorable  when  the  child  is  already  the  victim  of 
malnutrition  from  tuberculosis,  rickets,  or  syphilis.  The  chances  for 
recovery  are  worse  in  crowded  centres  of  population,  among  the  poor, 
in  teeming  tenement  houses,  where  a  change  of  air  and  proper  alimenta- 
tion cannot  be  secured.  Cases  beginning  in  the  early  summer  are  less 
hopeful  than  those  occurring  later.  The  prognosis  is  worse  in  children 
prematurely  weaned  and  improperly  fed  or  who  have  suffered  with  pre- 
vious attacks  of  diarrhoea.  Persistent  fever,  vomiting,  rapid  wasting, 
and  severe  nervous  symptoms  are  of  ill  omen.  "The  form  of  stool 
which  is  of  worst  augury  is  that  composed  of  greenish  matter  like 
chopped  spinach  in  dirty  brown,  stinking  fluid,  and  mixed  with  puru- 
lent mucus  and  blood ;"  the  thicker  and  more  homogeneous  the  motions 
become,  although  they  may  still  be  intensely  offensive,  the  more  favor- 
able is  the  prognosis.  Continuance  of  normal  dentition,  the  appearance 
of  tears,  and,  according  to  Eustace  Smith,  the  occurrence  of  an  eruption 
unconnected  with  the  exanthemata,  are  signs  of  favorable  import.  Re- 
covery is  possible  even  in  cases  in  which  the  symptoms  are  violent. 
Under  no  circumstances  are  the  recuperative  powers  of  nature  in  chil- 
dren more  wonderfully  exhibited  than  sometimes  in  aggravated  cases  of 
dysentery.  I  have  seen  restoration  to  health  wiien  high  fever,  vomit- 
ing, excessive  purging,  bloody  and  mucoid  stools,  rapid  emaciation,  and 
exhaustion  would  have  seemed  to  render  such  a  favorable  ending  hope- 
less. 

The  prognosis  in  amoebic  forms,  whether  gangrenous,  chronic,  or  of 
moderate  severity,  is  always  uncertain  ;  the  gravity  of  the  disease  lies 
in  its  tendency  to  persist :  the  latter  is  inherent,  depending  upon  the 
nature  of  the  lesions  and  the  fact  that  they  are  so  refractory  to  thera- 
peutical measures.  The  frequency  of  hepatic  complications,  the  con- 
stant tendency  to  chronicity  in  cases  not  rapidly  proving  fatal,  are  fac- 
tors rendering  it  very  difficult  to  foretell  the  result.  A  duration  of  two 
to  four  or  six  months  in  recovered  cases  and  an  average  mortality  of 
33|-  per  cent,  are  about  what  can  be  expected. 

Treatiment  of   Dysentery  in  General. — Prophylaxis. — It  is 


PROPHYLAXIS.  377 

a  truthful  sayinji^  and  worthy  of"  universal  acceptation  with  rop^ard  to 
<lys(Miti'rv,  as  ot"  other  infectious  tliseases,  that  "  an  ounce  of  preven- 
tion is  worth  a  pound  of  cure."  In  the  assumption  of  the  infectious- 
ness of  this  disease  reference  is  especially  made  to  the  diphtheritic  or 
<}pidemic  and  amoebic  forms.  The  difi'erences  of  opinion  ])revailing 
upon  this  subject  are  rather  as  to  what  constitutes  infection  or  con- 
tagion tiian  as  to  the  real  facts  of  the  case,  for,  as  stated  by  Wood- 
ward, "  tlie  majority  of  the  g-reat  observers,  no  matter  wiiat  tlieir  opin- 
ion in  other  respects,  agree  in  regarding  the  dejecta  as  contagious." 

Whether  the  evidence  upon  this  subject  is  satisfactory  or  not,  there 
can  be  no  doubt  as  to  the  duty  of  the  physician  in  the  premises,  both  as 
a  sanitarian  and  humanitarian,  which  is  to  take  the  safe  ground,  "  to 
€rv  aloud  and  sj)are  not "  in  teaching  the  doctrines  of  prevention,  and 
in  the  execution  of  the  same  in  his  practice.  These  means  consist,  first, 
in  the  avoidance  of  all  predisposing  causes,  or,  in  other  words,  in  a 
strict  obedience  to  well  known  hygienic  laws.  The  selection  of  proper 
sites  for  camping  grounds,  barracks,  and  hospitals,  the  prevention  of  over- 
crowding in  tenement  houses,  ships,  and  jails,  the  regulation  of  sewage, 
the  care  for  the  food  and  drink,  the  observance  of  the  strictest  cleanli- 
ness by  authoritative  control, — "  all  these  "  (as  mentioned  by  Whittaker), 
"  are  general  measures  that  suggest  themselves  in  the  prophylaxis  of 
this  or  any  disease."  To  which  should  be  added  the  provision  of  proper 
clothing  and  shelter  and  the  avoidance,  as  far  as  possible,  of  excessive 
fatigue  and  loss  of  rest.  These  rules,  apparently  simple,  are  not  always 
easy  of  accomplishment.  No  doubt  a  great  deal  has  been  done  in  this 
direction  in  recent  years,  but  the  difficulties  in  the  way  of  providing  a 
proper  quality  and  quantity  of  food  and  pure  water  supply  are  by  no 
means  easy  to  overcome  ;  especially  is  this  the  case  where  large  bodies 
■of  men  are  congregated,  as  in  camps,  armies  in  the  field,  prisons,  tene- 
ment houses,  also  in  the  abodes  of  poverty,  filth,  vice,  and  ignorance, 
whether  in  cities  or  rural  districts.  Hence  we  find  epidemic  dysentery 
still  occurring  far  too  frequently.  As  to  a  proper  food  supply,  without 
going  into  details  it  is  sufficient  to  say  that  the  constitutional  state 
developed  as  a  result  of  the  continuous  neglect  of  physiological  laws  in 
relation  to  nutrition,  whether  correctly  called  scurvy  or  not,  is  respon- 
sible for  an  enormous  increase  in  the  number  and  fatality  of  dysenteric 
disorders.  But,  however  important  a  part  has  been  and  still  is  played 
by  an  improper  regulation  of  the  food,  it  fades  into  insignificance  when 
compared  with  the  evil  of  impure  water.  The  writer  does  not  wish  to 
appear  dogmatic  upon  this  subject,  but,  having  strong  convictions,  wishes 
to  emphasize  this  point :  That  when  the  legend  can  be  truthfully  in- 
scribed upon  the  doorposts  of  every  house  in  the  land.  Pure  icater  only 
used  here,  then  will  these  desolating  enemies  of  mankind,  typhoid  fever, 
cholera,  and  dysentery,  cease  to  scourge,  just  as  surely  as  the  destroying 
angel  passed  over  the  bloodstained  doors  of  the  Israelites  of  old. 

The  problem  to  be  solved  is  the  prevention  of  fecal  contamination 
of  the  drinking  water.  How  difficult  this  is  to  accomplish  is  shown  by 
the  continued  extensive  prevalence  of  these  diseases  in  spite  of  the 
knowledge  which  has  been  disseminated  concerning  them  in  recent 
years.  While  the  information  as  regards  the  infective  cause  of  dysen- 
tery is  not  so  complete  as  in  cholera  and  typhoid  fever,  yet  we  are  fully 


a78  DYSENTERY. 

warranted,  nay  impelled,  to  observe  the  same  precautions  with  respect 
to  the  complete  destruction  of  the  infective  organisms  the  stools  may 
contain  in  dysentery.  The  word  "  destruction "  is  used  advisedly  in 
lieu  of  "  disinfection,"  as  the  latter  term  is  too  often  loosely  applied  and 
insufficient  means  employed  to  effect  the  purpose.  The  directions  recom- 
mended by  the  American  Public  Health  Association  for  disinfection  in 
infectious  diseases  are  in  harmony  with  modern  knowledge  upon  this 
subject.  I  shall  not  give  these  in  extenso,  as  details  can  be  found  else- 
where. The  most  certain  and  potent  disinfectant  is  fire.  Every  hos- 
pital should  be  provided  with  a  furnace  for  the  destruction  of  infected 
excreta ;  when  heat  is  not  available,  the  stools  should  be  mixed  with  a 
strong  solution  of  chloride  of  lime  (four  ounces  to  the  gallon  of  Avater) 
or  a  solution  of  bichloride  of  mercury  and  permanganate  of  potash,  twa 
drachms  of  each  to  the  gallon,  the  latter  requiring  a  longer  contact  with 
the  discharges,  but  having  the  advantage  of  being  odorless.  Careful 
attention  should  be  paid  also  to  the  disinfection  of  the  person  and 
clothing  of  the  patient.  For  the  former  purpose  cleansing  and  spon- 
ging the  body  with  a  solution  of  appropriate  strength  of  carbolic  acid, 
chlorinated  soda,  chloride  of  lime,  or  corrosive  sublimate  Avill  answer ; 
the  clothing  and  bed  linen  may  be  disinfected  by  immersion  in  a  3  to  4 
per  cent,  solution  of  carbolic  acid  and  thorough  boiling. 

Suspected  water  should  be  absolutely  condemned.  Every  effort 
should  be  made  to  ensure  pure  water.  The  habit  of  drinking  only  that 
which  has  been  previously  boiled  should  be  inculcated  and  encouraged  by 
the  physician  in  every  way  possible,  not  alone  in  the  prevention  of 
dysentery,  but  as  a  wise  measure  of  defence  against  other  infection. 
The  practice  of  drinking  water  without  previous  purification  from 
shallow  wells,  springs,  ponds,  tanks,  marshes,  and  pools  should  be  dis- 
couraged, as  the  water  from  such  sources  is  specially  liable  to  contamina- 
tion from  surface  drainage.  Running  water,  as  in  rivers  and  creeks,  is 
more  likely  to  purify  itself,  but  should  be  protected  from  infection  and 
cleansed  by  filtration  and  boiling.  It  is  unnecessary  to  go  into  further 
details  upon  this  subject,  as  the  proposition  will  not  be  disputed  that  the 
enlightenment  of  an  advancing  civilization  will  under  no  circumstances 
be  more  beneficently  displayed  than  in  the  perfection  of  the  means 
of  securing  pure  water.  When  the  nations  of  the  earth  learn  that  ta 
spend  millions  of  dollars,  if  need  be,  for  this  purpose  is  the  exercise 
of  a  true  economy,  then  will  epidemic  dysentery  and  kindred  diseases 
disappear. 

Medicinal  Treatment. — Before  giving  an  outline  of  the  manage- 
ment of  the  different  forms  of  dysentery  some  general  remarks  upon 
the  uses  and  powers  of  the  principal  medicinal  agents  advisable  will  be 
appropriate.  At  the  outset  it  should  be  understood  that  there  is  no 
specific  for  any  form  of  this  disease. 

As  was  demonstrated  by  Austin  Flint  the  natural  course  of  sporadic 
dysentery  is  toward  spontaneous  recovery  in  ten  to  fourteen  days ;  so 
the  effect  of  any  remedy  which  apparently  cures  should  be  judged  with 
this  fact  in  mind.  Specifics  for  the  cure  of  dysentery  have  been  vaunted 
from  time  immemorial.  In  1736  the  celebrated  Pringle  read  a  dis- 
course before  the  Edinburgh  Society  for  Improving  Natural  Knowledge, 
in  which  he  claimed  for  a  preparation  known  as  Young's  antidysenteric 


MEDTCLX.  I L    THE.  1 TMENT.  379 

powder,  or  ^'  rifriinn  (Dtfiiitoiili  (■('I'dhiiii,^''  that  it  was  a  p;pnnin('  sju'cifio 
I'or  dysentery.  Tlie  reputation  of  this  niedieine  rapidly  spread  tlirongh 
Europe,  but  it  was  soon  found  to  be  iincertiiin  in  its  action  and  often 
dan<>erous,  so  that  after  an  extensive  but  brief  popidarity  it  fell  into 
tlisuse.     Sueh  has  been  the  fate  of  many  other  so-called  specifics. 

Ipecac  is  the  remedy  which  has  attained  a  f^reatcr  reputation  than 
any  other  as  a  spccilic  for  dysentery.  Its  use  in  this  disease  was  made 
known  by  Piso  in  1G48;  he  described  it  as  a  "sacred  anchor,  as  the 
most  exquisite  gift  of  nature,"  claiming  that  it  not  only  evacuated  the 
morbid  humors  by  purging  as  well  as  by  vomiting,  but  produced  revul- 
sion from  the  diseased  intestine,  and  that  an  astringent  effect  succeeded 
its  primary  action.  It  was  forgotten  for  a  time  until  reintroduced  by 
Adrian  Helvetius  as  an  antidysenteric  nostrum.  The  secret  was  bought 
by  Louis  XIV.  and  given  to  the  profession  of  the  time,  by  whom  it 
was  regarded  as  a  specific  for  dysenteric  fluxes ;  but  the  belief  gradually 
died  out.  Broussais  used  his  influence  against  it,  though  it  still  c;on- 
tinued  to  be  prescribed  by  a  few  until  in  1851  it  was  made  the  subject 
of  a  special  essay  by  Savignac,  who  ascribed  its  beneficial  results  to  not 
only  its  emetic  and  purgative  action,  but  to  its  diaphoretic,  sedative, 
and  alterative  influence.  The  article  of  Savignac  did  not  attract  much 
attention.  In  1858,  Docker,  who  had  successfully  employed  ipecac  on 
the  island  of  Mauritius  in  the  treatment  of  dysentery,  called  renewed 
attention  to  the  subject.  His  plan  of  administration  (the  one  still  used) 
was,  having  put  the  patient  to  bed,  to  give  a  drachm  of  laudanum, 
apply  a  sinapism  over  the  stomach,  half  an  liour  later  to  give  from 
thirty  to  ninety  grains  of  powdered  ipecac,  usually  in  a  bolus ;  if  this 
was  vomited,  he  repeated  the  dose  until  it  was  retained.  A  single  dose 
often  sufficed  for  a  cure,  the  pains  promptly  subsided,  and  the  stools 
ceased.  He  gave  it  to  patients  of  various  constitutions  and  in  all  stages 
of  the  disease  with  equal  benefit — out  of  50  cases  he  lost  but  1 .  The  pub- 
lication of  Docker's  results  was  followed  by  the  rapid  and  successful 
introduction  of  his  method  in  India,  where  it  was  advocated  by  Donald- 
son, Cunningham,  Ewart,  and  others.  In  England  it  received  the  sup- 
port of  Waring,  Maclean,  and  Aitken.  During  the  American  Civil 
War  the  ipecac  treatment  was  not  very  thoroughly  tested ;  its  trial, 
however,  at  the  Ecklington  Hospital,  AVashington,  D.  C,  and  in  an 
epidemic  at  Columbia,  S.  C,  was  not  favorable.  Better  results  have 
been  reported  at  various  times  in  medical  journals  of  the  United  States 
by  the  non-emetic  use  of  the  drug  in  sporadic  dysentery  and  also  in 
chronic  fluxes.  It  has  been  used  to  a  certain  extent  on  the  continent 
of  Europe,  and,  it  is  stated,  with  fair  success  during  the  late  Franco- 
Prussian  War.  Maclean  has  been  a  most  enthusiastic  advocate  of  the 
ipecac  treatment.  He  says  in  1868,  "a  decade  after  the  introduction  of 
this  treatment  into  India,  that  it  is  now  almost  invariably  followed ;  it 
has  reduced  the  former  mortality  by  from  25  to  75  per  cent. ;  it  is,  in 
his  opinion,  the  most  simple,  the  most  successful,  the  most  conservative 
treatment  he  has  ever  seen  used  in  dysentery.  Year  by  year  under  its 
use  the  number  of  chronic  cases  is  becoming  smaller  and  hepatic  abscess 
less  frequently  seen."  Joseph  Ewart  in  1883  speaks  of  it  with  the 
same  enthusiasm.  Numerous  other  writers  in  India  corroborate  these 
vie-^vs.     Recently,  however,  there  has  been  a  modification  of  opinion 


380  DYSENTERY. 

upon  this  subject.  Dobie  ^  says  that  the  treatment  by  large  doses  of 
ipecac  has  fallen  into  disfavor.  Chowdhovry  says  that  both  in  civil 
hospitals  and  private  practice  it  has  been  found  unbearable  in  many 
cases.  While  neither  of  these  writers  have  lost  faith  in  the  ipecac 
treatment,  they  advocate  its  use  in  much  smaller  doses.  Upon  this 
subject  Woodward  judiciously  remarks  :  "  It  will  be  observed  that  in 
the  most  modern  times  the  use  of  ipecacuanha  in  the  treatment  of  the 
fluxes  has  re-established  the  reputation  it  enjoyed  in  the  seventeenth 
century,  and  is  regarded  in  many  quarters  with  a  confidence  as  blind  as 
that  reposed  in  it  by  Piso  or  Helvetius.  Nevertheless,  a  little  reflec- 
tion must  show  the  absurdity  of  expecting  benefit  from  such  a  remedy 
in  acute  diphtheritic  dysentery  after  the  formation  of  the  diphtheritic 
layer,  in  the  chronic  fluxes  after  extensive  ulceration  has  already 
occurred,  or  in  those  cases  which  owe  their  virulence  to  the  co-existence 
of  a  scorbutic  or  some  other  constitutional  taint.  It  is  easy  to  recog- 
nize, by  the  details  of  the  majority  of  the  successful  cases  recorded  in 
which  the  virtues  of  ipecac  are  most  lauded,  that  they  were  sporadic, 
for  the  most  part  mild  acute  forms,  and  against  the  small  number  of 
chronic  cases  reported  to  have  been  successfully  treated  must  be  offset 
the  contrary  results  of  the  larger  clinical  experience  of  the  Ecklington 
and  Dreadnought  hospitals."  While  the  above  is  perfectly  true,  and 
while  the  ipecac  treatment,  in  spite  of  oft-repeated  trials,  has  never 
gained  a  foothold  in  this  country,  w^e  must  concede  that  in  tropical  and 
certain  severe  cases  of  catarrhal  dysentery  it  is  a  remedy  of  great  value  : 
the  number  of  those  who  testify  upon  this  point  and  their  reliability 
leaves  us  no  room  for  doubt.  It  is  possible,  as  suggested  by  Ball, 
that  the  discrepancy  of  results  as  obtained  in  America  and  India  may 
be  due  to  the  fact  that  ipecac  possesses  especially  curative  powers  in  the 
amoebic  form  ;  if  so,  such  results  must  follow  only  in  the  earliest  stages, 
for  it  is  only  necessary  to  reflect  upon  the  nature  of  the  lesions  to  be 
convinced  that  we  cannot  rationally  expect  any  immediate  cure  from 
ipecac  or  any  other  remedy  after  the  intestinal  ulceration  has  fairly 
commenced.  As  regards  the  use  of  this  drug  in  much  smaller  doses, 
one  to  three  grains  every  two  to  three  hours,  while  this  method  has 
received  the  sanction  of  some  of  the  highest  authorities,  the  writer  must 
express  his  skepticivSm,  for  the  reason  that,  so  far  as  he  knows,  there  has 
been  no  systematic  experimentation  with  this  remedy  alone :  the  exigen- 
cies are  such  that  other  remedies  are  generally  prescribed  at  the  same 
time,  leaving  the  effects  of  the  ipecac  in  doubt.  Careful  clinical  obser- 
vation only  will  settle  these  questions. 

Opium. — The  history  of  the  use  of  this  remedy  in  the  treatment  of 
intestinal  fluxes  is  exceedingly  interesting.  Its  unique  and  incompar- 
able therapeutic  powers  have  caused  its  administration  to  enter  more  or 
less  into  every  plan  of  treatment  of  these  diseases  from  prehistoric  times 
down  to  the  present  day.  It  was  of  the  effect  of  opium  in  dysentery 
that  Sydenham  wrote  his  celebrated  eulogy  beginning,  "  And  here  I  can- 
not but  break  out  in  praise  of  the  great  God,  the  Giver  of  all  good 
things,  who  hath  granted  to  the  human  race,  as  a  comfort  in  their  afflic- 
tions, no  medicine  of  the  value  of  opium,  either  in  regard  to  the  num- 
ber of  diseases  it  can  control  or  its  efficacy  in  extirpating  them." 

'  London  Lancet,  1888. 


MEDICIXAL    'J'JUJATMJ'JNT.  881 

TIk'  position  of  o])iuin  us  a  ivmcdy  for  dysontoric  affections  is  a 
peculiar  one.  It  has  hei'U  used  by  tliose  who  abuse  it,  and  abused  by 
those  who  use  it.  The  controversy  as  to  its  proj)cr  phice  and  ])o\vers, 
which  has  been  of  very  long  standing,  is  still  unsettled.  \\'itliout 
attempting  to  enter  fully  into  the  history  and  merits  of  the  dis[)utation 
between  the  extremists  (»n  the  one  hand,  who  claim  that  opium  is  a  sov- 
ereign remedv  in  all  forms  and  stages  of  dysenti-rv  and  has  peculiar 
anti])iiiogistic  powers,  and  those,  on  the  contrary,  wh(»  hold  that  it  is 
procluctive  of  more  harm  than  good,  I  shall  endeavor  to  deline  its  true 
place  and  powers  in  the  treatment  of  dysenteric  disorders.  The  fact 
that  it  has  maintained  its  position  for  centuries  in  spite  of  the  very 
strong  opposition  to  its  use  and  the  excellent  reasons  for  the  same  is 
very  good  evidence  that  opium  is  possessed  of  j)eculiar  and  positive 
virtues.  As  an  analgesic  it  is  unsurpassed.  In  a  disease  where  pain, 
excessiv^e  intestinal  peristalsis,  loss  of  sleep,  and  ofttimes  both  primary 
and  secondary  nervous  depression,  play  such  an  important  part  it  is  diffi- 
cult to  dispense  with  opium  in  some  form  or  at  some  time,  no  agent  hav- 
ing yet  been  found  to  equal  it  for  the  relief  of  these  symptoms.  The 
objection  which  has  been  strongly  and  truthfully  urged  against  its  use 
is  that  it  produces  anorexia,  nausea,  arrest  of  secretion,  indigestion,  ner- 
vous depression,  constipation,  and  retention  of  acrid  irritant  contents  of 
the  intestine. 

While  freely  admitting  these  evils,  the  practical  conservative  thera- 
peutist still  finds  in  opium  a  remedy  difficult  to  dispense  with.  The 
ground  taken  by  George  B.  Wood,  Stille,  Flint,  and  a  host  of  the  fol- 
lowers of  these  great  leaders  of  medical  thought  in  this  country,  that 
opium  exercises  some  special  power  in  controlling  the  inflammatory 
process  of  the  intestines,  is  not  now  regarded  as  tenable,  for,  as  Ball 
pertinently  asks,  "  What  reason  is  there  to  suppose  that  in  croupous  and 
amoebic  inflammations  of  the  colon  Opium  exercises  any  more  of  an 
antiphlogistic  power  than  it  does  in  typhoid  infection  of  the  small  intes- 
tine or  in  diphtheria  of  the  throat  ?  For  my  own  part,"  he  says,  "  ex- 
perience has  taught  me  more  and  more  to  distrust  the  fallacious  effects 
of  opium  in  dysenteric  diseases,  and  I  am  quite  sure  that  this  conclusion 
is  in  accord  with  most  recent  anthorities."  Accepting  this  warning,  as 
well  as  that  of  Galen,  who  wrote,  sixteen  centuries  ago,  that  ''  those  who 
resort  to  anodyne  remedies  at  improper  times  or  immoderately  jugulate 
the  sick  along  with  their  pains,"  we  still  find  an  indispensable  place  for 
opium  :  especially  is  this  true  in  severe  cases  of  the  catarrhal  and  diph- 
theritic forms,  obviating  its  acknowledged  e\'il  effects  by  proper  doses 
and  judicious  combination  and  alternation  with  other  medicines.  Not 
expecting  any  specific  effect  upon  the  inflammatory  or  ulcerative  pro- 
cess, we  give  it  to  ease  the  pain,  to  reduce  the  excessive  frequency  of  the 
actions,  to  control  morbid  peristalsis,  to  relieve  the  agonizing  tenesmus, 
to  afford  needed  rest,  and  to  overcome  the  profound  nervous  shock  inci- 
dental to  the  diseases  we  are  dealing  with.  It  is  for  these  reasons  that 
those  who  have  urged  the  strongest  objections  against  the  prescription 
of  opium  have  themselves  employed  it  while  abusing  it,  and,  having 
most  excellent  grounds  for  so  doing,  they  are  nevertheless  compelled  to 
use  it.  Until  some  remedy  is  found  which  possesses  the  therapeutical 
powers  of  opium  without  its  objectionable  features  it  will  still  occupy  a 


382  DYSENTERY. 

prominent  place  in  the  list  of  remedies  for  the  treatment  of  dysenteric 
diseases. 

Purgatives, — Mild  purgation  for  the  purpose  of  evacuating  the  ali- 
mentary canal  of  the  peccant  humors,  being  in  accordance  with  the 
humoral  pathology,  has  been  resorted  to  in  the  treatment  of  intestinal 
fluxes  from  the  earliest  times.  It  was  generally  admitted  that  drastic 
cathartics  were  objectionable,  on  account  of  their  irritant  effects  ;  hence 
the  milder  laxatives,  especially  those  having  an  after  astringent  effect, 
were  preferred.  According  to  modern  views,  purgatives  are  used  in  the 
treatment  of  dysentery  to  fulfil  the  following  indications  :  (a)  To  cleanse 
the  alimentary  canal  of  various  irritants,  as  undigested  food,  hardened 
fecal  masses,  and  decomposing  secretions ;  (6)  to  increase  and  modify 
intestinal  and  other  glandular  secretion,  thus  aiding  absorption  and 
assimilation ;  (c)  by  increased  secretion  to  favorably  influence  congestive 
and  inflammatory  processes  of  the  intestines.  The  remedies  which  have 
been  most  extensively  used  to  accomplish  these  ends  are  rhubarb,  castor 
oil,  calomel,  and  the  salines ;  of  the  latter  especially  the  sulphates  of 
soda  and  magnesia.  As  to  rhubarb,  while  its  secondary  effect  may  render 
its  use  occasionally  advisable  in  mild  cases  or  in  children  with  irritant 
intestinal  accumulations,  its  tardy,  uncertain,  and  painful  action  ren- 
ders it  generally  objectionable. 

Castor  oil,  on  account  of  its  certain,  rapid,  and  generally  unirritant 
action,  has  been  extensively  used,  especially  in  England  and  the  United 
States.  Illustrative  of  the  extent  of  its  consumption.  Woodward  states 
that  nearly  a  quarter  of  a  million  of  quarts  were  purchased  by  the  pur- 
veying department  of  the  army  during  the  four  years  of  the  American 
Oivil  War,  and  either  alone  or  combined  with  laudanum  or  turpentine 
it  was  the  favorite  purgative  in  dysentery.  It  is  not  now  very  often 
prescribed  for  adults  on  account  of  its  nauseous  taste,  and  the  fact  that 
it  is  a  simple  evacuant ;  it  is,  however,  quite  frequently  given  with 
advantage  in  the  mild  fluxes  of  children,  as  well  as  of  adults,  in  the 
form  of  emulsion  and  in  combination  with  opiates  to  obviate  any 
griping  effects. 

Calomel  appears  to  have  been  first  used  in  the  treatment  of  dysentery 
early  in  the  seventeenth  century.  It  was  very  extensively  employed, 
and  an  immense  amount  of  harm  done  with  it  during  the  first  half  of 
the  present  century.  It  was  used  not  only  for  its  effects  upon  the  intes- 
tinal canal,  but  in  conjunction  with  mercurial  inunctions  and  opium  in 
order  to  produce  salivation.  The  extent  to  which  it  was  misused  is 
almost  incomprehensible.  Cunningham  in  1805  gave  it  in  twenty-grain 
doses  repeated  two  or  three  times  a  day,  one  of  his  patients  taking  in 
this  way  three  hundred  and  sixty  grains.  In  ordinary  dysenteries  John- 
son was  content  to  give  daily  twenty -four  to  forty-eight  grains  of  calo- 
mel with  two  to  four  grains  of  opium  and  ten  to  fifteen  of  antimonial 
powder  or  ipecac.  The  enormous  mortality  necessarily  resulting  from 
such  heroic  medication  did  not  appear  to  disabuse  the  minds  of  those 
who  resorted  to  it :  it  was  not  until  1844  that  this  practice  ceased  in 
India,  but  calomel  continued  to  be  used  in  more  moderate  doses  until 
1860,  when  it  was  displaced  almost  entirely  by  the  ipecac  treatment. 
The  abuse  of  this  medicine  in  Europe  and  in  the  United  States  was 
notable,  but  not  so  great  as  in  the  tropics. 


MFA)icL\.  1 L  rn /■;.  i  tmext.  383 

Diirino;  the  Aniorican  Civil  War  calonu'l  Avas  cxtciisivclv  used  in  tlio 
troatnuMit  ofdyscntcrv.  It  was  misused  to  siicli  an  extent,  in  the  opin- 
ion of  the  yni-o-eon  (Jeneral,  that  he  issued  an  order  directing  that  it  he 
struck  from  the  suj)|)ly  table  of  the  army,  and  that  no  further  re(|uisi- 
tion  for  this  medicine  should  be  approved  by  Medical  Directors.  \Vhile 
this  ]>iece  of  official  despotism  -svas  denounced  by  the  American  Medical 
Association  as  "an  unjust  charg-e  of  Avholesale  inalj)ractiee  a<;ainst  the 
army  suroeons,  and  as  unwise  and  unnecessary,"  it  illustrat<'s  the  change 
of  oj)inion  upon  this  subject,  for,  though  it  was  so  extensively  used 
twenty  years  ago,  Ball  comments  upon  the  fact  that  Osier  does  not 
even  mention  calomel  as  a  remedy  for  dysentery  in  his  recent  work  upon 
the  Practice  of  Medicine. 

In  spite  of  the  terrible  abuse  of  this  remedy  in  the  past,  and  the  fact 
that  it  has  been  negatively  placed  upon  the  black  list  by  such  a  high 
authority  as  Osier,  the  writer  is  of  the  opinion  that  calomel  judici- 
ously and  carefully  used  fulfils  some  important  indications  in  the  treat- 
ment of  dysentery  :  especially  is  this  the  case  in  the  presence  of  malarial 
complications.  Here  and  in  similar  conditions,  where  there  is  a  morbid 
condition  in  the  processes  of  absorption  and  secretion  of  the  alimentary 
glandular  organs,  calomel  exerts  a  unique  beneficial  influence.  It  should 
not  be  used  as  a  purgative,  for  we  have  those  which  are  milder  and  more 
rapid,  but  solely  for  its  alterative  effect,  which  can  be  obtained  by  small 
doses  and  without  harmful  results. 

Saline  Purgatives. — The  salines  have  long  sustained  a  well  deserved 
reputation  in  the  treatment  of  dysentery.  In  many  respects  they  are 
superior  to  any  other  purgative.  As  cleansing  agents  their  rapid  action, 
the  increased  secretion  produced  by  them,  their  mildness  and  certainty, 
are  special  advantages  ;  in  addition  to  which  they  are  acceptable  to  the 
stomach,  deplete  the  intestinal  bloodvessels,  and,  it  is  claimed  by  some, 
increase  the  secretion  of  bile.  Rapidly  following  their  use  the  bloody 
and  mucous  stools  are  replaced  by  free  liquid  fecal  dejections ;  the  tormina 
and  tenesmus  are  relieved  ;  many  cases  of  the  sporadic  form  require  no 
other  treatment  than  a  free  saline  purge.  The  sulphate  of  magnesia  or 
sulphate  of  soda  are  to  be  preferred.  Details  as  to  methods  of  admin- 
istration and  dosage  will  be  hereafter  mentioned. 

Vegetable  and  3Iineral  Astringents, — Remedies  of  this  class  adminis- 
tered by  the  stomach  have  been  more  or  less  extensively  used  in  the 
treatment  of  intestinal  fluxes  for  centuries.  It  will  only  be  necessary 
to  speak  of  a  few  of  them  as  representative  of  the  class.  They  are 
advised  for  the  supposed  effect  of  checking  excessive  and  abnormal  secre- 
tion and  of  stimulating  to  healthy  action  an  inflamed  or  ulcerated  mucous 
membrane. 

Tannic  or  gallic  acid  will  doubtless  represent  all  the  virtues  of  the 
vegetable  astringents ;  of  the  minerals,  the  salts  of  iron,  lead,  copper, 
and  silver  are  typical.  Most  of  the  members  of  this  group  have  very 
properly  been  discarded  in  the  treatment  of  dysentery.  Nitrate  of  silver, 
however,  still  has  the  sanction  of  high  authority,  especially  in  chronic 
cases.  In  its  administration  the  question  alw^ays  arises.  How  can  we 
rationally  expect  a  half  grain  of  this  easily  altered  salt  to  run  the  gaunt- 
let of  chemical  change  from  stomach  to  colon,  and  then  produce  any 
material  effect  upon  the  extensive  surface  of  the  latter,  as  it  is  generally 


384  DYSENTERY. 

given  in  combination  with  other  remedies  ?  The  verdict  upon  its  use  by 
most  clinicians  will  be  "  utility  doubtful." 

Antiseptics. — The  most  important  agents  of  this  class  are  bichloride 
of  mercury,  the  salts  of  bismuth,  creasote,  carbolic  acid,  salol,  naphtha- 
lin,  resorcin,  creolin,  tricresol,  etc.  These  remedies  have  been  advised 
for  use  per  os  upon  the  germicidal  theory,  and  prescribed  with  varied 
success  in  dysentery  and  kindred  aifections.  Without  stopping  to  dis- 
cuss the  merits  of  this  theory,  or  how  far  it  is  practicable  to  reach  from 
above  and  destroy  infectious  organisms  in  the  colon,  let  us  view  them 
from  a  clinical  standpoint. 

Corrosive  sublimate  was  recommended  by  Kopp  in  1827,  subsequently 
by  Eisenmann  and  Parkes,  more  recently  by  Ringer ;  the  latter  claims 
that  in  the  acute  fluxes  with  frequent  bloody,  slimy  stools  rapid  relief  is 
effected  by  hourly  doses  of  yro  **^  T2"o^  grain.  It  perhaps  may  do  good 
in  some  cases,  but  its  virtues  have  not  been  generally  substantiated. 

Subnitrate,  Subcarbonate,  SubgaUate,  and  Salicylate  of  Bismuth. — 
These  salts  of  bismuth  produce  very  similar  results,  and  the  consensus 
of  opinion  is  decidedly  favorable  as  to  their  beneficial  action,  more  espe- 
cially in  the  chronic  fluxes.  Exactly  the  modus  operandi  of  bismuth  is 
not  known  positively  :  judging  by  its  local  effects,  we  conclude  that  it  is 
slightly  astringent,  antiseptic,  and  protective.  When  perfectly  pure  it 
can  be  given  in  such  large  doses  (thirty  to  sixty  grains)  as  to  ensure  its 
passage  through  the  colon.  It  subserves  its  best  purpose  after  the  acute 
stage  has  passed  and  the  intestine  has  been  emptied  of  all  irritant  con- 
tents. In  chronic  cases  it  aids  in  the  healing  process  and  decreases  the 
frequency  of  the  stools. 

Creasote  and  Carbolic  Acid. — The  well  known  antiseptic  and  anti- 
putrescent  power  of  these  drugs  commend  them  for  trial  in  dysentery. 
The  difficulty  to  overcome  in  their  use  is  to  introduce  them  in  suf- 
ficiently large  quantities  to  produce  an  antiseptic  effect  upon  the  intes- 
tine without  poisoning  the  patient.  So  far,  this  objection  as  to  carbolic 
acid  has  proven  to  be  insuperable.  Recently  creasote  has  been  given  in 
much  larger  doses  in  the  treatment  of  tuberculosis  than  was  formerly 
thought  possible  ;  though  it  has  been  warmly  praised  in  some  quarters, 
its  positive  value  in  dysentery  has  not  been  established. 

NaphthcUin,  resorcin,  salol,  and  numerous  other  members  of  the 
phenol  group  have  been  advised  and,  especially  the  latter,  extensively 
used  in  dysentery  and  kindred  affections  upon  the  ground  that  effectual 
intestinal  antisepsis  could  be  produced  by  them  without  danger  of  toxic 
effects.  Good  results  have  been  claimed  for  naphthalin  given  in  five- 
grain  doses  three  or  four  times  daily.  I  can  speak  of  the  value  of  salol 
from  quite  an  extensive  experience  in  the  acute  diarrhoeas  and  dysenteries 
of  both  children  and  adults,  as  well  as  in  the  obstinate  looseness  of  the 
bowels  in  the  amoebic  form.  Combined  with  large  doses  of  bismuth,  it 
appears  to  exercise  better  control  over  this  obstinate  diarrhoea  than  any 
other  remedy.  It  can  be  given  in  large  doses  (twenty  grains  to  an 
adult)  and  kept  up  for  days  without  harmful  results. 

Tricresol. — A  combination  of  ortho-,  para-,  and  metacresols,  con- 
stituting tricresol,  now  obtained  in  a  pure  state  from  coal  tar,  has 
recently  been  the  subject  of  studious  investigation  by  chemists,  bacteri- 
ologists, and  surgeons  in  Germany  and  elsewhere.     This  new  claimant 


TREATMENT  OF  CATARRHAL  DYSENTERY.  385 

for  antiseptic  honors  is  siiid  to  possess  deeideil  advunta^^es  over  its  older 
competitors — viz.  that  it  will  act  in  the  presence  of  albumin,  and  that, 
beinij;  five  times  as  powerful  as  carbolic  acid,  it  will  ])ro(hice  intestinal 
antisepsis  without  dauo-er.  II.  Kolch  rej)orts  12  cases  of  tyj)ln>i<l  fi'ver 
recently  treated  with  this  a_i;'ent  alone,  *>ivin*>-  it  in  doses  of  one  and  one 
half  grains  dissolved  in  oUve  oil  by  means  of  potash  soap  in  capsule 
three  times  daily  after  milk.  The  result  was  rapid  convalescence  in 
thirteen  to  eighteen  days  and  an  absence  of  all  severe  symptoms.  If 
these  favorable  reports  are  confirmed,  the  remedy  commends  itself  in 
the  treatment  of  dysentery,  both  by  the  stomach  and  by  injecticjn  of  a 
solution  in  the  bowel. 

Medicatio)i  by  the  Rectum. — The  plan  of  treating  inflammatory  dis- 
eases of  the  lower  bowel  by  direct  medication  through  the  rectum  is 
not  new :  on  account,  however,  of  various  difficulties  it  did  not  grow 
into  general  favor  until  in  recent  years.  The  objections  to  rectal  medi- 
cation which  have  been  urged  are  the  pain  incident  to  the  introduction 
of  the  tubes  in  the  anus,  the  irritability  of  the  I'ectmn  causing  expulsion 
of  the  injection,  and  the  uncertainty  of  the  amount  of  the  drug 
absorbed.  The  advantages,  however,  of  local  treatment  are  so  positive 
as  to  warrant  the  eiforts  which  have  been  made  to  overcome  the  objec- 
tions, and  ])robably  the  greatest  advance  made  in  the  treatment  of 
dysenteric  diseases  has  been  in  the  extensive  use  of  local  means.  The 
indications  fulfilled  by  rectal  treatment  are  (a)  by  thorough  irrigation 
with  simple  warm  or  cold  water  to  cleanse  the  rectum  of  all  irritant 
contents ;  (6)  by  astringent  and  alterative  remedies  to  stimulate  healthy 
action  of  the  inflamed  or  ulcerated  mucous  membrane  and  control 
excessive  serous  exudation ;  (c)  by  the  use  of  antiseptics  to  destroy 
infective  organisms ;  {d)  by  the  local  action  of  anodynes  to  produce  a 
more  rapid  and  powerful  effect  than  when  the  remedy  is  introduced  by 
the  stomach.  Rectal  tenesmus  and  premature  expulsion  of  the  enemata 
can  best  be  overcome  by  the  previous  injection  of  a  cocaine  solution  or 
by  throwing  into  the  bowel  half  a  drachm  of  laudanum  in  half  an 
ounce  of  warm  starch-water.  To  thoroughly  irrigate  the  colon  one  and 
a  half  to  two  quarts  are  necessary.  A  large  sized  Nelaton's  catheter  or 
a  rubber  tube  made  for  the  purpose,  having  been  gently  introduced 
eight  or  ten  inches,  should  be  connected  with  a  fountain  syringe  or 
funnel,  with  the  patient  in  the  knee-elbow  position  or  with  the  hips 
elevated  on  a  pillow.  The  injection  should  be  allowed  to  flow  very 
gradually  into  the  bowel,  the  connecting  tube  being  compressed  occa- 
sionally and  the  abdominal  wall  gently  kneaded  in  the  direction  of  the 
colon  from  below  upward,  to  allow  the  intestine  to  adapt  itself  to  the 
distending  process  and  prevent  a  possible  rupture.  Very  happy  results 
have  followed  simple  irrigation  with  boiled  water,  the  griping  pains  and 
frequency  of  the  stools  being  rapidly  reduced.  In  other  cases  a  solution 
of  common  salt  or  borax,  about  two  drachms  to  the  pint  of  water,  has  a 
better  effect.  The  use  of  medicated  injections  will  be  mentioned  in 
connection  with  the  special  treatment. 

Treatment  of  Catarrhal  Dysextery. — Confinement  to  bed  is 
necessary  in  all  cases ;  the  attempt  to  be  up  and  to  take  exercise  of  any 
kind  is  prejudicial.  The  diet  should  be  carefully  regulated ;  no  splid 
food  should'  be  taken ;  milk,  chicken,  and  meat  broths,  and  light  farina- 

VoL.  I.— 25 


386  DYSENTERY. 

ceous  articles,  should  constitute  the  nourishment.  The  bowels  should  be 
cleared  out  by  a  saline,  half  an  ounce  of  Epsom,  Glauber's,  or  Rochelle 
salt ;  if  one  dose  should  not  act  freely,  it  may  be  repeated ;  the  occur- 
rence of  free  watery  stools  is  usually  followed  by  a  relief  of  the 
symptoms.  If  there  is  a  disposition  to  excessive  peristalsis,  the  salts 
can  be  followed  by  an  opiate  with  bismuth  or  salol  combined  with  the 
latter,  as  in  the  following  prescription : 

^.  Bismuthi  subnitratis,  Siij  ; 

Salol,  3j ; 

Pulveris  opii,  gr.  vj. 

Misce  et  in  chartulas  No.  vj  dividenda. 
Sig.  Take  one  powder  every  three  or  four  hours  according  to  frequency 
of  the  stools. 

In  two  or  three  days  it  may  be  necessary  to  repeat  the  saline.  Or  the 
case  can  be  treated  from  the  beginning  by  giving  small  doses  of  salts, 
one  to  two  drachms,  in  combination  with  four  to  five  drops  of  tincture 
of  opium,  taken  three  or  four  times  daily.  The  milder  cases  may  be 
relieved  by  simply  washing  out  the  colon  with  three  to  four  pints  of 
warm  water. 

Treatment  of  Diphtheritic  Dysentery. — The  problem  of 
treatment  here  is  not  so  simple.  The  lesions  are  so  severe  that  many 
cases  will  die  in  spite  of  everything  that  can  be  done.  The  indica- 
tions are  to  (a)  sustain  the  patient's  powers  by  nutritious,  unirritating 
food,  and  by  the  free  use  of  stimulants,  alcohol  and  strychnine ;  (6)  to 
counteract  malarial  complications  by  the  use  of  quinine,  and  scurvy 
by  fresh  vegetable  diet ;  (e)  to  relieve  pains,  obviate  nervous  depres- 
sion, produce  sleep,  and  hold  in  check  the  excessive  frequency  of  the 
stools,  for  which  purpose  opium  in  some  form  is  demanded ;  (<:?)  to 
cleanse  the  intestine  by  the  occasional  and  moderate  use  of  salines ; 
(e)  to  produce  a  healing,  protective,  and  antiseptic  effect  upon  the 
bowels  by  the  use  of  such  remedies  internally  as  bismuth,  salol, 
creasote,  turpentine,  tricresol,  naphthalin ;  (/)  to  cleanse  the  bowel 
by  irrigation  and  to  medicate  it  by  injections  of  antiseptic  and  astrin- 
gent remedies. 

In  a  disease  characterized  by  such  profound  constitutional  depression 
the  careful  selection  and  administration  of  food  become  a  matter  of 
great  moment.  The  digestive  powers  are  impaired ;  hence  peptonized 
milk,  milk  with  lime  or  Vichy  water,  koumyss,  or  matzoon,  liquid  pep- 
tonoids,  chicken  broth,  beef  juice,  should  be  prescribed — in  other 
words,  concentrated  nutritious  food  that  will  be  largely  absorbed  and 
leave  no  irritant  debris.  Alcoholic  stimulants  in  the  form  of  good 
whiskey,  brandy,  and  champagne  are  necessary  as  soon  as  adynamic 
symptoms  are  noticed,  or  even  to  anticipate  them  when  we  are  sure  of 
the  diagnosis.  Strychnine  is  useful,  not  only  for  its  stimulant  effect 
upon  the  heart,  but  for  its  tonic  effect  upon  the  muscular  coat  of  the 
intestine.  Quinine  is  required  whenever  a  malarial  factor  is  present : 
it  should  be  given  in  antiperiodic  doses,  fifteen  to  thirty  grains  daily, 
until  the  malarial  element  is  eliminated.  Small  doses  of  calomel  may 
also  be  required  in  the  presence  of  this  complication.     If  a  scorbutic 


TREATMENT  OF  AMCEBIC  DYSENTERY.  387 

taint  is  suspected,  lemon  or  lime  jiiiee,  onions,  wateivresses,  and  other 
fresh  unirritant  vegetables  are  recpiired  and  produce  rapid  improvement. 
It  is  difficult  to  dispense  with  opium  in  this  form  of  dysentery  ;  it 
may  be  given  by  injection  into  the  bowel,  thirty  or  forty  drops  of  the 
tincture  with  half  an  ounce  of  warm  starch  water,  repeated  often 
enough  to  control  the  excessive  frequency  of  the  stools,  the  violent 
tenesmus,  and  counteract  the  nervous  depression.  Its  tendency  to 
cause  retention  of  the  irritant  intestinal  contents  may  be  obviated  by 
an  occasional  saline  or  irrigation  with  hot  water.  If  the  rectum  is  too 
irritable  to  retain  an  enema  of  laudanum,  morphine  may  be  given 
hypodermically,  or  powdered  opium  by  the  stomach,  the  latter  in  doses 
of  one  to  two  grains  every  three  or  four  or  six  hours,  according  to 
effects.  A  combination  of  opium  with  large  doses  of  bismuth  and  salol 
or  creasote  is  an  excellent  one  in  severe  cases,  as  in  the  following  pre- 
scription : 

1^.  Bismuthi  subnitratis,  3vj  ; 

Tincturse  opii  deodoratse,  giij  ; 

Creasoti,  gtt.  xxiv ; 

AqujB  menthae  piperitse,  5vj. — M. 

Sig.  Take  one  tablespoonful  every  three  or  four  hours. 

Cocaine  given  internally  often  has  a  happy  effect  in  obviating  tenesmus ; 
it  mav  be  given  in  doses  of  one  to  two  grains  everv  four  or  six  hours. 
Cleansing  enemata  can  be  followed  by  antiseptic  injections,  as  of  creolin 
or  tricresol,  3ij— siv,  in  a  quart  of  warm  water.  Injections  of  carbolic 
acid  or  corrosive  sublimate  are  dangerous,  because  if  used  in  sufficient 
quantities  to  avail  as  germicides  they  are  apt  to  produce  toxic  effects. 
Ordinary  astringent  injections,  as  of  alum,  tannic  acid,  acetate  of  lead, 
or  nitrate  of  silver,  may  be  of  service  when  the  stools  are  large  and 
serous. 

Treatment  of  A^necebic  Dysentery. — In  the  early  stages,  before 
the  ulcerative  processes  have  fairly  commenced,  the  ipecac  treatment 
finds  its  application.  It  is  possible  that  the  remedy  may  have  some 
destructive  effect  upon  the  organisms ;  at  any  rate,  the  testimony,  as 
previously  related  by  those  who  have  tried  it  in  tropical  dysentery,  is 
conclusive  as  to  its  value.  It  is  necessary  to  take  precautions  that 
the  ipecac  should  be  retained  :  the  nauseant  or  emetic  effects  are  not 
desired ;  the  stomach  should  be  quieted  by  the  pre%'ious  administra- 
tion of  thirty  drops  of  laudanum  or  by  hypodermic  injection  of  one 
quarter  grain  of  morphine.  It  should  be  empty  :  no  liquid  should  be 
allowed.  A  large  mustard  plaster  is  applied  to  the  epigastrium,  and 
half  an  hour  after  the  opiate  thirty  grains  of  ipecac  given  in  a  bolus ; 
the  dose  may  be  repeated  the  second  or  third  time,  or  it  may  be  given 
in  smaller  quantities,  five  to  ten  grains  in  repeated  doses. 

The  diet  in  this  form  of  the  disease  is  a  matter  of  great  import- 
ance. Upon  this  point  Ball  quotes  from  Graves's  Clinical  Lectures,  in 
which  he  says  :  "  I  have  found  several  cases  Avhich  had  obstinately 
resisted  the  most  varied  remedies  assiduously  employed  get  well  rapidly 
after  a  liberal  allowance  of  meat  was  given ;  and  at  present,  when 
called  on  to  treat  a  case  of  dysentery  of  long  standing,  the  first  thing  I 


388  DYSEXTERY. 

do  is  to  put  my  patient  on  full  meat  diet."  I  can  add  my  testimony  as 
to  the  value  of  this  suggestion.  The  ordinary  dietetic  rules  are  not 
applicable  in  amcebic  dysentery  or  in  any  chronic  form.  There  is 
hardly  any  disease  characterized  by  such  rapid  anaemia  and  wasting :  it 
is  nothing  unusual  to  find  patients  taking  the  ordinary  diet  of  milk  and 
slops  to  lose  in  weight  a  pound  daily,  or  to  find  them  gain  rapidly  when 
placed  on  a  full  diet  of  nitrogenous  food,  as  scraped  meat,  raw  or 
slightly  cooked,  soft-boiled  eggs,  broiled  fish,  nutritious  soups,  or 
cooked  tender  meats  when  the  patient  will  chew  them  thoroughly.  A 
moderate  amount  of  toasted  bread  can  be  allowed  under  the  same 
restrictions.  Rectal  injections  of  a  solution  of  quinine  from  1  :  5000  to 
1  :  1000  have  been  recommended  by  Osier,  Councilman  and  Lafleur, 
and  others,  from  a  suggestion  by  Losch,  who  found  that  the  amcebse 
were  killed  by  such  solutions  outside  of  the  body.  The  beneficial 
result  of  this  treatment  is  subjudice.  My  personal  experience  was  not 
satisfactory ;  the  matter  will  have  to  be  determined  l^y  further  trial. 
There  can  be  no  question,  however,  as  to  the  value  of  nitrate  of  silver 
injections :  the  bowel  ha^'ing  been  first  washed  out  by  a  large  enema  of 
warm  water  (two  quarts),  introduced  gently  and  slowly,  as  previously 
suggested,  is  to  be  followed  by  the  silver  injection,  30  grains  to  the 
quart.  This  should  be  retained  as  long  as  possible  and  given  twice 
daily.  Strong  injections  of  small  quantities  do  no  good,  as  they  fail  to 
reach  the  ulcerated  surfaces.  Other  astringents  are  useful,  as  sulphate 
of  copper,  alum,  and  acetate  of  lead,  but  generally  are  inferior  to  the 
silver  salt.  Injections  of  corrosive  sublimate  have  been  recommended 
by  some  high  authorities.  I  have  already  mentioned  the  objections  to 
this  agent :  if  used  in  small  quantities,  it  will  not  reach  the  extensive 
surface  of  the  colon ;  if  in  large  quantities,  it  is  likely  to  be  absorbed 
and  produce  serious  poisonous  effects.  The  same  objection  applies  to 
carbolic  acid.  Xext  to  nitrate  of  silver,  I  have  found  creolin  to  pro- 
duce the  best  results ;  it  can  be  used  in  the  proportion  of  half  an  ounce 
to  the  quart  of  warm  water.  Iodoform  is  inapplicable,  on  account  of 
its  insolubility  and  the  large  quantity  required.  Tricresol  is  an  anti- 
septic which  is  likely  to  jDrove  of  value. 

Opiates  are  not  usually  indicated  in  this  form  of  dysentery,  except 
perhaps  in  the  gangrenous  form  to  restrain  excessive  peristalsis  and  give 
the  patient  rest.  Large  doses  of  bismuth  (thirty  to  forty  grains)  and 
salol  in  ten-  to  twenty-grain  doses  are  of  distinct  value  for  the  arrest 
of  obstinate  diarrhoea.  The  above  suggestions  are  also  applicable  to 
non-amoebic  forms  of  chronic  dysentery.  A  change  of  climate  or  a  sea 
voyage  ^vill  sometimes  effect  a  cure  when  other  means  fail.  The  min- 
eral acids,  preparations  of  pepsin,  iron,  quinine,  arsenic,  and  strychnine 
are  of  servuce  in  promoting  nutrition  and  as  aids  to  counteract  anaemia. 
Reference  has  been  made  to  the  necessity  of  requiring  patients  ^^dth 
dysentery  to  assmne  the  recumbent  position.  This  is  a  matter  of 
such  importance  in  all  forms  of  the  disease  that  reiterated  attention  is 
called  to  it.  Except  in  very  chronic  cases,  where  the  intestinal  symp- 
toms are  to  a  great  extent  in  abeyance,  and  where  gentle  exercise  may 
be  permitted,  the  patients  should  persistently  remain  in  bed ;  they  should 
not  be  allowed  to  get  up  for  any  purpose  :  the  sitting  posture  which 
many  patients  insist  upon  while  at  stool  favors  very  decidedly  both  the 


TREATMENT.  389 

pain  and  the  frocjuency  of  the  dejections.  They  shonld  also  be  taught 
to  restrain  ;is  niueli  as  j)ossihle  the  desire  to  empty  the  bowel. 

Some  remarkable  cures  have  recently  been  re])orted  of  chronic  dys- 
entery by  the  use  of  an  infusion  or  fluid  extract  of  a  plant  growing  in 
Mexico  and  Southwestern  Texas  known  as  the  chapparro  amargrm). 
R.  T.  Knox  of  Gonzales,  Texas,  reports  the  cure  of  a  long-continued 
and  most  obstinate  attack  of  chronic  (probably  amccl)ie)  dysentery,  of 
which  he  was  himself  the  victim,  by  the  use  of  this  remedy  when  all 
other  means  faithfully  tried  had  failed.  Similar  good  results  have  been 
recorded  by  J.  W.  Nixon  and  others.  The  remedy  is  not  narcotic, 
but  excessively  bitter  and  astringent.  In  doses  of  one  half  to  two 
drachms  of  the  fluid  extract  it  produces  no  disagreeable  effects.  The 
reported  cases  are  too  few  to  predicate  any  basis  for  a  positive  opinion  as 
to  the  virtues  of  this  drug,  but  chronic  dysentery  is  a  disease  so  difficult 
to  manage  that  any  agent  offering  a  prospect  of  doing  good  is  worthy  of 
trial.  The  fluid  extract  can  be  used  in  the  doses  mentioned,  and  can  be 
prescribed  in  connection  wdth  the  other  treatment  suggested. 

The  management  of  non-amoebic  forms  of  chronic  dysentery  is  prac- 
tically the  same  as  herein  given. 

I  have  now  under  observation  in  my  wards  four  cases  of  dysentery, 
ranging  in  duration  from  six  w'eeks  to  six  years.  A  trial  is  being  made 
with  chapparro  in  very  much  larger  doses  than  as  above  mentioned, 
one  of  these  patients  taking  an  ounce  of  the  fluid  extract  every  four 
hours,  the  average  dose  being  half  an  ounce  every  four  to  six  hours. 
In  two  cases  various  other  methods  of  treatment  had  been  used  with- 
out any  decided  benefit.  In  order  more  thoroughly  to  test  the  vir- 
tues of  the  remedy,  every  other  medicine  w^as  discontinued,  and  only 
the  ordinary  precautions  as  to  diet  and  quietude  are  enforced.  While  I 
am  not  able  to  pronounce  absolutely  as  to  the  final  result,  the  symptoms 
have  been  rapidly  ameliorated  :  one  case  is  apparently  cured,  the  others 
decidedly  improved.  The  effects  w^ere  more  pronounced  from  the  fact 
that  when  the  supply  of  the  drug  w^as  exhausted  the  patients  relapsed, 
and  again  improved  w^hen  the  medicine  was  resumed. 

The  compound  tincture  of  benzoin,  in  doses  of  half  a  drachm,  re- 
peated every  three  or  four  hours,  is  an  excellent  remedy  for  the  relief 
of  intestinal  hemorrhage,  pre\dously  mentioned  as  an  occasional  com- 
plication. 


THE  PLAGUE. 

By  WILLIAM  M.  WELCH,  M.  D. 


Synonyms. — English  :  The  Bubo  Plague,  The  Pest ;  Latin  :  Pestis, 
Pestilentia,  Pestis  Inguinaria ;  French  :  La  Peste  ;  German  :  Die  Pest, 
Beulenpest. 

Definition. — The  plague  is  an  infectious  febrile  disease  which  has 
prevailed  epidemically  at  different  times  in  various  countries,  and  is 
characterized  by  buboes  or  swelling  of  the  inguinal  or  other  lymphatic 
glands.  It  is  frequently  attended  by  carbuncles,  petechise,  or  purpuric 
spots  distributed  over  different  parts  of  the  body. 

History. — During  the  Middle  Ages,  and  even  at  a  later  period, 
almost  every  variety  of  pestilential  disease  that  prevailed  in  epidemic 
form  and  was  attended  by  great  mortality  was  included  under  the  term 
"  plague."  It  is  believed  that  Galen  was  largely  responsible  for  this 
confusion  by  reason  of  a  definition  given  by  him,  as  follows  :  "  When  a 
disease  attacks  a  number  of  persons  in  one  place,  it  is  an  epidemic ;  and 
when  many  are  destroyed,  it  is  a  plague."  But  a  gradually  increasing 
knowledge  of  diseases  has  resulted  in  a  differentiation  so  distinct  and 
definite  that  confusion  of  terms  no  longer  exists :  those  terms  which 
formerly  applied  to  a  large  group  of  diseases  have  either  been  limited  to 
certain  maladies  or  discarded  altogether,  while  new  names  have  been 
found  for  the  others.  The  term  "  plague "  is  now  restricted,  as  the 
definition  indicates,  to  a  contagious  febrile  disease  presenting  certain 
definite  symptoms  and  pathological  processes,  most  prominent  among 
which  are  the  formation  of  buboes. 

No  very  reliable  account  of  the  plague  is  to  be  found  previous  to  the 
sixth  century,  although  it  is  believed  to  have  existed  in  Egypt,  Libya, 
and  Syria  before  the  Christian  era.  The  first  extensive  epidemic  of  the 
disease  in  Europe  occurred  in  Constantinople  in  the  year  542  a.  d.,  dur- 
ing the  reign  of  Justinian,  and  hence  has  frequently  been  spoken  of  as 
the  Justinian  plague.  From  that  time  until  the  latter  part  of  the 
seventeenth  century  plague  epidemics  frequently  occurred  in  Europe  : 
so  frequently,  indeed,  that  this  disease  was  more  dreaded  than  any  other 
that  prevailed.  It  was  especially  rife  and  fatal  during  the  Middle 
Ages,  and  even  continued  in  various  countries  as  a  devastating  scourge 
for  a  few  centuries  later. 

In  the  seventeenth  century  there  were,  according  to  Sir  Gilbert 
Blane,  no  less  than  forty-five  epidemics  of  the  plague  in  various  parts 
of  Europe.  Fourteen  of  these  occurred  in  Holland,  where  the  disease 
was  introduced  by  the  Dutch  engaged  in  the  Levant  trade.  From  Hol- 
land the  infection  was  conveyed  to  England,  and  in  that  country  as 
many  as  tw^elve  epidemics  occurred.  The  most  notable  epidemics  in 
both  of  these  countries  were  in    1665.     This  has  often  been  termed 


391 


392  THE  PLAGUE. 

the  year  of  the  "  Great  Plague."  The  disease  spread  with  such  great 
rapidity  and  manifested  so  much  virulence  that,  it  is  said,  7165  deaths 
occurred  in  a  single  week,  and  no  less  than  68,526  in  one  year,  in  the 
city  of  London  and  its  suburbs.  When  we  consider  the  population  of 
London  at  that  time,  it  is  evident  that  this  was  a  very  large  mortality 
rate. 

After  a  long  interval  of  comparative  absence  of  the  plague,  it  reap- 
peared in  the  early  part  of  the  eighteenth  century.  It  was  met  with 
most  frequently  in  the  Turkish  dominions.  During  this  century  no  less 
than  nineteen  epidemics  occurred  in  Egypt  and  nine  in  Turkey.  Epi- 
demics occurred  also  in  Germany,  Russia,  Spain,  Poland,  Greece,  Italy, 
Sweden,  and  France.  An  epidemic  most  notable  for  its  severity  visited 
Marseilles  in  1720-21.  Within  the  present  century  the  disease  has  pre- 
vailed at  different  times  in  Egypt,  Turkey,  Greece,  and  Russia.  It  has 
also  visited  Germany,  Syria,  Italy,  Persia,  and  some  other  countries. 
In  1844  the  disease  disappeared  from  Europe  and  Asia,  but  reappeared 
with  great  virulence  in  Arabia  in  1853,  and  somewhat  later  was  seen  in 
North  Africa,  Persia,  and  Hindostan.  During  the  period  from  1873  to 
1877  the  pestilence  prevailed  with  unusual  severity  in  almost  every  part 
of  Arabia.  In  1878-79  it  committed  great  ravages  in  Astrakhan.  The 
most  recent  epidemic  of  the  plague  occurred  in  China  in  1894.  It  pre- 
vailed in  Hong-Kong,  Canton,  and  some  other  districts.  Owing  to  the 
ignorance  and  superstition  of  the  Chinese,  no  reliable  statistics  could 
be  collected,  but  it  is  known  that  the  epidemic  was  very  severe  and 
fatal.  Fortunately,  this  pestilential  disease  has  never  visited  America, 
or,  if  it  has  been  seen  at  all,  it  has  never  prevailed  in  epidemic  form. 

Etiology. — All  modern  authors  concur  in  the  belief  that  the  plague 
owes  its  origin  to  a  specific  contagium.  While  the  disease  has  always 
been  confined  to  the  Eastern  Hemisphere,  yet  it  is  universally  admitted 
that  the  contagium  is  not  indigenous  to  any  country  or  soil.  There  is  no 
doubt,  however,  that  certain  circumstances  may  combine  to  favor  the 
propagation  and  action  of  the  infecting  principle — such,  for  example,  as 
poverty^  overcrowding,  personal  uncleanliness,  improper  or  insufficient 
food,  and  the  like.  All  observers  agree  that  the  physical  and  social 
wretchedness  resulting  from  poverty  is,  except  the  contagium  itself,  the 
most  potent  factor  in  the  spread  of  the  disease.  While  this  fact  has 
been  noticed  in  all  epidemics,  it  was  so  conspicuous  in  the  great  epidemic 
of  London  in  1665  that  the  writers  who  described  the  disease  at  that 
time  termed  it  "  the  plague  of  the  poor.'' 

Certain  local  conditions  are  also  known  to  be  favorable  to  the  spread 
of  the  plague.  In  the  Eastern  countries,  where  the  disease  prevailed  in 
past  ages  with  such  great  virulence,  the  state  of  civilization  was  wretch- 
edly low,  and  a  large  proportion  of  the  inhabitants  were  not  only  insuf- 
ficiently fed  or  forced  to  subsist  on  the  most  unwholesome  food,  but 
lived  in  crowded  dwellings  that  were  poorly  constructed  and  badly 
ventilated.  No  regard  whatever  was  paid  to  sanitary  laws.  Improper 
drainage  existed  in  all  cities,  towns,  and  villages ;  masses  of  decompos- 
ing animal  and  vegetable  matter,  including  human  dejecta,  were  allowed 
to  accumulate ;  human  corpses  were  commonly  kept  too  long  before 
burial,  and  even  then  they  were  interred  at  an  insufficient  depth ; 
the  dwelling-houses  had  simply  an  earth  floor,  and  not  infrequently  a 


ETIOLOGY.  393 

horrible  (xlor  was  cinittod  from  the  (lecoinposiiijr  dead  Ixxlies  of  some 
previous  oeeiipaiits  who  liad  been  buried  oiilv  a  few  feet  beneath. 
AVlien  sueh  a  deplorabh'  condition  exists,  it  is  not  snrprisin^  that  the 
phigue,  onee  introduced,  should  lini^er  and  commit  great  ravages.  After 
the  introduction  of  better  sanitary  regulations  in  Egypt  and  Turkey,  in 
1844  the  plague  disappeared,  but  it  returned  again  ten  years  later,  when 
these  regulations  were  disregarded.  The  importance  of  sanitary  meas- 
ures was  fully  realized  in  China  during  the  recent  epidemic.  A  com- 
mittee of  the  Sanitary  Board  has  emphatically  expressed  the  o[)inion 
that  the  speedy  stamping  out  of  the  plague  in  that  country  in  1894  was 
due  to  thorough  cleansing  and  disinfection  of  the  houses  in  which  cases 
had  existed. 

AVhatevcr  the  local  conditions  or  the  habits  of  the  people  of  any  countiy 
may  be,  the  plague  never  originates  autochthonously,  as  was  formerly  sup- 
posed, but  is  always  introduced  by  a  previous  case  and  commiuiicated  from 
one  person  to  another.  The  theory  that  the  disease  is  spread  by  infection 
has,  it  is  true,  often  been  assailed,  and  evidence  to  prove  its  non-con- 
tiigious  nature  presented,  but  all  modern  authors  agree  that  the  pre- 
ponderance of  testimony  is  to  be  found  on  the  affirmative  side  of  the 
question.  Even  the  Turks,  who  are  not  very  familiar  with  the  theories 
taught  in  more  enlightened  countries,  have  gradually  arrived  at  the 
conclusion  that  the  plague  is  infectious.  It  would  appear,  however, 
that  in  order  for  an  epidemic  to  arise  and  continue  with  great  severity 
-certain  favorable  local  conditions  must  be  present — such,  for  example,  as 
have  already  been  described.  So  also  moderately  warm  weather  and 
dampness  or  a  marshy  conformation  of  soil,  such  as  exists  at  the  mouths 
of  rivers,  are  favorable  to  the  development  and   spread  of  the   disease. 

Individual  predisposition  to  the  plague  varies,  as  in  most  other  con- 
tagious diseases.  Some  persons  appear  to  be  entirely  immune,  while 
others  take  the  disease  after  the  slightest  exposure.  Sex  exerts  no 
influence  whatever  over  the  predisposition.  Intemperance  and  all  habits 
that  depress  the  vital  forces,  if  they  do  not  render  the  individual  more 
susceptible,  are  sure  to  predispose  him,  if  attacked,  to  a  severe  form  of 
the  disease.  Age  appears  to  exert  some  influence  over  the  predisposi- 
tion, as  it  has  been  observed  that  persons  over  fifty  years  of  age  are 
seldom  attacked.  The  plague  differs  from  most  other  infectious  diseases 
in  that  one  attack  does  not  confer  immunity  against  subsequent  attacks. 

Although  bacteriology  has  not  brought  to  light  any  specific  micro- 
organism to  explain  the  infectious  nature  of  the  plague,  yet  such  a 
pathogenic  germ  is  believed  to  exist.  That  the  disease  is  really  infec- 
tious has  been  demonstrated  in  various  ways.  Many  instances  are 
recorded  of  the  contagium  having  been  conveyed  from  one  city  or  locality 
to  another  by  means  of  infected  individuals.  On  the  other  hand,  it  has 
never  been  known  to  originate  in  any  district  or  island  which  has  had 
no  communication  with  an  infected  locality,  but,  like  infectious  diseases 
in  general,  it  follows  the  line  of  travel.  The  disease  has  often  been  con- 
fined to  an  infected  area  by  means  of  a  rigid  quarantine.  Transmission 
of  the  contagium  has  occurred  through  the  bedding,  clothing,  and  other 
effects  of  patients.  The  corpses  of  persons  who  had  died  of  the  plague 
have  been  known  to  transmit  the  infection,  even  when  a  long  time  had 
elapsed  after  death.     This  fact  was  recognized  ages  ago  in  some  of  the 


394  THE  PLAGUE. 

Eastern  countries,  and  consequently  the  reopening  of  graves  of  persons 
who  had  died  of  the  plague  was  made  a  penal  oifence.  "  Such  grave- 
yards were  therefore  frequently  surrounded  with  walls,  upon  which 
notices  were  posted  to  the  effect  that  the  reopening  of  a  grave  would  be 
punished  as  a  capital  oifence."  ^ 

It  would  seem  that  the  poison  of  the  plague  is  capable  of  remaining 
for  a  long  time  in  an  active  state  outside  of  the  body,  as  epidemics  not 
infrequently  break  out  anew  after  a  long  interval  and  without  any  fresh 
importation  of  the  infection.  The  contagium  of  the  plague  is  believed 
to  enter  the  system  usually  through  the  lungs.  A  few  instances  are 
recorded  showing  that  it  is  possible  to  produce  the  disease  by  inoculation. 
The  presence  of  the  infection  in  the  circulation  is  first  manifested  in  the 
lymphatic  system,  causing  swelling  and  inflammation  of  the  glands. 

The  stage  of  incubation  is  short,  being  usually  from  two  to  five  days. 
It  may,  however,  be  as  long  as  seven  or  eight  days,  but  rarely  longer. 

Pathological  Anatomy. — The  gross  pathological  changes  are  not 
numerous  :  no  careful  examination  has  ever  been  made  of  the  blood. 
Swelling  and  inflammation  of  the  lymphatic  glands  are  the  only  constant 
abnormal  changes  found  after  death.  The  inflammation  is  not  always 
limited  to  the  glands,  but  extends  more  or  less  to  the  contiguous  tissue, 
in  which  extravasation  of  blood  is  often  found.  More  often  the  inguinal 
glands  are  the  ones  involved,  although  it  is  not  unusual  to  find  glandular 
swellings  in  the  axilla,  the  neck,  and  other  external  portions  of  the  body. 
The  deep  seated  lymphatic  glands,  and  even  those  within  the  cavities 
of  the  body,  are  also  not  infrequently  enlarged.  The  external  glands, 
especially  those  in  the  inguinal  region,  are  very  liable  to  undergo  sup- 
puration. When  those  in  the  axilla  are  severely  involved  the  inflamma- 
tion sometimes  extends  to  the  pleura. 

Petechise,  ecchymoses,  and  carbuncles  are  frequently  found  in  the 
skin.  The  carbuncles  often  present  large  sloughs,  surrounded,  of  course,^ 
by  an  inflammatory  process.  Ecchymoses  are  sometimes  found  in  the 
mucous  and  serous  membranes.  Parenchymatous  degeneration  has  been 
noticed  in  the  various  internal  organs  of  the  body  :  the  spleen,  especially, 
is  said  to  be  almost  always  hypertrophied,  soft,  and  of  dark  color 
(Liebermeister). 

Symptoms. — In  studying  the  symptoms  of  the  plague  it  is  found 
most  convenient  to  divide  the  disease  into  four  stages :  First,  the  pro- 
dromal or  invasive  stage ;  second,  the  febrile  stage ;  third,  the  stage 
of  the  local  manifestations ;  fourth,  the  stage  of  convalescence. 

First  Stage. — The  disease  usually  begins  somewhat  suddenly  by 
feelings  of  lassitude,  loss  of  strength,  general  uneasiness,  and  mental 
anxiety.  Headache  is  commonly  present,  together  with  vertigo  and  a 
sense  of  fulness  in  the  head.  The  face  is  generally  pale,  the  eyes, 
languid,  the  intellectual  faculties  impaired,  and  the  gait  unsteady  or 
staggering,  resembling  that  of  an  intoxicated  person.  It  is  not  unusual 
to  find  nausea  and  vomiting,  and  even  diarrhoea,  at  this  stage.  These 
early  symptoms  may  be  either  very  mild  or  very  severe,  and  may  con- 
tinue from  a  few  hours  to  two  or  three  days.  During  this  period  there 
is  usually  but  little  if  any  fever. 

The  second  stage  is  ushered  in  by  chilliness  or  rigors,  followed  by 

'  Liebermeister,  v.  Ziemssen's  Cydopcedia. 


SYMPTOMS.  ;iy;j 

i'ebrile  reaction.  Thoiv  is  a  continuance  of  most  of  tlio  synij^toins 
already  mentioned,  some  of  wiiieli  may  assume  still  greater  prominence — 
such  as  the  languor,  debility,  headache,  dizziness,  and  the  irritability 
of  the  stomach.  Precordial  uneasiness  is  very  commonly  complained 
of.  The  fever  often  becomes  very  intense.  It  is  not  innisiial  to  Hnd 
the  temperature  of  the  body  rise  as  high  as  104°  F.,  but  more  fretjuently 
it  ranges  between  101°  and  104°  F.  There  are  present  also  the  usual 
concomitant  symptoms  of  high  fever,  such  as  a  hot  and  dry  skin, 
uncpiencliable  thirst,  furred  tongue,  and  accelerated  respirations.  The 
pulse  is  not  only  frequent,  but  feeble,  and  sometimes  irregular  or  inter- 
mittent. In  severe  cases  it  may  vary  from  120  to  150.  The  tongue  at 
first  is  somewhat  swollen,  moist,  and  covered  with  a  white  fur,  but  later 
it  becomes  brown  or  almost  black,  and  sometimes  fissured,  while  dark 
sordes  collects  on  the  teeth  and  lips.  The  eyes  are  injected,  the  face 
flushed  or  livid,  and  the  countenance  is  greatly  changed.  At  first  the 
bowels  are  constipated,  but  toward  the  end  are  relaxed,  the  passages 
becoming  dark,  oflFensive,  and  sometimes  bloody.  A  dark  grumous  or 
bloody  vomit  is  not  uncommon.  The  urine  also  is  often  tinged  with 
blood.  When  these  symptoms  are  present  the  patient  soon  sinks  into 
a  typhoid  condition ;  delirium,  stupor,  or  profound  coma  supervene,  and 
death  often  results  about  the  time  the  lymphatic  glands  begin  to  enlarge. 

In  the  most  malignant  cases  the  fatal  blow  appears  to  be  given  at  the 
very  commencement  of  the  disease.  Such  cases  are  characterized  by 
severe  nervous  symptoms  and  extreme  prostration,  from  which  the  vital 
forces  never  rally,  and  death  often  results  in  less  than  twenty-four 
hours  without  any  development  whatever  of  the  local  manifestations. 

Usually  the  febrile  symptoms  are  not  of  uniform  violence  through- 
out the  twenty-four  hours,  but  there  are  remissions  and  exacerbations. 
The  reinissions  occur  in  the  morning  and  toward  evening,  the  exacer- 
bations in  the  middle  of  the  day  and  at  night.  The  morning  remission 
and  the  nocturnal  exacerbation  are  most  marked.  The  remission  is 
often  so  great  as  to  lead  the  patient  to  hope  that  convalescence  has 
begun.  The  subsidence  of  the  fever  is  not  infrequently  attended  with 
free  perspiration,  and  when  this  occurs  on  the  third  or  fifth  day  of  the 
disease  it  is  regarded  as  a  favorable  indication.  After  the  febrile  symp- 
toms have  continued  for  two  or  three  days  the  inguinal  lymphatic  glands 
enlarge  and  become  sensitive  to  pressure.  The  intensity  of  the  fever 
now  diminishes,  although  the  temperature  often  fluctuates  considerably 
throughout  the  succeeding  stage. 

The  third  stage  is  characterized  by  the  development  of  the  local 
lesions.  Usually  the  earliest  evidence  of  localization  of  the  disease  is 
found  in  the  inguinal  region,  and  consists  of  inflammation  and  swelling 
of  the  lymphatic  glands.  This  symptom  is  often  preceded  by  a  shoot- 
ing pain  in  the  part.  Next  to  this  region,  the  glands  in  the  axilla  are 
most  frequently  affected.  Those  in  the  neck,  and  even  in  other  parts 
of  the  body,  are  often  attacked  in  severe  cases.  The  swellings  vary 
very  considerably  in  size.  Sometimes  they  are  so  small  as  to  be  difficult 
of  detection ;  in  other  cases  they  become  as  large  as  a  hen's  egg  or  even 
much  larger.  In  the  neck  the  swelling  has  been  known  to  attain  enor- 
mous dimensions  within  a  few  hours,  becoming  so  large,  indeed,  as  to 
cause  asphyxiation  from  pressure.     The  swelling,  however,  is  apt  to  be 


396  THE  PLAGUE. 

greatest  in  the  inguinal  region,  and  the  glands  which  are  attacked  are 
usually  those  lower  down  on  the  thigh  than  in  the  case  of  venereal 
buboes.  Suppuration  may  occur,  or  the  inflammation  may  disappear  by 
resolution.  The  former  is  thought  to  be  the  more  favorable  mode  of 
termination.  The  suppurative  process  is  apt  to  be  slow,  continuing 
often  as  long  as  two  or  three  weeks  before  the  pus  is  discharged.  After 
this  the  abscess  slowly  heals,  leaving  a  permanent  scar. 

Carbuncles,  which  are  less  frequent  than  buboes,  usually  make  their 
appearance  at  a  later  period.  They  may  appear  upon  any  part  of  the 
body,  but  are  more  often  found  on  the  lower  extremities,  the  buttocks, 
and  the  back  of  the  neck.  Sometimes  there  is  but  one  or  there  are  very 
few,  and  at  other  times  they  are  quite  numerous.  They  may  be  either 
small  or  large.  In  favorable  cases,  instead  of  gangrene  developing, 
which  is  often  the  case,  the  slough   separates  early  by  suppuration. 

Petechise,  vibices,  or  extensive  ecchymoses  are  often  seen  in  the  last 
stage  of  fatal  cases.  Aubert  regarded  these  symptoms  as  almost  a 
certain  sign  of  death. 

It  should  be  stated  that  it  is  not  possible  in  ever\'  case  of  the  plague 
to  find  clearly  marked  the  three  stages  just  described.  Sometimes  the 
first  symptom  that  attracts  attention  is  a  so  called  "  boil,"  which  has 
made  its  appearance  without  premonition.  Occasionally  the  disease  is 
so  mild  that  the  patient  is  not  obhged  to  go  to  bed.  Such  cases  may  be 
seen  in  mild  epidemics  or  toward  the  close  of  severe  ones.  On  the  other 
hand,  in  the  most  severe  form  of  the  disease  cases  have  been  known  to 
terminate  fatally  within  a  few  hours,  without  any  appreciable  prelimi- 
nary symptoms.  In  this  class  of  cases  death  results  from  shock  pro- 
duced by  the  ^^rulence  of  the  poison.  More  frequently,  however,  in 
the  fatal  cases  death  takes  place  betvs-een  the  third  and  fifth  days.  After 
the  eighth  or  ninth  day,  or  even  after  the  seventh  according  to  Lieber- 
meister,  the  dangerous  period  of  the  disease  is  past,  yet  death  may 
result  from  sequelae.  The  subsidence  of  the  fever  on  the  third  or  fifth 
day,  with  profuse  perspiration,  as  already  mentioned,  is  regarded  by 
most  observers  as  favorable. 

Fourth  Stage. — In  most  of  the  cases  which  terminate  favorably  con- 
valescence begins  from  the  sixth  to  the  tenth  day,  but,  on  account  of 
the  suppuration  and  a  large  number  of  discharging  sinuses,  is  often 
very  slow.  During  this  stage  certain  sequelse  are  liable  to  arise,  among 
which  may  be  mentioned  furuncles,  secondary'  abscesses,  parotitis,  dropsy, 
partial  paralysis,  and  mental  disturbances.  Pneumonia,  attended  by  a 
typhoid  condition,  is  sometimes  seen,  and  when  it  occurs  is  always  very 
fatal.  In  pregnant  women  abortion  is  apt  to  take  place,  and  this  com- 
plication is  almost  always  followed  by  death.  A  genuine  relapse  has 
been  known  to  occur  when  convalescence  seemed  fully  established. 

DiAG-xosiS. — It  is  difficult  to  distinguish  the  plague  only  at  the 
beginning  of  an  epidemic  or  in  cases  which  are  atypical.  When  the 
disease  is  known  to  be  prevalent  the  diagnosis  in  well  marked  cases  is 
usually  easy  enough.  Some  doubt  might  exist  in  the  mind  of  the  diag- 
nostician during  the  first  day  or  two  of  the  illness,  but  the  early  appearance 
of  shooting  pain  in  the  inguinal  region,  rapidly  followed  by  tenderness 
and  swelling  of  the  glands  and  the  formation  of  buboes,  is  calculated  to 
reveal  the  true  nature  of  the  disease  ;  but    if   anv  doubt  should  still 


imOGNOSLS—TREA  TMENT.  897 

exist,  it  would  soon  bo  removod  by  tlie  nij)icl  spread  of  tlio  mulady, 
the  development  of  carbuncles  and  petechia',  and  the  friirhtful  in(jr- 
tality. 

The  diseases  with  which  the  plaiiue  is  most  liable  to  be  ('(diibunded 
are  lvnn)hadenitis,  scrofulous  or  syphilitic  alfections  associated  with 
fever,  malignant  typhus,  pernicious  j)aludal  fever,  and  malignant  pus- 
tule. But  a  reasonable  familiarity  with  the  symptoms  of  these  diseases 
will  usuallv  enable  tiie  diagnostician  to  exclude  then\  when  considering 
the  ditfevential  diagnosis  l)ctwcen  them  and  the  plague. 

Prognosis. — As  the  i)laguc  is  an  exceedingly  fatal  disease,  the  |)rog- 
nosis  in  well  marked  cases  should  be  guarded.  Some  idea  of  the  great 
fatality  of  the  disease  may  be  formed  by  considering  the  results  of  cer- 
tain epidemics.  For  example,  it  was  estimated  that  in  Marseilles  in 
1720,  out  of  a  population  of  90,000,  80,000  suffered  from  the  disease, 
and  of  this  number  40,000  perished.  Likewise,  in  Toulon  in  1721,  out 
of  a  population  of  26,000,  about  20,000  took  the  disease,  and  of  these 
16,000  died.  Also,  in  Moscow  in  1770-71,  nearly  one-half  of  the 
entire  population  perished.  In  various  epidemics  the  death  rate  among 
persons  attacked  has  ranged  from  50  to  90  per  cent. 

In  individual  cases  the  unfavorable  symptoms  may  be  enumerated  as 
follows :  sudden  and  extreme  prostration  at  the  onset ;  a  tendency  to 
syncope,  stupor,  or  coma ;  injected  eyes,  stammering  speech,  unsteadi- 
ness of  gait,  and  a  drunken  expression ;  a  low  muttering  delirium  ;  ex- 
cessive oppression  of  breathing,  and  an  irregular  or  intermittent  pulse ; 
a  dry,  black  tongue ;  hiccough,  severe  precordial  pain,  and  vomiting  of 
dark  grumous  material ;  the  appearance  of  petechise,  vibices,  and  large 
ecchymoses.  On  the  other  hand,  the  favorable  symptoms  are  early  and 
decided  remissions  in  the  fever,  and  its  subsidence  on  the  third  or  fifth 
day,  with  moderate  perspiration  ;  a  limited  involvement  of  the  lymphatic 
glands ;  the  development  of  buboes,  advancing  rapidly  to  suppuration  ; 
no  great  loss  of  strength ;  the  cessation  of  the  nervous  symptoms ;  and 
a  return  of  the  natural  expression  of  the  countenance. 

Treatment. — It  is  sometimes  easier  to  prevent  than  to  cure  a  dis- 
ease, and  this  is  particularly  true  of  the  plague  ;  for  it  is  certain  that  a 
great  deal  may  be  accomplished  in  the  way  of  prophylaxis  by  suitable 
measures  energetically  applied,  while  it  seems  impossible  to  change  the 
course  of  the  disease  after  symptoms  have  appeared.  Some  of  the 
severest  epidemics  of  this  disease  have  not  only  been  limited  in  their 
spread,  but  were  conquered  by  quarantine  and  hygienic  measures. 

The  history  of  the  latest  epidemics  in  Egypt  is  very  instructive  as 
showing  what  may  be  accomplished  by  a  rigid  quarantine  system.  The 
importance  of  this  measure  was  also  very  forcibly  demonstrated  at 
Noja,  Italy,  when  the  plague  prevailed  there  in  1815.  The  city  was 
surrounded  by  three  separate  military  cordons,  one  outside  of  the  other, 
thus  preventing  absolutely  any  person  from  either  entering  or  leaving 
the  infected  locality,  and,  as  a  result,  the  disease  was  confined  within 
the  limits  of  this  cordon  sanitaire.  It  is  reasonably  believed  that  by 
this  severe  measure  Lower  Italy,  and  even  Europe,  were  spared  from 
the  decimating  ravages  of  the  scourge.  So  also  in  the  province  of 
Astrakhan  in  1878-79  the  plague  was  prevented  from  spreading  by  the 
same  rigid  restrictions. 


398  THE  PLAGUE. 

A  writer^  who  is  thoroughly  familiar  with  the  history  of  this  disease 
says :  "  The  extinction  of  the  plague  was  a  gradual  process,  and  kept 
pace  in  great  measure  with  the  development  and  perfection  of  the  quar- 
antine system  as  carried  out,  not  only  with  reference  to  the  East,  but 
also  between  neighboring  countries  of  Europe.  Indeed,  I  cannot 
understand  how  any  one  pretending  to  criticise  facts  in  an  unprejudiced 
manner,  and  with  some  regard  to  the  condition  of  the  plague  in  the 
East,  can  for  a  moment  hesitate  to  attribute  the  chief  cause  of  the  dis- 
appearance of  the  plague  from  European  soil  to  the  development  of  a 
well  regulated  quarantine  system." 

Under  the  head  of  Etiology  (page  392)  attention  has  been  directed  to 
the  fact  that  poverty,  overcrowding,  bad  ventilation,  unwholesome  or  insuf- 
ficient food,  and  unhealthy  surroundings  are  important  factors  favoring 
the  propagation  and  dissemination  of  the  infection.  It  is  evident,  there- 
fore, that  in  the  administration  of  sanitary  laws  these  conditions  should 
receive  attention.  Exposed  persons  should  not  only  be  properly  fed 
and  have  their  dwelling  rooms  well  ventilated,  but  they  should  bathe 
regularly  and  avoid  intemperate  and  all  other  depressing  habits.  It  is 
clearly  the  duty  of  the  state  or  municipality  in  which  the  disease  exists 
to  correct  all  bad  hygienic  conditions  or  unsanitary  surroundings.  The 
polluted  soil  should  be  saturated,  if  possible,  with  some  active  disin- 
fectant ;  all  articles  of  clothing,  bedding,  etc.  which  have  been  in  con- 
tact with  the  sick  should  be  promptly  disinfected,  as  well  as  the  dwell- 
ing in  which  the  patient  resided.  The  bodies  of  persons  having  died 
of  the  plague  should  be  buried  in  accordance  with  strict  sanitary  regu- 
lations, or,  preferably,  reduced  to  ashes  speedily  by  the  process  of 
incineration. 

Clinically  considered,  there  is  no  special  form  of  treatment  for  the 
plague :  all  that  can  be  done  is  to  treat  the  symptoms  as  they  arise. 
The  fever  may  be  mitigated  by  febrifuge  mixtures  or  some  of  the  least 
depressing  antipyretics  of  the  coal-tar  products.  Cold  sponging,  or 
even  cold  baths,  may  prove  of  great  service  when  the  temperature  is 
high.  As  suppuration  of  the  buboes  is  thought  to  be  desirable,  this 
process  should  be  encouraged  by  warm  poultices,  and  as  soon  as  pus  has 
formed  it  should  be  evacuated  and  the  parts  treated  in  accordance  with 
antiseptic  principles.  The  danger  of  collapse  in  the  early  stage  of 
the  disease  may  be  lessened  by  confining  the  patient  to  bed  and  insti- 
tuting at  once  a  supporting  plan  of  treatment.  As  death  is  generally 
caused  by  cardiac  paralysis,  strychnine  and  alcohol  should  be  given  in 
large  doses.     A  Kberal  amount  of  suitable  nourishment  is  required. 

^Hirsch,  quoted  by  Liebenneister,  loe.  cit. 


INFLUENZA. 

By  JAMES  C.  WILSON,  M.  D. 


Definition. — An  acute  infectious  disease  occurring  in  widely  ex- 
tended epidemics,  characterized  by  catarrh  of  the  mucous  membranes  of 
the  respiratory  tract,  less  frequently  of  the  digestive  tract,  by  quickly 
oncoming  debility,  and  by  nervous  symptoms.  There  is  a  strong  tend- 
ency to  complications,  especially  pneumonia.  Uncomplicated  cases  are 
rarely  fatal  except  in  feeble  or  aged  persons.  The  attack  does  not  con- 
fer subsequent  immunity. 

Synonyms. — Epidemic  catarrhal  fever ;  la  Grippe.  This  disease  has 
an  extensive  literature  and  innumerable  synonyms.  Many  of  these 
terms  are  the  outcome  of  efforts  on  the  part  of  the  profession  to  give  it 
descriptive  designations ;  others  are  of  popular  origin,  suggested  by  its 
sudden  occurrence,  certain  of  its  symptoms,  or  its  widespread  prevalence. 
The  Russians  have  called  it  Chinese  catarrh  ;  the  Germans  and  Italians, 
the  Russian  disease ;  the  French,  Italian  fever  or  Spanish  fever.  In 
two  instances  the  popular  name  has  found  its  w^ay  widely  into  medicine 
and  medical  literature  almost  to  the  exclusion  of  the  studied  terms  l)y 
which  science  has  sought  to  designate  it.  These  are  influenza  and  la 
grippe. 

The  derivation  of  la  grippe  is  obscure.  It  has  been  traced  to  the 
Polish  chri/pka  (raucedo)  ;  others  have  derived  it  from  agripper  (to 
snatch).  The  term  influenza  is  of  Italian  origin.  It  is  said  that  the 
disease  received  this  name  because  its  sudden  outbreak  and  wide  prev- 
alence were  attributed  to  some  influence  of  the  stars,  or,  according  to 
others,  from  a  secondary  signification  of  the  word  indicating  something 
fluid,  transient,  or  fashionable. 

History. — Influenza  is  distinctly  an  epidemic  disease.  It  has  pre- 
vailed since  the  beginning  of  the  sixteenth  century  in  great  pandemics. 
Many  of  the  accounts  of  epidemic  diseases  of  earlier  date  doubtless 
refer  to  influenza,  but  they  are  not  sufiiciently  exact  to  warrant  us 
in  inferring  its  undoubted  existence.  According  to  Parks,  it  is  men- 
tioned in  the  Avritings  of  Hippocrates,  who,  however,  gives  no  exact 
description.  Several  epidemics  of  catarrhal  fever,  Italian  fever,  and 
the  like,  which  were  probably  influenza,  occurred  in  the  ninth  century. 
In  the  year  827  a.  d.  a  cough  which  spread  like  the  plague  was  re- 
corded. In  876  there  appeared  in  Italy  a  similar  epidemic  which  spread 
with  great  rapidity  all  over  Europe.  In  1173  a  widespread  malady,  of 
which  the  symptoms  were  chiefly  catarrhal,  raged  throughout  Europe, 
and  epidemics  of  a  like  character  occurred  during  the  following  century 
(1239-99).  There  are  to  be  found  records  of  six  similar  epidemics  in 
the  fourteenth  century,  and  seven  great  \'isitations  of  influenza  occurred 

399 


400  INFLUENZA. 

in  the  fifteenth  century.  Aitken  ^  speaks  of  a  very  fatal  prevalence  of 
influenza  throughout  France  in  1311,  and  of  an  epidemic  in  1403  in 
which  the  mortality  was  so  great  that  the  courts  of  law  in  Paris  were 
closed  in  consequence  of  the  deaths. 

The  earliest  accurately  described  epidemic  of  the  British  islands  is 
that  of  the  year  1510.  The  disease  apparently  started  from  Malta,  in- 
vaded Sicily,  then  Italy,  Spain,  and  Portugal,  then  crossed  the  Alps  into 
Hungary  and  Germany,  extending  westward  into  France  and  Britain. 
Its  track  widened  over  all  Europe  from  the  southeast  to  the  extreme 
northwest,  and  it  is  said  that  not  a  single  family  and  scarce  a  person 
escaped  it.  It  was  attended  by  "a  grievous  pain  "in  the  head,  heaviness, 
difficulty  of  breathing,  hoarseness,  loss  of  strength  and  appetite,  rest- 
lessness, retchings  from  a  terrible  tearing  cough.  Presently  succeeded  a 
chilliness  and  so  violent  a  cough  that  many  were  in  danger  of  suffoca- 
tion. The  first  day  it  was  without  spitting,  but  about  the  seventh  or 
eighth  day  much  viscid  phlegm  was  spit  up.  Others  (though  fewer) 
spat  only  water  and  froth.  When  they  began  to  spit,  cough  and  short- 
ness of  breath  were  easier.  None  died  except  some  children.  In  some 
it  went  off  with  a  looseness,  in  others  by  sweating.  Bleeding  and  purg- 
ing did  hurt"  (Thomas  Short). 

The  epidemic  of  1557,  starting  westward  from  Asia,  spread  over 
Europe,  and  then  crossed  the  Atlantic  to  America.  The  malady  broke 
out  in  England  in  the  month  of  September.  "  Presently  after  were 
many  catarrhs,  quickly  followed  by  a  more  severe  cough,  pain  of  the 
side,  difficulty  of  breathing,  and  a  fever.     The  pain  was  neither  violent 

nor  pricking,  but  mild.    The  third  day  they  expectorated  freely 

Some,  but  very  few,  had  continued  fevers  along  with  it;  many  had 
double  tertians  ;  others  simply  slight  intermittent.  All  were  worse  by 
night  than  by  day ;  such  as  recovered  were  long  valetudinary,  had  a 
weak  stomach  and  hypped."  Gravid  women  either  aborted  or  died. 
This  epidemic  spread  with  frightful  rapidity.  Thousands  were  attacked 
at  the  same  time.  The  entire  population  of  Nismes,  with  scarcely  an 
exception,  fell  ill  with  it  upon  the  same  day.  It  was  extremely  fatal. 
The  disease  raged  in  some  parts  until  the  middle  of  the  following  year 
(1558),  and  carried  off  in  Delft  alone  five  thousand  of  the  poor.  In  all 
cases  mild  treatment  was  called  for,  with  warm  broths  and  speedy  im- 
mersals,  "  to  recall  the  appetite  and  keep  the  vessels  of  the  throat 
open." 

About  a  quarter  of  a  century  later,  in  1580,  a  great  epidemic  of 
influenza  spread  from  the  southeast  toward  the  northwest,  over  Asia, 
Africa,  and  Europe  from  Constantinople  and  Venice,  and  extended  over 
Hungary  and  Germany  to  the  farthest  regions  of  Norway,  Sweden,  and 
Russia.  It  prevailed  in  England,  and  was  described  by  Dr.  Short.  In 
Italy  it  was  rife  during  August  and  September,  in  England  from  the 
middle  of  August  to  the  end  of  September,  and  in  Spain  during  the  whole 
summer.  In  most  places  its  duration  was  about  six  weeks.  The  termi- 
nation was,  as  a  rule,  favorable.  In  the  account  of  Dr.  Short  it  is  stated 
that  "  few  died  except  those  that  were  let  blood  of  or  had  unsound 
viscera."  In  some  districts,  on  the  contrary,  the  course  of  the  disease  was 
very  severe.     In  Rome  two  thousand  died  of  it,  according  to  the  author 

^  Practice  of  Medicine. 


HISTORY.  lol 

just  cited,  but  Zut'1/.cr  states  tluit  victiuis  of  tlie  epulemie  in  the  Ktonial 
City  numbered  not  less  tiian  nine  thousand,  and  adds  that  Madrid  must 
have  been   alm(»st  de|)<)j)uhited  l)y  it. 

This  hitih  mortality  has  been  attril)ute<l  to  the  bloodletting  practised 
in  the  treatment  of  the  disease.  The  symj>toms  are  similar  to  those  of 
tlie  previous  epidemies,  with  great  shortness  of  breath,  which  continued 
in  many  eases  some  time  after  the  tlisappearanee  of  the  catarrhal 
troul)le. 

Influenza  reappeared  in  Germany  in  1  •")!»].  An  epidemic  extending- 
from  Holland  throuuh  France  and  into  Italy  occuri-ed  in  l.">!);5.  In 
IGIO  catarrh  prevailed  throughout  Europe.  In  1G26-27  epidemic 
catarrhal  fevi'r  made  its  ap])earance  in  Italy  and  France;  in  l(j42— 4o, 
in  Holland  ;  in  1(J47,  in  S[)ain  and  the  colonies  of  the  \\'estei-n  Wdrld  ; 
and  again  in  IGoo  in  North  Anierica.  Noah  Webster,  in  his  work 
entitled  ^I  Brief  Hi.sfori/  of  Epidemic  and  Pestilenti(d  iJi.srd.sc-i,  ])ub- 
lished  in  Loudon  in  1800,  states  that  the  outbreak  of  1647  was  the  first 
epidemic  of  catarrh  mentioned  in  American  annals.  Epidemic  catarrh 
revisited  Austria,  Germany,  and  England  in  1658  and  again  in  1675. 
The  first  of  these  two  epidemics  is  described  by  Willis,  the  second  by 
Sydenham,  as  they  occurred  in  England,  and  the  accounts  arc  to  be 
found  in  the  Annals  of  Influenza.  About  this  time  the  disease  began  to 
be  known  as  influenza,  and  it  is  interesting  to  note  that  the  influence  of 
the  stars  suggested  itself  in  connection  with  its  sudden  appearance  and 
Avide  prevalence.  Willis  writes  that  "about  the  end  of  April  (1658) 
suddenly  a  distemper  arose  as  if  sent  by  some  blast  of  the  stars,  which 
laid  hold  of  very  many  together — that  in  some  tOAvns  in  the  space  of  a 
week  above  a  thousand  people  fell  sick  together." 

Epidemics  occurred  in  Great  Britain  and  Europe  in  1688,  1693,  and 
in  1709.  Epidemic  catarrh  spread  in  1712  widely  over  Euro])e  from 
Denmark  to  Italy.  In  1729-30  a  great  epidemic  swept  over  Europe. 
In  five  months  the  disease  overspread  Russia,  Poland,  Germany,  Sweden, 
and  Denmark.  In  Vienna  sixty  thousand  persons  fell  ill  of  it.  In  the 
autumn  it  reached  France  and  Switzerland  and  extended  to  England  ;  it 
extended  to  Italy,  thence  to  Spain,  from  which  country  it  found  its  May 
to  Mexico.  The  symptoms  were  those  already  described  as  characteriz- 
ing the  attack  in  previous  epidemics.  The  attack  began  with  pains  in 
the  limbs,  and  fever,  hoarseness,  catarrh,  dyspncea,  and  cough  followed. 
Delirium,  drowsiness,  and  faintness  occurred  in  some  cases.  Turbid 
urine,  copious  sweating,  looseness  of  the  bowels,  and  nosebleeding  were 
common.  In  Switzerland  only  children  and  old  persons  died.  In  this 
pandemic  the  disease  was  not  very  fatal. 

Influenza  invaded  Saxony  and  Poland  two  years  later,  and,  s]n'ead- 
ing  through  Germany,  Switzerland,  and  Holland,  reached  Great  Britain 
in  December,  1732.  Thence,  toward  the  end  of  January,  it  spread 
to  France,  Italy,  Spain,  and  westward  to  North  America,  passing  on 
to  the  islands  of  the  West  Indies  and  to  South  America.  The  dis- 
ease in  this  epidemic  ran  a  favorable  c<nirse,  the  attack  terminating  in 
from  three  to  fourteen  days,  Avith  sweating,  bleeding  from  the  nose,  or 
an  abundant  discharge  from  the  nasal  passages.  The  aged  and  those 
suffering  from  chronic  pubnonary  disease  mostly  perished.  In  Scotland 
three  forms  of  the  attack  were  described — the  cephalic,  the  thoracic,  and 

Vol.  I.— 26 


402  INFLUENZA. 

the  abdominal.  This  pandemic  slowly  extended  over  Eastern  Europe 
and  lasted  nntil  1737.  It  is  of  this  outbreak  that  John  Huxham  of 
Plymouth  wrote  as  follows  :  "  About  this  time  a  disease  invaded  these 
parts  which  was  the  most  completely  epidemic  of  any  I  remember  to 
have  met  with  ;  not  a  house  was  free  from  it ;  the  beggar's  hut  and  the 
nobleman's  palace  were  alike  subject  to  its  attacks,  scarce  a  person 
escaping  either  in  town  or  country  ;  old  and  young,  strong  and  infirm, 
shared  the  same  fate."  .  .  .  .  "  The  disorder  began  at  first  with  a  slight 
shivering ;  this  was  presently  followed  by  a  transient  erratic  heat  and 
headache  and  a  violent  and  troublesome  sneezing ;  then  the  back  and 
lungs  were  seized  with  flying  pains,  which  sometimes  attacked  the  heart 
likewise,  and,  though  they  did  not  long  remain  there,  yet  were  very 
troublesome,  being  greatly  irritated  by  the  violent  cough  which  accom- 
panied the  disorder,  in  the  fits  of  which  a  great  quantity  of  thin,  sharp 
mucus  was  thrown  out  from  the  nose  and  mouth.  These  complaints 
were  like  those  arising  from  Avhat  is  called  catching  cold,  but  presently 
a  slight  fever  came  on,  which  afterward  grew  more  violent ;  the  pulse 
was  now  very  quick,  but  not  in  the  least  hard  and  tense  like  that  in  a 
pleurisy ;  nor  was  the  urine  remarkably  red,  but  very  thick  and  inclin- 
ing to  a  whitish  color ;  the  tongue,  instead  of  being  dry,  M'as  thickly 
covered  with  a  whitish  mucus  or  slime ;  there  was  an  universal  com- 
plaint of  want  of  rest  and  a  great  giddiness.  Several  likewise  were 
seized  with  a  most  racking  pain  in  the  head,  often  accompanied  by  a 
slight  delirium.  Many  were  troubled  with  a  tinnitus  aurium,  or  singing 
in  the  ears ;  and  numbers  suffered  from  violent  earaches  or  pains  in  the 
meatus  auditorius,  which  in  some  turned  to  an  abscess.  Exulcerations 
and  swelling  of  the  fauces  were  likewise  very  common.  The  sick  were 
in  general  very  much  given  to  sweat,  which,  when  it  broke  out  of  its 
own  accord,  was  very  plentiful  and  continued  without  striking  in  again, 
and  did  often  in  the  space  of  two  or  three  days  wholly  carry  off  the 
fever.  You  have  here  a  description  of  this  epidemic  disease  such  as  it 
prevailed  hereabouts,  attacking  every  one  more  or  less;  but  still,  con- 
sidering the  great  multitude  that  were  seized  by  it,  it  was  fatal  to  but 
few,  and  that  cliiefly  infants  and  consumptive  old  people.  It  generally 
went  off  about  the  fourth  day,  leaving  behind  a  troublesome  cough, 
which  was  very  often  of  long  duration,  and  such  a  dejection  of  strength 
as  one  would  hardly  have  suspected  from  the  shortness  of  the  time. 

''  On  the  whole,'  this  disorder  was  rarely  mortal,  unless  by  some  very 
great  error  arising  in  the  treatment  of  it ;  however,  this  very  circum- 
stance proved  fatal  to  some,  who,  making  too  slight  of  it,  either  on 
account  of  its  being  so  common  or  not  thinking  it  very  dangerous,  often 
found  asthmas,  hectics,  or  even  consumptions  themselves,  the  forfeitures 
of  their  inconsiderate  rashness." 

Widely  extended  epidemics  prevailed  in  Europe  and  America  in 
quick  succession  between  the  years  1737  and  1780.  One  of  the  most 
remarkable  epidemics  of  this  disease  is  that  described  as  the  epidemic 
of  1782.  It  came  from  the  East,  from  Asia  into  Russia.  From  St. 
Petersburg  it  spread  during  the  winter  and  spring  over  Sweden,  Germany, 
Holland,  and  France  ;  in  the  autumn  it  show^ed  itself  in  Italy,  Spain, 
and  Portugal.  In  Vienna  three  fourths  of  the  population  fell  ill  of  it  so 
suddenly  that  it  for  the  first  time  received  its  appellation  "  Blitz  catarrh." 


inSTOR  Y.  403 

XmiR'i'oii.s  oiitljivak.s  of  inHiK'iizu  occiirrcd  in  Kurojtc  an<l  Aiiicrica 
during-  the  years  1788-90.  One  of  these  has  been  well  descrihcd  hy 
Dr.  John  Warren  of  Boston  in  a  h'tter  to  liettsoni.  This  h'tter  is 
dated  ^lay  .'>0,  17SM),  and  anion<i::  otiier  matters  of  <;reat  interest  res|)eet- 
ino;  the  disease  it  is  stated  that  "  onr  l)eh»ved  Presich-nt,  W'asliinjrton, 
is  but  now  on  the  reeovery  from  a  very  severe  and  {hin<reroiis  attack 
of  it  in  that  eity "  [New  York].  Xo  great  epidemic  followed  until 
1798,  when  the  malady  again  showed  itself  in  Russia  and  spread  over 
the  greater  part  of  Euro[)e,  continuing  to  })revail  in  various  parts  until 
1803. 

In  the  year  1830  iiiHuen/a  again  became  pandemic.  It  showed 
it.self  first  in  China  ;  in  September  it  reached  the  Indian  Archipelago, 
invaded  Russia,  and  reached  Moscow  in  November,  whence  it  spread 
rapidly  to  Poland,  Prussia,  Denmark,  Fiidand,  and  Germany.  By 
June  it  had  reached  England,  sweeping  southward  in  the  early  winter 
into  Italy  and  westward  across  the  Atlantic  to  North  America,  where 
it  still  prevailed  in  various  regions  in  the  United  States  at  the  close  of 
the  winter  of  1831-32.     Meanwhile  it  continued  in  the  East. 

In  June,  1833,  it  again  showed  itself  in  Ru.ssia,  and  repeated  its 
wanderings  as  before.  From  1837  to  1851  numerous  epidemics  took 
place.  The  epidemic  of  1847-48  has  been  described  by  many  writers, 
and,  with  much  exactness  as  it  occurred  in  London,  by  Peacock.  It  is 
estimated  that  one  fourth  of  the  entire  population  of  that  city  were 
affected  by  the  disease.  The  epidemic  prevailed  in  London  for  six 
months,  and  it  is  interesting  to  note  that  although  the  deaths  registered 
for  the  entire  period  as  from  influenza  amounted  to  only  1739,  the 
report  of  the  Registrar  General  showed  that  during  the  six  Aveeks  the 
epidemic  was  at  its  height  not  less  than  five  thousand  persons  died  in 
the  metropolitan  districts  in  excess  of  the  average  mortality  of  the 
period,  the  increased  death  rate  showing  itself  in  nearly  every  class  of 
disease,  the  local  maladies  which  had  been  the  prominent  affection  being 
doubtless  in  many  cases  assigned  as  the  cause  of  death. 

Influenza  prevailed  over  a  wide  area  of  the  L'nited  States  during  the 
early  months  of  1879. 

From  the  time  of  the  great  epidemic  of  1847-48  the  disease  affected 
a  smaller  proportion  of  the  inhabitants  of  the  localities  in  which  it 
appeared,  and  proved  a  comparatively  unimportant  malady.  For  this 
reason  it  for  many  years  occupied  a  less  conspicuous  place  in  medical 
literature. 

In  1889  influenza  again  appeared  in  the  form  of  a  veritable  pandemic. 
It  first  showed  itself  early  in  the  spring  in  the  steppes  of  Tartary, 
appearing  in  Bokhara  in  May.  It  advanced  thence  by  two  routes — 
eastward  toward  the  Chinese  Empire,  and  westward  over  Russia  and 
Europe  to  the  United  States.  Scattered  cases  showed  themselves  in 
New  York  and  Philadelphia  about  the  middle  of  December.  In  a  few 
days  the  disease  became  epidemic,  and  prevailed  very  generally  in  the 
Eastern  cities  during  the  last  week  of  the  year.  It  spread  with  great 
rapidity  throughout  the  United  States.  In  April,  1890,  it  had  reached 
Mexico,  New  Zealand,  Australia,  and  South  America.  In  many  of  the 
infected  regions  the  disease  has  prevailed  with  great  intensity,  the  larger 
number  of  the  inhabitants  being  affected.     It  has  subsided  only  to  recur 


404  INFLUENZA. 

at  irregular  intervals  with  gradually  diminishing  intensity  until   the 
present  time  (autumn,  1896). 

During  this  period  influenza  has  again  become  a  familiar  disease  and 
has  been  carefully  and  thoroughly  studied.  On  the  one  hand,  many  of 
the  popular  delusions  and  professional  conjectures  in  regard  to  it  have 
been  dispelled,  while,  on  the  other,  some  of  the  shrewd  observations  of 
the  older  practitioners  have  been  confirmed.  The  bacterial  nature  of 
the  infecting  principle  has  been  demonstrated.  From  the  date  of  the 
present  pandemic  the  disease  takes  its  proper  nosological  position  among 
the  acute  infectious  maladies.  Much  work,  however,  remains  to  be  done. 
Where  and  under  what  conditions  the  infecting  principle  originates,, 
and  what  the  influences  may  be  that  from  time  to  time  call  it  into 
activity  and  send  it  forth  in  definite  directions  over  the  earth,  are  yet 
unknown. 

Catarrhal  aifections  have  frequently  prevailed  among  domestic 
animals  during  epidemics  of  influenza.  Horses,  dogs,  and  cats  have 
manifested  these  disorders.  Neat  cattle  and  sheep  have  been  less  com- 
monly affected.  These  epizootics  have  in  some  instances  preceded  tha 
outbreak  of  influenza  among  men  ;  in  other  instances  they  have  appeared 
at  the  same  time  ;  while  in  a  widespread  outbreak  among  horses  in  the 
United  States  in  1872  the  disease  did  not  afi'ect  man  exce23t  to  a  limited 
extent.  In  1880  in  the  United  States,  following  an  outbreak  of  influenza 
among  men,  an  extensive  epizootic,  chiefly  afl^ecting  horses,  prevailed  in 
Canada  and  the  United  States  east  of  the  Mississippi  River. 

Etiology. — 1.  Predisposing  Influences. — When  the  disease  invades  a 
community  a  large  proportion  of  the  population  is  attacked  without  dis- 
tinction of  age,  sex,  social  condition,  or  occupation.  Previous  illness, 
affords  no  protection.  Aged  and  infirm  persons  and  those  of  nervous 
temperament  are  peculiarly  liable  to  suffer,  but  the  robust  possess  no 
immunity.  All  races  and  dwellers  in  every  climate  are  liable  to  the 
attack.  Upon  the  outbreak  of  an  epidemic  adults  are  attacked  earlier 
than  children.  In  some  epidemics  children  have  manifested  a  slight 
relative  immunity. 

Influenza  is  not  self-protective.  An  attack  confers  no  exemption 
from  the  disease  in  subsequent  outbreaks,  and  independently  of  relapses,, 
which  frequently  occur,  individuals  have  been  known  to  experience  a 
second  attack  during  the  prevalence  of  the  same  epidemic.  Local  unhy- 
gienic conditions  favor  the  prevalence  of  the  disease  in  its  more  severe 
forms,  and  the  increase  of  the  death  rate  during  outbreaks  of  influenza 
is  proportionately  greater  in  districts  in  which  there  is  ordinarily  a  high 
mortality  as  compared  with  healthier  places.  Influenza  bears  no  rela- 
tion with  known  atmospheric  conditions.  It  prevails  at  all  seasons  of 
the  year,  and  is  in  no  way  dependent  upon  low  temperature  nor  abrupt 
changes  of  the  weather.  It  has  prevailed  in  very  high  latitudes  and  at 
all  altitudes.  Epidemics  have  recurred  at  irregular  periods.  It  was  at 
one  time  thought  that  the  disease  recurred  in  cycles  of  about  one  hun- 
dred years.  This  view  is  unsupported  by  the  facts.  A  review  of  the 
history  of  the  subject  shows,  however,  that  at  intervals  of  twenty-five 
to  forty  years  great  epidemics  have  swept  over  vast  areas  of  the  earth's 
surface,  while  more  limited  outbreaks  have  occurred  with  greater  or  less 
frequency  in  the  years  succeeding  the  pandemics.     It  does  not,  how- 


ETIOLOGY.  40') 

ov<T,  apiM'nr  possihU^  to  establish  anything''  like  a  regular  pericxlicity  in 
the   rc'tiii'ii   ot"  the  disease. 

Tlie  great  epideiiiies  have  in  most  instances  spread  in  a  direction 
from  the  east  or  northeast  toward  the  west  and  south.  On  other  (x-ca- 
.sions  they  liave  taken  the  opposite  course,  and  sometimes  they  have  ap- 
])eared  to  radiate  in  various  directions  from  several  centres.  In  conse- 
«|uenct'  <)f  these  facts  two  views  have  arisen  concerning  the  origin  of  the 
affection  :  First,  that  each  epidemic  starts  out  from  some  single  unknown 
source  and  spreads  thence  from  i)oint  to  point,  inviiding  more  distant 
localities  successively  as  it  advances,  until  at  length  it  dies  out  in  regions 
remote  from  the  starting  point.  It  in  no  Avise  conflicts  with  this  view 
that  outbreaks  recur  from  time  to  time  in  the  regions  thus  successively 
invade<l.  Tlie  second  view  is  that  influenza  arises  not  from  some  single 
})artit'ular  place,  but  that  the  infecting  principle  is  widespread  in  nature, 
and  called  into  activity  from  time  to  time  by  unknown  atmos})heric  or 
telluric  causes,  and  that  the  great  epidemics,  being  made  up  of  successive 
outbreaks  of  the  disease,  have  many  distinct  points  of  origin. 

The  j^rogress  of  influenza  from  place  to  place  has  usually  been  rapid. 
In  this  respect,  however,  the  epidemics  have  shown  great  diversity. 
The  disease  has  sometimes  travelled  slowly.  It  is  said  to  have  overrun 
Europe  in  six  weeks,  and  on  other  occasions  it  has  occupied  six  months 
in  doiny;  so.  It  has  sometimes  attacked  reo^ions  w*idelv  remote  from  each 
other  within  short  intervals  of  time,  and  has  appeared  at  the  same  time 
in  different  (juarters  of  the  globe.  A  careful  study  of  the  facts  relating 
to  the  recent  pandemic  shows  that  influenza  follows  the  lines  of  travel 
and  advances  at  about  the  ordinary  rate  of  commercial  intercourse.  The 
mere  fact  that  the  disease,  first  noted  in  Central  Asia  in  the  spring  of 
1889,  extended  westward  toward  Europe  and  eastward  toward  China 
serves  to  explain  its  simultaneous  appearance  in  distant  quarters  of  the 
globe.  The  well  established  fact  that  the  infecting  principle  may  be 
transmitted  by  fomites  renders  intelligible  at  least  the  occasional  out- 
breaks at  sea  and  at  distant  points  where  the  disease  had  not  previously 
prevailed  in  the  ordinary  manner. 

When  influenza  develops  in  a  community  it  continues  to  prevail,  as  a 
rule,  from  four  weeks'  to  two  months,  exceptionally  for  a  much  longer 
time.  The  epidemic  of  1831  was  continuously  prevalent  in  Paris  for 
nearly  a  year.  The  epidemics  are  occasionally  heralded  by  scattered 
cases.  More  commonly  the  disease  attacks  almost  simultaneously  great 
numbers  of  inhabitants  of  infected  districts,  so  that  when  the  epidemic 
is  severe  the  sick  may  be  soon  counted  by  thousands  and  business  is  some- 
times seriously  interfered  ^^nth.  The  epidemics  rapidly  reach  their 
height,  and  usually  subside  almost  as  suddenly  as  they  began.  During 
the  prevalence  of  the  disease  since  the  winter  of  1889—90  scattered  cases 
and  groups  of  cases  have  occasionally  occurred  in  the  intervals  between 
the  recurring  annual  outbreaks.  In  large  cities  the  disease  makes  its 
appearance  nearly  at  the  same  time  in  several  different  localities,  and 
s])reads  from  these  as  foci  of  infection  throughout  the  entire  community. 
Cities  and  large  towns  are  generally  affected  earlier  than  the  villages 
surrounding  them. 

2.  The  Exciting  Cause. — Among  the  questions  finally  settled  by  a 
study  of  the  disease  in  the  recent  epidemic  is  that  of  its  contagiousness. 


406  INFLUENZA. 

Influenza  is  highly  contagious,  and  extends  by  direct  or  indirect  com- 
munication from  the  sick  to  the  well.  Until  recently  the  view  was 
almost  universally  held  that  the  cause  of  the  disease  was  miasmatic  in 
its  nature  and  spread  independently  of  direct  contact.  It  is  interesting 
in  this  connection  to  note  that  Haygarth,  writing  of  the  outbreaks  of 
1775  and  1782,  declares  as  the  result  of  his  observations  that  the  influ- 
enza spreads  "by  the  contagion  of  patients  in  the  distemper;"  and 
Falconer,  writing  of  the  epidemic  of  1803,  says,  "I  have  no  doubt  that 
it  is  contagious  in  the  strictest  sense  of  the  word." 

The  following  personal  observation  is  in  accord  with  the  general  ex- 
perience of  recent  times  :  In  the  first  days  of  an  outbreak  of  influenza 
a  physician  was  called  in  the  evening  to  see  the  child  of  a  medical  friend. 
The  little  patient,  who  had  been  sick  two  days,  was  supposed  to  be 
developing  enteric  fever.  It  subsequently  proved  that  he  had  influenza, 
which  rapidly  attacked  every  member  of  the  household.  The  physician 
called  in  consultation  spent  twenty  minutes  at  the  bedside  of  the 
patient,  going  over  the  history  of  the  case  and  making  a  careful  physi- 
cal examination.  Twenty  four  hours  later  he  developed  a  violent 
attack  of  influenza  which  confined  him  to  his  bed  for  a  week. 

That  the  belongings  of  the  patient  may  constitute  fomites  and  the 
corpse  itself  prove  a  source  of  infection  is  established  by  the  observa- 
tion of  White  and  Guiteras  in  regard  to  a  localized  outbreak  in  a  remote 
community  in  1880.  These  observers  have  placed  upon  record  the 
following  circumstance  :  "  Influenza  prevailing  in  Europe,  an  American 
gentleman  in  bad  health  contracted  the  disease  in  London  ;  improved  ; 
suffered  a  relapse  in  Paris,  and  died  there  at  the  end  of  September, 
1879.  His  body  was  embalmed  and  sent  home.  Following  the 
exposure  of  the  remains  of  this  person  to  the  view  of  his  fiimily  there 
was  an  outbreak  of  influenza  with  characteristic  symptoms  which  affected, 
first,  members  of  that  family ;  next,  friends  living  in  close  association 
with  them  ;  next,  the  medical  attendant  of  some  of  them ;  and  finally, 
the  housekeeper  and  one  or  two  patients  of  one  of  the  physicians  Avho 
wrote  the  paper,  the  whole  number  being  about  twenty  cases." 

In  the  spring  of  1892,  Pfeiffer,  at  the  Hygienic  Institute  of  Berlin, 
succeeded  in  isolating  among  the  micro-organisms  found  in  the  nasal 
and  bronchial  secretions  of  patients  suffering  from  influenza  a  bacillus 
which  he  regards  as  characteristic.  This  micro-organism  is  a  short 
rod  about  one  half  the  length  and  nearly  the  same  thickness  as  the 
bacillus  of  mouse-septicsemia.  It  is  non-motile ;  it  stains  in  I^ofiler's 
methylene  blue  or  Ziehl's  carbol-fuchsin,  and  presents  the  appearance 
of  two  bulbous  ends  joined  by  a  narrower  and  less  deeply  stained 
central  portion.  It  occurs  in  great  numbers  in  the  nasal  secretions, 
and  is  frequently  seen  in  the  sputa  almost  in  pure  culture.  At  the 
close  of  the  attack  the  bacilli  become  relatively  few  in  number,  but 
persist  for  some  time  after  the  subsidence  of  active  symptoms.  Kruse 
states  that  in  doubtful  cases  the  diagnosis  of  influenza  can  be  established 
with  certainty  and  without  difficulty  by  an  examination  of  the  sputum. 
Cover-glass  preparations  are  stained  with  a  dilute  pale  red  solution  of 
carbol-fuchsin  in  water,  and  the  bacilli  may  be  readily  recognized.  This 
bacillus  was  demonstrated  by  Canon  in  the  blood  of  a  series  of  consecu- 
tive cases  at  the  Moabit  Hospital  of  Berlin.     The  cultures  have  been 


SYMPTOMS.  407 

grown  in  agar  containing  a  small  ainoniit  of  sugar.  It  grows  with 
(litKculty  in  bouillon,  which  remains  ch'ar.  It  rc(|uircs  lor  its  culture 
a  tcmju'raturc  which  li(iuclics  gelatin.  It  grows  best  on  culture  media 
in  which  luemoglobin  is  present.  Inoculation  exju'riments  have  been, 
as  a  rule,  .successful,  though  A'oges  failed  to  produce  influenza  in  the 
lower  animals  Avith  Pfeilfcr's  bacillus.  Pfeiffer  was  able  to  demonstrate 
the  presence  of  this  bacillus  in  all  cases  of  true  influenza  examined.  It 
is  not  found  in  other  diseases.  It  must  thus  be  regarded  as  ehanu'ter- 
istic. 

The  disease  is  communicated  from  the  sick  to  the  well  by  direct  con- 
tact and  close  association.  It  is  probable  that  the  infecting  principle, 
like  that  of  measles  and  pertussis,  is  inhaled  with  the  inspired  air. 

Pathological  Axatomy. — Uncomplicated  influenza  is  rarely  fatal. 
As  a  rule,  the  unfavorable  termination  is  due  to  lung  complications. 
The  lesions  are  congestion  and  catarrhal  swelling  of  the  mucous  mem- 
brane of  the  upper  air-passages  and  the  bronchial  tubes.  These  lesions 
may  be  restricted  to  the  trachea  and  larger  bronchi  or  extend  to  the 
finest  twigs.  They  may  consist  of  great  thickening  and  deep  capillary 
injection  of  the  mucous  lining  of  the  tubes,  which  contain  clear  frothy 
mucus  or  thick  viscid  masses  of  muco-purulent  secretion  unmixed  with 
air.  The  bronchial  glands  have  been  found  to  be  enlarged  and  softened. 
A  catarrhal  condition  of  the  mucosa  of  the  stomach  and  intestines  has 
been  observed.  The  mesenteric  glands  may  be  slightly  enlarged.  The 
spleen  has  been  found  moderately  enlarged. 

Symptoms. — General  Description  of  the  Disease. — Influenza  in  in- 
dividual cases  presents  the  widest  variation  as  regards  intensity,  from 
a  trifling  indisposition  to  an  illness  of  the  gravest  kind,  which  may 
terminate  in  death.  In  this  respect,  with  the  exception  that  the  range 
of  variation  is  greater,  influenza  resembles  other  acnte  infectious  diseases. 
The  variations  are,  however,  to  some  extent  related  to,  first,  the  previous 
health  of  the  individual,  his  age,  and  the  power  of  resisting  morl)id 
influences  which  he  possesses ;  second,  the  character  of  the  prevailing 
epidemic. 

Cases  of  great  severity  are  occasionally  observed  during  the  prev- 
alence of  mild  epidemics.  In  every  epidemic,  however,  the  majority 
of  the  snfferers  manifest  the  disease  in  a  mild  form,  very  many  in  what 
may  be  termed  a  rudimentary  form. 

The  period  of  incubation  is  brief,  varying  from  a  few  hours  to  two 
or  three  days.  This  period  is  nsually  unattended  by  subjective  symp- 
toms. 

The  onset  of  the  attack  is  abrupt,  and  in  most  instances  is  marked 
by  chilliness  or  a  chill  of  moderate  severity,  which  may  be  prolonged 
and  repeated ;  fever  rapidly  supervenes.  There  is  headache,  usually 
severe,  with  ]3ain  back  of  the  eyeballs,  severe  pain  in  the  back,  limbs, 
and  joints,  and  a  general  feeling  of  soreness,  with  tenderness  upon  pres- 
sure. These  symptoms  are  accompanied  by  mental  and  physical  depres- 
sion, with  malaise  and  restlessness.  The  forces  of  the  circulation  are 
notably  depressed.  The  spleen  is  slightly  enlarged.  There  is  no  cha- 
racteristic eruption.  The  duration  of  the  attack  is  from  three  or  four  to 
seven  days,  and  the  patient  only  slowly  regains  his  habitual  physical 
and  mental  vigor. 


408  INFLUENZA. 

In  mild  cases  the  chill  may  be  slight,  transient,  or  absent  altogether. 
The  headache  and  muscle  pains  are  of  moderate  intensity.  There  is 
malaise ;  weariness  upon  bodily  and  mental  effort ;  disinclination  for 
affairs ;  some  difficulty  in  fixing  the  attention ;  and  not  infrequently 
slight  mental  confusion.  To  these  nervous  disturbances  are  added 
catarrhal  symptoms,  such  as  coryza  and  erythematous  angina  and  a  tick- 
ling cough.  The  fever  is  slight,  the  temperature  not  rising  above  101° 
F.,  or  the  temperature  may  remain  subfebrile  throughout.  A  large  pro- 
portion of  the  patients  suffering  from  influenza  in  the  milder  form  are 
able  to  continue  their  ordinary  avocations.  No  very  great  degree  of 
intensification  of  the  symptoms  is  necessary,  however,  to  compel  the 
patient  to  betake  himself  to  bed. 

In  the  severer  cases  the  chill  is  more  marked,  the  shivering  more 
prolonged.  Fever  is  rapidly  established,  the  acme  being  reached  within 
twenty-four  or  thirty-six  hours.  The  temperature  may  rise  to  104- 
105°  F,  Sensations  of  heat  alternate  with  chilliness.  In  many  cases 
there  are  annoying  sweats.  Headache  is  intense  ;  there  is  pain  in  the 
orbits  and  at  the  root  of  the  nose.  Sneezing,  redness  of  the  eyes  and 
edges  of  the  nostrils,  a  thin  discharge  from  the  nose,  and  lachrymation 
occur.  Epistaxis  is  occasionally  observed.  The  throat  is  sore  ;  there  is 
a  tickling  sensation  in  the  upper  air-passages,  hoarseness,  and  sometimes 
dyspnoea.  The  cough  is  paroxysmal,  distressing,  and  at  first  unpro- 
ductive. It  occasionally  causes  vomiting  like  that  which  occurs  in  the 
paroxysms  of  whooping  cough.  Chest  pains,  stitches  in  the  side,  loss  of 
the  sense  of  smell  and  of  taste  also  occur. 

The  catarrhal  symptoms  in  other  cases  are  but  slightl}'  developed. 
The  patient  presents  the  symptoms  of  an  acute  infection  of  varying 
severity,  beginning  with  chill  and  fever.  There  is  great  depression 
together  with  backache  and  pains  in  the  limbs  such  as  occur  in  dengue, 
with  which  influenza  has  been  confounded,  or  variola.  The  appetite  is 
lost ;  thirst,  constipation,  and  diminished  secretion  of  urine  occur.  The 
pulse  may  be  full  and  compressible ;  more  commonly  it  is  feeble,  small, 
and  irregular.  It  is,  as  a  rule,  only  moderately  increased  in  frequency. 
In  many  cases  there  is  slight  blueness  of  the  lips  and  finger  tips ;  the 
patient  is  distressed  by  restlessness  and  want  of  sleep.  At  the  end  of 
four  or  five  days  the  febrile  symptoms  decline,  at  times  gradually,  more 
commonly  abruptly,  and  the  defervescence  is  often  accompanied  by 
copious  sweats,  spontaneous  diarrhoea,  increased  flow  of  sedimentary 
urine,  and  considerable  amelioration  of  the  subjective  symptoms.  The 
catarrhal  symptoms  outlast  the  fever  two  or  three  days,  but  cough  and 
expectoration  may  persist  for  some  time.  During  the  attack  there  are 
evidences  of  a  profound  disturbance  of  the  functions  of  the  nervous  sys- 
tem. There  is  depression  alike  of  the  body  and  mind,  with  mental 
duJness,  and  in  some  cases  delirium.  Slight  convulsions  may  occur  ; 
cutaneous  hyperesthesia  is  often  present,  and  areas  of  burning  pain  in 
the  skin  are  encountered.  Neuralgia,  muscle  pain,  and  aching  referred 
to  the  bones  are  very  common  and  often  severe. 

Symptoms  referable  to  the  nervous  system  may  dominate  the  clinical 
picture  from  the  onset  or  may  become  prominent  at  any  time  during  its 
course.  Blinding  headache,  intolerance  of  light  and  sound,  intense 
rhachialgia  may  be  associated  with  delirium  and  a  tendency  to  stupor. 


SYMPTOMS. 


409 


Painful  rio:i(lity  of  the  muscles  of  the  buck  of  the  neck  and  jreneral 
<.!onviilsi()ns  may  occur.  There  may  he  intcmse  fever  or  the  temperature 
mav  he  subnormal,  with  slow,  irre<;nlar  pulse  and  respiration. 

In  other  cases  gastro-intestinal  symptoms  are  prominent,  wliile  those 
referable  to  the  respiratory  system  are  less  urgent.  We  observe  nausea, 
occasional  vomitinii',  a  heavily  coated  tontrue,  complete  inability  to  take 
food,  gastric  tenderness,  slight  tym])any,  and  a  tendency  to  diarrhfea. 
The  attack  mav  develop  abru])tly,  with  sym])toms  like  thos(!  of  cholera 
morbus.  The  fever  and  peculiar  nervous  dei>ression  arc,  however,  the 
same. 

Finallv,  cases  occur  in  which  there  is  but  little  of  the  usual  tendency 
to  localiziition  of  the  infectious  process;  the  patient  suffers  from  fever 
of  varying  intensity,  with  great  depression  and  simultaneous  and  equal 
implication  of  the  respiratory,  circulatory,  nervous,  and  gastro-intes- 
tinal  organs. 

Herpes  occurs  in  a  considerable  proportion  of  the  cases.  Urticaria  is 
less  common.  Diifuse  erythematous  rashes  and  instances  of  purpura  have 
been  observed. 

Attempts  have  been  made  to  arrange  the  foregoing  forms  of  influenza 
into  different  categories,  and  in  theory  a  thoracic,  cardiac,  gastro-intes- 


FiG.  36. 


F. 
105 

104° 

103' 

102° 

lOl' 

100° 

99° 

98° 

97 

DAY  OF 
DISEASE 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

WI 

E 

M 

E 

|l 

\\ 

\  \ 

\ 

1 

\ 

\ 

\ 

\ 

I 

\ 

/ 

' 

/ 

A 

/\ 

/ 

1  /     \ 

K 

\ 

\ 

l/ 

\, 

\j    \ 

/ 

\/ 

Y 

1 

2 

3 

4 

5 

G 

7 

c. 


—40 


— 38 


Temperature  in  Influenza— Critical  Defervescence. 

tinal,  and  nervous  variety  may  be  recognized.  In  practice,  however, 
the  various  described  types  merge  so  gradually  into  each  other,  and  are 
so  modified  by  the  indi\'idual  peculiarities  of  the  sick  and  by  the  com- 


410 


INFL  UENZA. 


plications  which  arise  in  the  course  of  the  attack,  that  there  is,  as  a  rule, 
but  little  advantage  in  referring  particular  cases  to  theoretical  categories. 

The  DURATION  of  the  milder  forms  of  influenza  is  from  two  to  three 
days.  In  well  developed  cases  without  complications  convalescence  sets 
in  between  the  fourth  and  seventh  days.  Severe  cases  with  complica- 
tions may  be  protracted  for  several  weeks.  Relapses  occur  in  about  10 
per  cent,  of  the  cases. 

Analysis  of  the  Principal  Symptoms. — The  Fever. — In  un- 
complicated cases  the  temperature  rises  rapidly  to  101-105°  F.  in  the 


Fig.  37. 


F 
106' 

105° 

104° 

103° 

102° 

101° 

100° 

99' 

98° 

97° 

DAY  OF 

DISEASE 

IVl 

E 

M 

E   ^ 

1    E 

M 

E 

M 

E 

M 

E 

IVl 

E 

/ 

f\ 

/ 

V 

/ 

/ 

I 

h 

' 

1 

• 

n 

A 

/ 

/  \ 

r\ 

1    \ 

/ 

V 

/ 

1 

2 

3 

4 

5 

6 

7 

c. 

^-41° 


-40 


—39 


Temperature  in  Influenza— Interrupted  Crisis. 

first  twenty-four  or  thirty-six  hours.  From  this  point  it  falls  by  a 
defervescence  usually  critical ;  sometimes  by  an  interrupted  crisis ; 
sometimes  by  rapid  lysis.  The  temperature  reaches  the  normal  usually 
in  the  course  of  from  one  to  four  days  ;  less  commonly  secondary  rises 
of  temperature  occur  after  an  afebrile  period  of  one  or  two  days — inter- 
mittent form ;  or,  again,  the  fall  of  temperature  does  not  reach  the  nor- 
mal, and  is  succeeded  by  a  series  of  rises,  defervescence  occurring  some 
time  before  the  close  of  the  first  week — remittent  form.     The  accom- 


ANALYSfS   OF  THE  PnrXCfl'AL   SYMrTOMS. 


411 


panying-  clKU'ts  represent  the  more  eoimiion  loriiis  ot"  the  tornjx'rattire 
curve.  One  reealls  the  statement  of  the  ehroiiieh'r  of  an  early  epicU'mie  : 
"Some  had  continual  fevers  alon^-  witii  it;  many  had  double  tertians; 
others  simply  slioht  intcrmittont."  There  is  no  constant  relation  be- 
tween the  heijiht  to  which  the  temperature  rises  and  the  severity  of  the 
other  symptoms  ;  subjective  distress  may  be  moderate  in  patients  show- 
ing a  temperature  of  104-105°  F.,  while  other  patients  in  whom  the 
thermometer  marks  a  fever  of  101-102°  F.  may  suffer  agonizing  pain 


F 
105 

104 

103' 

102° 

101° 

100° 

99° 

98 

97° 

DAY  OF 
DISEASE 

M(  E 

M 

E 

M 

E 

ME 

M    E 

M 

E 

M,E 

I 

\ 

A 

/  \ 

A 

'  \ 

/ 

/ 

\   1 

\  1 

Y 

A 

/  \ 

\ 

^ 

\ 

\ 

\ 

, 

l\ 

V 

1  \ 

\ 

\ 

J 

\ 

V 

1 

I    i  » 

/ 

\  'A 

/     1 

\/ 

v/ 

V 

V 

1 

2 

3 

■1 

5 

!J 

-   1 
*    1 

—38 


Influenza— Rapid  Lysis. 

in  the  head,  back,  and  limbs.  The  temperature  rises  early  in  the  course 
of  the  disease,  and  may  subside  before  other  characteristic  phenomena 
show  themselves  ;  or,  again,  the  temperature  may  be  still  high  when  the 
headache,  pains,  or  even  the  catarrhal  symptoms,  have  subsided.  If  the 
fever  continue  beyond  the  seventh  or  eighth  day,  it  will  usually  be 
found,  upon  careful  examination,  to  be  due  to  some  complication,  as  a 
rule  involving  the  respiratory  tract.  The  temperature  curve,  due  to  the 
influenza  infection,  not  infrequently  merges  into  that  of  a  complicating 
bronchitis,  broncho-pneumonia,  or  croupous  pneumonia. 

The  pulse  has  no  constant  characteristics.  Its  frequency  is  mode- 
rately increased ;  very  often  with  high  temperature  the  pulse  does  not 
exceed  100.  It  is  less  forcible  than  in  health  ;  compressible  even  when 
full ;  often  irregular,  changing  in  character  in  the  course  of  a  few  hours. 
In  some  cases  the  pulse  is  slow. 

The  urine  is  usually  diminished,  sometimes  temporarily  suppressed. 


412 


INFLUENZA. 

Fifi.  39. 


F 
105' 

104° 

103' 

102' 

101' 

100° 

99' 

98° 

97' 

DAY  OF 
dlSEASE 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

W! 

E 

IVl 

^ 

I 

\ 

\ 

1 

j 

1 

J 

1 

A 

\/ 

]/ 

1 

2 

3 

i 

0 

6 

7 

Influenza— Intermittent  Type. 


Fig.  40. 


F 
104' 

103° 

102° 

101° 

100' 

99° 

98° 

97° 

DAY  OF 
DISEASE 

M 

E 

IVl 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

II 

\ 

1 

\ 

A 

1  \ 

/  \ 

1   ' 

1  I 

1 

/  1 

j 

I 

I 

\ 

I 

A 

\ 

•  \ 

\/ 

\ 

1 

/ 

\ 

/ 

\ 

A  1 

^ 

1  \  1 

\  / 

V 

u 

1 

3 

3 

i 

5 

0 

7 

c. 

r— 40° 


—38 


Influenza— Remittent  Type. 


AyALy:sis  uF  Tin-:  vniyciVAL  HYMrroMs.  41  ;3 

As  a  rule,  it  shows  little  clianiio,  and  is  not  commonly,  as  in  other  febrile 
diseases,  coneentnited  and  hi«;h  cdjored.  It  deposits  on  coolinti;  a  sedi- 
ment of  urates,  whieh  toward  the  end  of  the  fever  is  often  very  abun- 
dant. Deferveseenee  is  in  many  instances  attended  by  a  eoi)ious  excre- 
tion of  urine.  Albuminuria  occasionally  occurs,  especially  in  compli- 
cated cases.  Griffiths  and  Ladell  isolated  from  the  urine  in  influenza  a 
toxic  fever-producing  ptomaine  which  causes  death  in  animals  in  eight 
hours.  The  substance  was  found  to  be  a  whitish  crystalline  body  hav- 
ing- the  formula  C,,H,,NO„  soluble  in  water  of  slightly  alkaline  reaction. 

The  skin  in  some  cases  is  hot  and  dry  during  the  febrile  movement ; 
more  commonly  there  is  sweating  from  the  onset,  often  continued 
through  the  course  of  the  illness,  and  frequently  being  very  marked 
during  convalescence.  Sudamina  occur.  The  face  is  often  flushed,  and 
there  are  irregular  erytiieniatous  niottlings  of  the  skin,  especially  upon 
the  neck  and  chest.  Other  forms  of  erythema,  and  especially  erythema 
n(xlosum,  have  been  frequently  observed.  Labial  herpes  is  often  seen 
in  cases  not  complicated  by  pneumonia.     Urticaria  is  not  uncommon. 

Disturbances  of  the  digestive  tract  are  more  or  less  prominent  in 
almost  all  cases.  In  many  instances  they  are  such  as  are  usually  seen  in 
febrile  disorders — namely,  loss  of  appetite,  thirst,  impaired  taste,  pasty 
tongue,  tenderness  in  the  epigastrium,  and  constipation.  Xausea  and 
vomiting  sometimes  usher  in  the  attack,  and  in  some  cases  vomiting 
continues  for  several  days.  In  the  so-called  abdominal  form  of  influ- 
enza these  symptoms  are  more  severe,  and  diarrhoea  frequently  consti- 
tutes an  urgent  svmptom.  In  some  of  the  epidemics  the  intestinal 
catarrh  has  shown  a  tendency  to  run  into  dysentery. 

The  countenance  expresses  anxiety  and  depression.  There  is  pallor, 
together  \\dth  injection  of  the  conjunctivae,  puffiness  of  the  eyelids,  and 
redness  of  the  tissues  of  the  nostril.  The  facies  is  sometimes  slightly 
flushed  and  may  suggest  that  of  enteric  fever. 

Catarrh. — A  more  or  less  extensive  hypertemia  of  the  mucous  mem- 
brane of  the  respiratory  tract  is  invariably  present,  and  may  be  said  to 
be  characteristic  of  the  disease.  There  is  eoryza,  often  severe.  The 
eyelids  may  be  swollen  and  reddened ;  there  is  lachrymation  ;  sneezing  is 
frequent,  and  in  many  cases  there  is  an  abundant  discharge  from  the 
nostrils.  Epistaxis  is  not  rare.  Erythematous  angina,  with  tickling 
sensations  and  difficulty  of  swallowing,  is  frequent.  In  many  cases  the 
catarrhal  symptoms  are  restricted  to  the  upper  air-passages.  Implica- 
tion of  the  larynx  is  shown  by  huskiness  or  loss  of  voice.  Hoarseness 
is  common. 

Cough  is  a  prominent  symptom.  It  is  commonly  frequent  and  dis- 
tressing, sometimes  paroxysmal  from  the  beginning  of  the  attack,  almost 
always  so  at  some  period  of  its  course.  The  spasmodic  character  of  the 
cough  in  some  of  the  older  epidemics  led  to  a  confusion  of  diagnosis 
between  influenza  and  whooping  cough.  The  cough  is  apt  to  be  Avorse 
toward  evening  and  at  night.  In  some  cases  it  leads  to  vomiting,  and 
by  its  violence  and  persistence  gives  rise  to  myalgia  in  the  muscles  of 
respiration  and  occasionally  to  hernia.  It  is  at  first  dry  or  attended 
Avith  a  scanty  muco-serous  expectoration  ;  later  the  sputa  become  muco- 
purulent, and  they  are  sometimes  streaked  or  mingled  with  blood. 
Toward  the  close  of  the  attack  the  cough  becomes  less  urgent  and  loses 


414  INFLUENZA. 

its  spasmodic  character.  In  some  of  the  epidemics  cough  has  not  been 
a  prominent  symptom,  and  cases  may  be  encountered  in  most  epidemics 
in  which  well  developed  influenza  runs  its  course  w^ith  little  or  no  cough. 
Various  rales  may  be  detected  during  the  course  of  the  attack  as  in  ordi- 
nary acute  bronchitis.  In  other  cases  rales  are  absent  and  the  ausculta- 
tory signs  are  negative. 

Dyspncea  is  not  infrequent.  It  may  occur  in  cases  where  none  of  the 
objective  signs  of  any  pulmonary  lesion  can  be  discovered.  In  this  case 
it  may  be  of  nervous  origin,  and  a  direct  disturbance  of  the  function  of 
the  vagus  has  been  invoked  in  explanation  of  it.  This  view  is  rendered 
plausible  by  the  fact  that  the  dyspnoea  is  occasionally  intermittent  and 
paroxysmal.  In  some  of  the  epidemics  orthopnoea  and  suffocative 
attacks  have  been  common.  Stitches  in  the  side  and  substernal  pain 
occur  without  appreciable  physical  signs.  Haemoptysis  may  occur  in 
patients  who  present  no  physical  signs  of  lung  disease. 

Nervous  System. — Marked  lowering  of  muscular  strength  is  a  very 
early  symptom  and  constitutes  one  of  the  most  remarkable  features  of 
the  disease.  Patients  are  extremely  weak  from  the  onset  of  the  attack 
and  exhausted  by  slight  bodily  effort.  The  ordinary  strength  is  not 
regained  until  convalescence  is  far  advanced. 

Headache  is  a  constant  symptom.  In  addition  to  the  general  head- 
ache which  marks  the  onset  of  the  specific  fevers,  severe  pain  across  the 
brows  and  in  the  orbits  is  scarcely  ever  absent.  These  pains  are  referred 
to  the  region  of  the  frontal  sinuses  and  nasal  ducts,  sometimes  to  the 
region  of  the  antrum  of  Highmore  or  to  the  Eustachian  tube  and  the 
middle  ear.  They  are  often  most  intense.  They  last  commonly  until 
the  end  of  the  attack,  and  in  many  cases  persist  as  sequels.  The  head 
pains  increase  in  severity  toward  evening.  In  some  instances  the  occur- 
rence of  epistaxis  has  afforded  temporary  relief.  The  headache  may  be 
limited  to  one  orbit,  one  side  of  the  forehead,  or  one  side  of  the  face. 
Neuralgia  in  the  distribution  of  the  branches  of  the  fifth  pair  is  not 
infrequent.  Hypersesthesia  of  the  surface  of  the  head  and  neck  and 
painful  stiffness  of  the  muscles  of  the  neck  are  encountered.  Among 
the  more  constant  symptoms  of  influenza  are  the  very  severe  pains  in 
the  back  and  limbs  already  referred  to.  There  are  sensations  of  sore- 
ness and  bruising,  such  as  follow  severe  and  unaccustomed  muscular 
effort ;  dull  tearing  and  burning  pains  may  be  felt  in  particular  mus- 
cles or  tendons,  and  are  very  common  in  the  calves  of  the  legs.  These 
pains  are  neither  relieved  nor  aggravated  by  gentle  movement  or  by 
moderate  pressure. 

Restlessness,  insomnia,  and  anxiety  occur  in  most  of  the  severe 
attacks.  Dizziness  and  faintness  are  not  uncommon.  Mild  delirium 
is  frequent;  the  more  intense  forms  of  delirium  are  occasionally  ob- 
served. Somnolent  states  may  also  occur.  Hebetude  and  torpor  have 
characterized  some  epidemics.  In  grave  cases  painful  cramps,  subsultus 
tendinum,  twitchings,  and  trembling  of  the  hands  occur.  The  mental 
power  is  enfeebled. 

Special  Senses. — The  acuteness  of  the  special  senses  is  diminished. 
The  sense  of  smell  is  frequently  entirely  lost,  and  that  of  taste  greatly 
impaired.  Many  patients  complain  of  a  disagreeable  coppery  or  metallic 
taste.      The   hearing   is   somewhat   blunted.      Severe   earache   is   not 


COMPLICATIONS  AND'SEQUELJE.  41  o 

uucoiuiiion.  Siip})iiratiuii  ot"  tin-  inirMk'  car  and  pedoratioii  ot"  the 
meinbraiio  occur  in  a  considerable  proportion  ot"  the  cases. 

Complications  and  8EQri:L.E. — The  most  important  complications 
are  those  connected  with  tiie  respiratory  tract,  Tiie  liypenemia  and 
bronchitis  which  occur  in  the  severer  cases  cannot  be  projK'rly  looked 
upon  as  complications.  In  many  instances,  liowever,  the  bronchitis 
becomes  intense,  imj)licating  the  large  and  small  tubes  and  giving  rise 
to  a  prolonged  symptomatic  fever,  which  may  even  be  accompanied  by 
delirium.  Broncho-pneumonia  is  not  infrequent  in  children  and  aged 
persons,  and  may  lead  to  a  fatal  result  from  progressive  restriction  of 
the  respiratory  surface  or  cardiac  failure.  This  complication  develops 
insidiously  usually  about  the  fourth  or  fifth  day,  but  it  may  set  in  as 
early  as  the  second  day,  or  later  during  convalescence.  The  symptoms 
are  frequently  at  first  obscure,  and  extensive  involvement  of  the  lung 
may  take  place  without  great  rise  of  temperature.  Croupous  pneumonia 
is  less  common.  It  is  a  late  complication,  occurring  toward  the  close 
of  the  attack  or  when  the  patient  is  beginning  to  get  aljout.  It  jn'esents 
the  usual  physical  signs  of  pneumonia,  and  does  not  commonly  differ 
in  other  respects  from  croupous  pneumonia  of  the  ordinary  form.  Both 
lungs  are  frequently  involved.  The  crisis  may  occur  late  or  deferves- 
cence may  take  place  by  lysis.  In  some  cases,  however,  the  pneumonia 
occurring  after  grippe  is  afebrile.  Great  feebleness  of  respiration  and 
a  tendency  to  cardiac  asthenia  characterize  this  form  of  pneumonia. 
Low  muttering  is  apt  to  occur,  and  there  is  frequently  jaundice  with 
slight  intestinal  hemorrhage.  Abscess  or  gangrene  of  the  lung  may 
follow  the  pneumonia  of  grippe. 

Pleurisy  is  not  an  uncommon  complication,  and  empyema  may  occur. 
Purulent  pericarditis  may  occur  in  connection  with  pneumonia  or  inde- 
pendently of  that  complication.  In  aged  persons  serous  eifusion  into 
the  pleural  sacs  is  now  and  then  encountered. 

Parotitis  is  a  rare  complication  of  influenza. 

The  infecting  principle  of  grippe  exerts  a  powerful  depressing  influ- 
ence upon  the  heart,  both  during  and  after  the  attack.  The  nutrition 
of  the  cardiac  muscle  is  impaired  and  its  innervation  is  deranged  and 
enfeebled.  Cardiac  asthenia,  often  of  a  high  grade,  results.  I  have 
not  personally  seen  either  endo-  or  pericarditis  occur.  The  murmurs 
which  I  have  noted  have  been  endocardial  and  either  dynamic  or 
litem  ic. 

Among  the  complications  relating  to  the  nervous  system  cerebro- 
spinal meningitis  is  to  be  mentioned.  It  is  fortunately  of  compai"atively 
rare  occurrence.  The  cases  may  run  an  acute  course  like  that  of 
epidemic  cerebro-spinal  fever,  with  intense  headache,  convulsions, 
delirium,  stupor,  and  opisthotonos,  or  the  symptoms  may  be  of  moderate 
intensity  and  terminate  in  slow  recovery. 

Abscess  of  the  brain  may  occur  as  a  complication.  Cases  have  been 
reported  by  Bristowe,  Sharkey,  and  others. 

Peripheral  neuritis  not  infrequently  develops  during  the  course  of 
the  attack. 

General  asthenia  constitutes  the  chief  and  most  constant  sequel. 
The  profound  nutritive  derangements  of  the  acute  process  are  at  once 
followed  by  manifest  loss  of  strength  of  varying  grade  and  duration. 


416  'INFLUENZA. 

It  is,  however,  often  extreme — altogether  out  of  proportion  to  the 
intensity  of  the  symptoms  and  their  duration — and  frequently  lasts  for 
weeks  or  months.  It  is  important  in  this  connection  to  note  that  this 
post-influenzal  asthenia  bears  no  constant  relation  to  the  original  severity 
of  the,  case,  many  apparently  light  attacks  being  followed  by  profound 
and  prolonged  loss  of  strength,  while  cases  of  great  intensity  often  ter- 
minate in  comparatively  early  and  complete  recovery.  Xor  is  this  dif- 
ference in  many  instances  merely  accidental.  The  manifest  explanation 
is  to  be  found  in  the  fact  that  in  severe  cases  the  patients  are  obliged  to 
keep  the  bed  and  receive  perforce  necessary  care  during  the  active 
period  of  the  attack,  while  those  whose  symptoms  are  slight  remain  up 
and  are  neglected. 

1.  Sequelae  relating  to  the  Respiratoey  Tract. — 1.  Bron- 
chitis.— It  is  not  to  be  wondered  at  that  an  acute  affection  characterized 
by  active  catarrhal  processes  aflFecting  the  mucous  membrane  of  the  re- 
spiratory tract  should,  in  a  considerable  proportion  of  the  cases,  be  fol- 
lowed by  a  lasting  and  troublesome  bronchitis.  This  is  the  sequel  that 
more  than  all  others  attracted  the  attention  of  physicians  in  the  earlier 
epidemics.     I  have  noted  two  principal  forms  : 

(a)  Subacute  bronchitis,  with  little  constitutional  disturbance,  but 
marked  physical  signs,  and  an  abundant  tenacious,  muco-purulent 
expectoration.  This  condition  lasts  for  several  weeks  and  terminates 
in  complete  recovery. 

(6)  A  bronchitis  which  resists  ordinary  treatment,  and,  with  varying 
ameliorations  and  exacerbations,  gradually  establishes  itself  as  chronic. 
In  other  words,  the  attack  of  influenza  proves  the  starting-point  of  a 
bronchitis  which  is  chronic  from  the  outset. 

2.  Broncho-pneumonia  has  been  observed  in  a  large  proportion  of 
the  cases,  not  only  as  a  complication,  but  also  as  a  sequel — a  fact  for 
which  the  catarrhal  inflammation  of  the  respiratory  mucous  membrane 
and  the  acute  prostration  sufficiently  account. 

3.  Croupous  Pneumonia. — All  practitioners  have  been  impressed  with 
the  frequency  with  which  croupous  pneumonia  develops  in  the  course 
of  influenza  or  during  convalescence.  The  association  of  these  two 
diseases  has  much  to  do  with  the  high  death  rate  of  influenza  in  certain 
epidemics — more,  perhaps,  than  has  generally  been  ascribed  to  it,  for 
the  reason  that  the  symptoms  of  influenza  may,  in  cases  of  unusual 
severity,  mask  those  of  the  intercurrent  affection.  Nor  is  it  remarkable 
that  pneumonia,  so  often  intercurrent  in  acute  diseases,  should  arise  as 
a  complication.  Occurring  as  a  sequel  of  influenza,  pneumonia  fre- 
quently involves  the  upper  lobe — apex  pneumonia.  It  occasionally 
runs  a  very  protracted  course,  and  under  these  circumstances  often 
assumes  the  guise  of  tuberculosis — pneumonic  phthisis  or  phthisis 
florida.  I  have  encountered  several  cases  in  which  the  differential 
diagnosis  presented  great  difficulty,  was  rendered  hopeful  only  by  the 
absence  of  tubercle  bacilli  from  the  sputum,  and  finally  confirmed  by 
recovery.  In  these  cases  high  and  irregular  temperature,  continuing 
for  several  weeks,  with  copious  muco-purulent  expectoration,  rapid 
wasting,  sweating,  apex  dulness,  with  diffuse  subcrepitant  rales,  especially 
when  there  is  a  marked  family  predisposition  to  pulmonary  tuberculosis, 
render  the  clinical  picture  alarmingly  like  that  of  a  galloping  consump- 


SFQUEL.E  RELATING   TO   THE  RESPIRATORY  TRACT.         417 

tion.     All  the  cases  of  this  nature  that  1  have  seen  terminated  in  com- 
plete recovery. 

4.  Pill  1)10 nari/  Co)tstuiipt)oi>. — Far  more  numerous,  however,  have 
been  the  eases  in  ^hich  influenza  has  been  the  point  of  departure  for 
actual  ])ulnu)n;irv  eonsuni])tion.  TJie  patients  have  been  persons  in 
whom  the  hereditary  j)redisposition  was  marked  or  who  were  living 
under  conditions,  such  as  association  with  consumptives,  which  singu- 
larly exposed  them  to  infection.  Under  these  circumstances  the  symp- 
toms of  influenza  have  passed  away,  leaving,  usually,  merely  debility 
with  slight  cough  and  expectoration,  such  as  attend  an  ordinary  bron- 
chitis. But  these  symptoms  have  persisted,  not  yielding  to  treatment, 
and  after  a  time,  npon  examination,  tubercle  bacilli  and  localized  dul- 
ness  have  been  found. 

5.  Pleurisy. — Whether  or  not  the  infecting  principle  of  influenza 
directly  causes  pleurisy  cannot  in  the  present  state  of  knowledge  be 
positively  affirmed.  Plastic  pleurisy  constantly,  pleurisy  with  effusion 
occasionally,  arise  in  connection  with  croupous  pneumonia  and  tubercu- 
losis occurring  as  sequels  of  influenza.  The  stitch  in  the  side  of  influ- 
enza is  probably  in  most  cases  pleurodynia,  as  it  is  unaccompanied  by 
friction  sounds  and  as  a  rule  quickly  passes  away.  Intercostal  neural- 
gia is  not  rare,  even  with  herpes  zoster,  in  the  course  of  or  as  a  sequel 
of  influenza,  and  may  sometimes  mislead ;  but  it  is  certain  that  second- 
ary infections,  to  which  the  lesions  of  the  bronchial  mucous  membrane 
expose  patients  suffering  from  the  grippe,  sometimes  toward  the  close  of 
the  attack,  and  often  during  convalescence,  may  reach  the  pleura  and 
give  rise  to  inflammation  of  that  structure.  The  pleurisy  arising  under 
these  circumstances  may  be  plastic  or  it  may  be  accompanied  by  serous 
or  purulent  effusion,  and  does  not  diifer  from  that  caused  by  similar  in- 
fections under  ordinary  circumstances.  To  this  general  statement  there 
must,  however,  be  noted  an  exception.  In  a  number  of  instances  in 
persons  previously  in  good  health  I  have  seen  influenza  followed  by 
pleurisy  of  an  unusual  form.  The  symptoms  have  been  acute  and  very 
severe.  Among  them  the  following  were  especially  marked :  Great 
pain,  limited  to  the  region  of  the  apex,  irregular  high  temperature, 
often  reaching  104-105°  F.,  coarse,  rubbing  friction  sounds,  slowly 
increasing  dulness,  with  feeble  distant  breath  sound,  no  bronchial  res- 
piration ;  cough  has  been  slight  or  absent,  and  there  has  been  little  or 
no  expectoration  ;  constitutional  disturbance  has  been  great ;  the  physi- 
cal signs  at  the  base  and  upon  the  opposite  side  have  been  without 
significance.  These  phenomena  have  warranted  the  diagnosis  of  a 
rapidly  developing  apex  pleurisy  with  great  thickening — a  diagnosis 
confirmed  in  my  experience  by  a  single  post-mortem  examination.  In 
other  instances  recovery  has  slowly  taken  place  with  retraction,  re- 
stricted movement,  and  permanent  impairment  of  resonance,  though  the 
general  health  of  the  patients  has  remained  good,  and  it  has  been  im- 
possible to  find  in  their  occasional  scanty  morning  sputa  tubercle  bacilli. 

6.  Asthma. — In  neurotic  individuals  asthma  has  occurred  as  an 
accompaniment  of  bronchitis  following  influenza. 

7.  Otitis  media  constitutes  one  of  the  more  distressing  complications 
and  sequels  of  influenza.  It  is  more  likely  to  arise  in  cases  in  which 
nasopharyngeal  lesions  are  prominent  or  persistent.      The    superficial 

Vol.  I.— 27 


418  INFLUENZA. 

layer  of  the  mucous  membrane  of  the  nasopharynx  in  the  acute  stage 
rapidly  undergoes  patchy  necrosis,  and  there  is  an  abundant  irritating 
discharge.  The  ear  trouble  may  occasionally  arise  without  great  pain, 
but,  as  a  rule,  the  suffering  is  severe  and  tends  to  recur  after  perforation 
of  the  tympanic  membrane  as  the  thick  discharge  and  necrotic  tissue 
accumulate.  Rapid  disorganization  of  the  structures  of  the  middle  ear 
sometimes  occurs,  with  permanent  deafness  as  a  result.  In  many  cases 
the  suppuration  yields  stubbornly  to  treatment  and  persists  for  weekg  or 
months. 

II.  Sequelae  relating  to  the  Circulatory  System. — 1. 
Cardiac  Disorders. — Hearts  impaired  by  previous  disease  of  the  valves 
or  wall  often  undergo  additional  damage  and  pre-existing  symptoms  are 
aggravated.  But  it  is  not  always  the  damaged  heart  that  suffers. 
Many  of  the  worst  cases  occur  in  persons  of  previous  good  health. 
Robust,  self-reliant  men  who  scarcely  know  what  sickness  is  become 
feeble,  hypochondriacal,  and  valetudinarian.  It  has  been  a  pitiable 
sight  to  witness  the  sufferings,  partly  physical,  largely  mental,  of  some 
of  these  patients.  The  actual  cardiac  symptoms  are  heart  conscious- 
ness, sometimes  distress,  sometimes  actual  precordial  pain,  usually 
paroxysmal,  occasionally  suggestive  of  angina  pectoris,  breathlessness 
and  faintness  upon  effort,  unsatisfactory  sleep,  disturbed  by  dreams  and 
startings,  headache,  and  great  languor  and  malaise.  The  physical  signs 
are  simply  those  of  enfeebled  and  irregular  heart  action.  They  consist 
of  weak  impulse,  faint  first  sound,  and  now  and  then  an  indistinct  soft 
systolic  murmur.  The  pulse  is  small,  feeble,  arhythmic,  and  intermit- 
tent. Much  more  distressing  to  the  patient  and  his  friends  are  the  men- 
tal symptoms.  To  his  general  feeling  of  depression  and  disability  are 
added  tormenting  fears  of  permanent  invalidism  or  sudden  heart  failure. 
The  condition  is  always  distressing,  sometimes  alarming.  Fortunately, 
however,  experience  has  shown  that  the  prognosis  is  favorable.  These 
cases,  even  after  they  have  lasted  a  year  or  two,  quickly  recover  under 
proper  treatment.  In  another  group  of  cases  the  nutrition  of  the  heart 
muscle  is  fairly  well  maintained,  its  innervation  being  chiefly  affected. 
Here  we  have  the  intermittent  heart.  At  regular  or  irregular  intervals 
the  heart  drops  a  beat.  If  the  patient  is  aware  of  this  fact,  either  from 
feeling  his  own  pulse  or  from  the  disagreeable  precordial  sensation  which 
sometimes  occurs,  he  is  apt  for  a  time  to  be  much  distressed  by  it. 
Presently,  however,  with  returning  health  the  heart  dropping  ceases  to 
annoy  him.  In  a  small  proportion  of  cases  it  continues  to  be  a  lasting 
cause  of  distress  and  valetudinarianism.  Cardiac  intermittence  does 
not  always  yield  readily  to  treatment,  and  once  fully  established  becomes 
in  a  small  proportion  of  the  cases  a  permanent  symptom. 

Precordial  pain,  arhythmia,  tachycardia,  and  bradycardia  are  com- 
mon after  influenza. 

2.  Simple  ancemia  may  occur  after  grippe  as  after  other  acute  diseases. 
It  is  neither  constant  nor  intense,  the  brunt  of  the  infection,  save  in  ex- 
ceptional cases,  falling  rather  upon  the  nervous  system  than  the  blood. 
There  is  nothing  especial  in  the  anaemia  of  convalescence  from  influenza. 
It  usually  yields  to  treatment  and  terminates  in  recovery. 

3.  Pernieious  Ancemia. — In  four  instances,  however,  I  have  seen 
that  form  of  anaemia  called  pernicious    follow  grippe.     One  of  these 


DIAGNOSIS.  419 

cases  WHS  of  peculiar  interest  as  an  illustration  of  the  tendency  of  the 
infection  to  select  in  its  attack  the  tissue  of  least  resistance — the  weak 
spot  in  the  oroanisni.  A  oc'iitleiuan  at>;e(l  fifty  nine,  su])pose(l  to  he  iu 
full  health,  had  mild  influenza  in  the  spring  of  1891.  lie  kept  about, 
but  was  for  several  days  feverish  and  depressed.  Catarrhal  symptoms 
were  slight.  From  this  time  he  suddenly  grew  pale,  and  died  in  eight- 
een months,  having  presented  all  the  symptoms  and  blood  conditions 
of  pernicious  aniemia.  This  patient's  father  died  at  an  advanced  age  of 
diabetes  mellitus.  His  only  son  died  at  the  age  of  thirty  seven  of 
malignant  hemorrhagic  measles,  and  a  grandson,  the  child  of  the  last, 
had  benign  hemorrhagic  measles. 

III.  SeQIHOL.E    KIOLATINU    TO   THE   GaSTRO-INTESTINAL   TrACT. 

These  present  little  that  is  peculiar,  and  as  a  rule  are  not  persistent. 
Occasionally  a  tendency  to  diarrhoea  persists,  and  I  have  seen  mem- 
branous enteritis  follow  the  gastro-intestinal  form  of  grippe  in  several 
instances.  The  suggestion  tliat  catarrhal  appendicitis  may  arise  as  a 
late  result  of  gastro-intestinal  influenza  is  worthy  of  serious  considera- 
tion. 

IV.  Sequelae  relating  to  the  Nervous  System. — Headache, 
insomnia,  and  neuralgia  are  common  sequelae.  The  nervous  derange- 
ments which  follow  grippe  may  consist  of  mere  general  loss  of  tone — 
neurasthenia  with  gastric,  cardiac,  or  spinal  symptoms  predominating, 
or  they  may  assume  the  definite  aspect  of  substantive  aflPections,  such  as 
hysteria  or  chorea ;  again,  various  motor  and  sensory  palsies,  manifesta- 
tions of  peripheral  neuritis,  may  arise ;  finally,  psychic  disorders,  as 
melancholia  and  the  insanities  of  malnutrition,  may  occur.  The  nature 
of  the  nervous  trouble  is  doubtless  determined  by  hereditary  or  pre- 
viously acquired  predisposition  on  the  part  of  the  individual,  and  its 
course  is  not  different  from  that  of  similar  affections  arising  under  other 
circumstances,  and  especially  after  the  other  acute  infections,  as,  for 
example,  enteric  fever.  The  prognosis  is  in  the  main  favorable.  With 
reference  to  insanity  following  influenza,  so  far  as  I  can  learn  its  fre- 
quency has  been  greatly  overestimated,  and  it  is  probable  that  persistent 
insanity  arising  as  a  sequel  of  this  affection  is  in  point  of  fact  rare,  and 
that  it  occurs  chiefly,  if  not  solely,  in  those  already  strongly  predis- 
posed to  mental  disorder,  in  whom  the  attack  acts  as  an  exciting  cause, 
not  specifically,  but  in  the  same  way  as  any  other  powerful  perturbating 
agent. 

Diagnosis. — The  direct  diagnosis  of  influenza  is  under  ordinary  cir- 
cumstances unattended  with  difficulty.  The  progress  of  the  outbreak, 
the  number  of  individuals  attacked  nearly  at  the  same  time  or  in  quick 
succession,  the  rapidly  developing  asthenia,  and  the  prominence  of  the 
nervous  symptoms  serve  to  distinguish  it  from  other  epidemic  diseases. 
The  bacteriological  diagnosis  can  be  sometimes  made  by  an  examination 
of  the  bronchial  sputum,  and  can  be  verified  in  doubtful  cases  by 
cultures. 

The  differential  diagnosis  between  influenza  and  non-specific  catarrhal 
affections  attended  by  fever,  malaise,  weakness,  severe  headache,  and 
pains  in  the  limbs  may  be  made  by  due  regard  to  the  causative  relations  of 
the  two  affections.  Outbreaks  of  simple  catarrh  occur  as  the  result  of 
sudden  changes  in  the  weather,  and  are  for  that  reason  most  frequent  in 


420  INFLUENZA. 

changeable  seasons,  and  especially  at  the  end  of  winter  and  in  the 
early  spring.  Influenza,  on  the  other  hand,  is  not  in  any  way  dependent 
upon  the  vicissitudes  of  the  season,  and  may  occur,  as  has  been  shown, 
indifferently  at  all  times  of  the  year,  in  wet  or  dry,  mild  or  cold  seasons, 
and  in  every  variety  of  climate.  No  difficulty  attends  the  difFerential 
diagnosis  between  influenza  and  ordinary  sporadic  catarrhal  fevers,  which 
lack  the  characteristic  depression,  neuralgic  and  rheumatoid  pains,  and 
the  irritating  cough  and  dyspnoea. 

Some  of  the  cases  of  influenza  bear  a  strong  resemblance  to  enteric 
fever  in  the  first  week.  Malaise,  headache,  obtunded  hearing,  mental 
depression,  fever,  epistaxis,  coated  tongue,  tender  belly,  and  diarrhoea 
are  observed  in  both  affections.  The  temperature  curves  are,  however, 
unlike,  and  the  acute  attack  of  influenza  in  uncomplicated  cases  runs  its 
course  ere  the  period  at  which  splenic  tumor  and  rose  spots  establish  the 
diagnosis  of  enteric  fever.  Anders  has  called  attention  to  the  occur- 
rence of  influenza  during  the  period  of  incubation  of  enteric  fever. 
This  accidental  association  of  the  two  diseases  may  sometimes  occasion 
difficulty  in  diagnosis.  Cerebro-spinal  fever  has  sometimes  prevailed 
during  epidemics  of  influenza.  The  occasional  occurrence  of  cases 
of  influenza  with  marked  nervous  symptoms,  intense  head  pains,  pain- 
ful retraction  of  the  muscles  of  the  back  of  the  neck,  and  vomiting, 
renders  the  differential  diagnosis  between  these  two  affections  extremely 
difficult  and  in  some  instances  impossible.  Whether  the  infecting 
prineij)le  of  influenza  is  capable  of  directly  giving  rise  to  infection  of 
the  meninges  or  not  remains  to  be  determined. 

Dengue,  or  breakbone  fever,  closely  resembles  influenza.  Each  of 
these  diseases  prevails  in  pandemics,  developing  suddenly,  advancing 
rapidly,  affecting  almost  all  the  inhabitants  of  regions  invaded.  They 
resemble  each  other  in  the  frequency  of  relapses  and  the  liability  to 
repeated  attacks  during  the  same  outbreak  ;  in  the  fact  that  they  are  not 
self-protective  ;  in  the  want  of  accord  between  the  gravity  of  the  symp- 
toms and  the  low  death  rate  of  uncomplicated  cases ;  in  the  suddenness 
of  the  attack,  intensity  of  the  pains,  and  high  degree  of  mental  and 
physical  depression.  Influenza  lacks,  however,  the  cutaneous  mani- 
festations, the  remission  in  the  course  of  the  fever,  and  the  tend- 
ency to  arthritis  which  are  seen  in  dengue.  It  differs  from  dengue 
also  in  the  liability  to  serious  complications  and  in  prevailing  in  all 
climates. 

Prognosis  and  Mortality. — Death  scarcely  ever  occurs  in  un- 
complicated cases  except  at  the  extremes  of  life.  The  very  young  bear 
influenza  badly ;  the  aged  bear  it  worse  still.  Pre-existing  disease 
often  modifies  the  course  of  influenza  unfavorably.  Individuals  suffer- 
ing from  chronic  bronchitis,  emphysema,  fatty  heart,  and  nephritis  offer 
poor  resistance  to  the  depression  of  grippe.  Phthisis  and  other  ex- 
hausting diseases  increase  the  danger  of  the  attack.  Cases  attended  by 
very  severe  symptoms  usually  recover,  unless  the  patients  be  very  young 
or  very  old  or  the  subjects  of  some  complicating  malady.  The  prog- 
nosis in  individual  cases  is  greatly  modified  by  the  character  of  the  pre- 
vailing epidemic.  In  some  of  the  epidemics  the  death  rate  has  been 
low  and  the  mortality  from  other  diseases  not  greatly  increased.  More 
commonly  the  death  rate  of  endemic  affections  is  much  increased,  and 


THE  ATM  EST.  421 

in  sonu'  of  the  older  cpidcinics  influcnzn  apjx'urs  to  have  been  attciidcd 
bv  a  hi<2;h  direct  (U'atli  rate. 

Tlie  deaths  from  inHiienza  reported  in  I*aris,  Deeeniher,  1H80,  and 
flannarv,  1890,  nnnibered  oidy  'Jl.'>,  whik'  the  general  mortality  ex- 
ceeded the  average  by  5500. 

Trkatment. — PrnpJii/Id.vis. — Ett'eetive  preventive  measures  are  as 
yet  unknown.  Unfavorable  sanitary  conditions,  overcrowding,  damp 
unhealthy  dwellings  a])pear  to  increase  the  prevalence  and  severity  of 
the  disease  ;  the  opposite  conditions  of  living  do  not,  however,  secure 
immunity.  During  an  epidemic  the  aged,  those  enfeebled  by  chronic 
diseases,  those  subject  to  bronchitis,  consumption,  emphysema,  degenera- 
tive disease  of  the  muscles  of  the  heart,  and  nephritis,  should  be  cared 
for  with  solicitude,  since  they  constitute  the  ckiss  especially  prone  to  the 
graver  complications  of  the  disease  and  contribute  a  large  contingent 
of  the  fatal  cases.  During  an  epidemic  the  isolation  of  a  patient  who 
has  developed  the  symptoms  of  the  disease,  either  in  his  home  or  in 
a  hospital  or  other  public  institution,  does  not  secure,  as  in  certain 
of  the  other  contagious  diseases,  protection  for  those  about  him — a 
fact  to  be  explained  by  the  activity  of  the  infecting  principle  and  the 
intense  susceptibility  of  individuals  in  all  classes  of  society.  The 
segregation  of  the  patients  and  their  attendants  and  the  disinfection 
of  the  belongings  of  the  patient  and  the  apartments  are  not  neces- 
sary. The  nasal  and  bronchial  discharges  should,  however,  be  disin- 
fected. Every  case,  however  mild,  should  be  regarded  as  likely  to  be 
serious,  and  the  patient  should  be  confined  to  the  bed  or  to  the  couch 
for  some  days. 

Prophylaxis  against  the  attack  is  theoretical  and  to  a  great  extent 
impracticable  ;  prophylaxis  against  sequels  is  in  the  highest  degree  prac- 
tical and  useful. 

The  Management  of  Cases. — The  treatment  of  influenza  is  expectant 
and  supporting.  i!^ot  only  are  epidemics  self-limited,  tending  to  rapidly 
exhaust  the  susceptibility  of  a  community,  but  the  individual  attack  is 
also  of  definite  duration  and  self- limited,  tending  to  run  its  course  in 
from  three  to  four  or  at  most,  in  the  absence  of  complications,  in  from 
seven  to  ten,  days.  Where  the  duration  of  the  attack  is  prolonged 
beyond  the  period  indicated,  complications  are  almost  invariably  present. 
In  all  epidemics  the  majority  of  the  cases  are  of  mild  intensity.  The 
management  of  this  group  of  cases  should  be  for  the  most  part  hygienic. 
Patients  are  uncomfortable  and  anxious,  easily  fatigued,  and  unfitted  for 
their  usual  avocations.  It  is  only  exceptionally  that  they  consult  the 
physician.  It  is  unfortunate,  however,  that  this  is  the  case,  since  those 
who  continue  their  avocations  and  duties  and  expose  themselves  to  un- 
favorable influences  during  the  attack  not  infrequently  manifest  at  a 
later  period  the  most  serious  results  of  the  disease.  In  point  of  fact, 
the  patient  should  even  in  the  milder  cases  abandon  for  the  time  being 
his  ordinary  avocation.  He  should  remain  within  doors,  preferably 
upon  a  couch,  for  at  least  two  days,  and  only  gradually  resume  his 
accustomed  duties. 

The  diet  should  be  restricted  to  the  ordinary  fever  foods.  Milk  is 
especially  indicated,  and  may  be  given  in  doses  of  from  one  litre  to  a 
litre    and   a    half  during    twenty-four    hours    in   divided  doses.     Egg 


422  INFLUENZA. 

albumen  stirred  into  water,  flavored  with  a  little  brandy  or  wine,  or 
eggnog,  milk  punch,  or  gruel,  may  occasionally  with  advantage  re- 
place the  ordinary  allowance  of  milk.  Hot  beef  tea  or  concentrated 
meat  extracts  are  to  be  avoided.  They  very  frequently  increase  the 
headache  and  languor.  Cold  drinks  in  moderate  quantity  are  usually 
acceptable  to  the  patients.  Weak  wine  whey,  a  mixture  of  equal  parts 
of  seltzer  water  and  milk  iced,  koumyss,  matzoon,  and  similar  pre- 
parations, enable  the  nurse  to  furnish  the  necessary  changes  where  the 
stomach  is  irritable. 

The  administration  of  alcoholic  stimulants  must  be  regulated  in  part 
according  to  the  previous  habits  of  the  patient,  in  j^art  according  to  his 
immediate  condition.  Abstemious  persons  may  not  need  them,  but 
those  who  have  been  in  the  habit  of  taking  alcohol,  the  aged,  and  those 
debilitated  from  previous  sickness  are  benefited  by  the  judicious  use  of 
alcoholic  beverages. 

Early  in  the  course  of  the  attack  a  laxative  may  be  necessary.  This 
may  consist  of  some  form  of  saline  or  a  laxative  dose  of  calomel,  or  the 
latter  administered  at  night,  followed  by  the  former  in  the  morning. 
Caution  is,  however,  necessary  in  the  use  of  purgatives  in  influenza, 
since  in  a  very  considerable  proportion  of  the  cases  gastro-intestinal 
symptoms  with  diarrhoea  occur,  and  in  some  instances  are  difficult  of 
control. 

The  analgesic  antipyretics  are  to  be  used  cautiously  in  view  of  the 
tendency  to  general,  and  especially  to  cardiac,  asthenia.  Nevertheless, 
the  guarded  administration  of  antipyrin,  phenacetin,  migranin,  and 
other  members  of  this  drug  group  are  often  necessary  to  relieve  the 
agonizing  pain  of  influenza.  Small  doses  of  phenacetin  and  sodium 
salicylate,  administered  in  powder  or  capsule  at  short  intervals,  very 
often  exert  a  powerful  influence  in  mitigating  the  suiferings  of  the 
patient.  Small  doses  of  Dover's  powder  repeated  at  intervals  of  two  or 
three  hours  are  likewise  of  benefit.  I  cannot  say  that  I  have  seen  any 
advantage  from  the  use  of  warm  baths,  foot  baths,  or  diaphoretic  drinks, 
the  patients  usually  preferring  to  remain  undisturbed.  Advantage 
sometimes  follows  the  administration  of  small  doses  of  morphine,  with 
which,  in  the  case  of  extreme  sweating,  minute  quantities  of  atropin  may 
be  added.  If  there  be  great  restlessness  and  jactitation,  the  hypoder- 
mic injection  of  morphine,  together  mth  hyoscin  hydrobromate,  proves 
useful.  Quinine  in  small  doses  is  mthout  eifect.  In  large  doses  it 
simply  augments  the  sufferings  of  the  patient.  There  is  no  adequate 
evidence  to  show  that  quinine  in  any  dose  favorably  modifies  the 
course  of  the  attack  or  aborts  its  duration.  During  convalescence 
iron  and  bark,  and  in  particular  strychnine  in  full  doses,  are  to  be 
administered. 

In  the  milder  cases  the  catarrhal  symptoms  call  for  no  special  meas- 
ures of  treatment.  When  intense  the  corvza,  tonsillitis,  laryngitis,  and 
bronchitis  are  to  be  treated  upon  general  therapeutic  plans.  Inunctions 
of  fatty  substances  about  the  brow  and  over  the  bridge  of  the  nose  are 
sometimes  useful  in  relieving  the  distress  of  the  coryza.  Animal  fats, 
such  as  washed  lard,  cold  cream,  and  the  like,  are  preferable  to  the  min- 
eral fats — cosmoline  and  vaseline.  A  2  per  cent,  solution  of  morphine 
and   cherry-laurel  water  may  be  snuffed  into  the  nostrils.     The  pains 


TREATMENT.  423 

associated  witli  the  coryza  and  tlie  iiciivalfjic  pains  arc  to  sonic  extent 
mitigated  bv  a  flannel  nightcap  or  silk  iuindUerciiief'  tied  about  the 
head.  Tickling  cougli  may  be  relieved  by  steam  inhalations  and  the 
application  of  sinapisms  over  the  manubrium.  In  the  graver  eavSes 
prominent  indications  for  treatment  are  to  be  found  in  the  fever,  the 
catarrhal  i)roeess,  the  asthenia,  and  the  pain  and  sleeplessness.  It  is 
especially  important  that  the  failure  of  the  powers  of  tiie  circulation 
whicli  arc  cliaracteristic  of  the  disease  should  be  anticipated  by  efficient 
supporting  treatment.  This  is  particularly  urgent  in  the  case  of  influ- 
enza affecting  infants,  the  very  old,  and  those  previously  debilitated 
from  any  cause. 

The  febrile  movement  is  not  usually  excessive,  almost  always  transi- 
ent. A  fever  regimen  should  be  adopted.  The  disinclination  to  take 
food  is  often  so  great  that  a  sufficient  quantity  can  scarcely  be  adminis- 
tered, especially  in  the  early  days  of  the  attack.  Small  amounts  of 
nourishment  must  be  given  at  regular  hours.  As  convalescence 
begins  patients  should  be  urged  to  take  food.  The  quantity  taken  at 
one  time  should  be  increased  and  the  intervals  between  feedings  pro- 
longed. At  least  enough  fluid  should  be  taken  to  assuage  thirst.  The 
ingestion  of  simple  beverages  exerts  a  favorable  action  upon  the  skin 
and  kidneys.  The  frequency  of  spontaneous  sweating  and  the  readiness 
with  which  free  perspiration  may  be  induced  must  be  looked  upon  as  a 
contraindication  to  the  use  of  diaphoretic  drugs. 

General  and  local  bloodletting,  emetics,  uauseants,  and  drastic  purga- 
tives are  to  be  avoided  in  the  treatment  of  influenza. 

For  the  relief  of  the  distressing  cough  no  drugs  are  more  effectual 
than  opium  and  its  derivatives,  especially  morphine  and  codeine.  It  is 
important  to  observe  the  same  caution  in  administering  this  group  of 
medicines  to  infants  and  aged  persons  in  influenza  that  is  necessary  under 
other  circumstances.  The  influence  of  carbolic  acid  in  restraining  cough 
makes  it  a  useful  adjuvant.  The  bromides,  paraldehyde,  chloralamide, 
trional,  and  chloral  may  be  used  for  the  relief  of  jactitation  and  in- 
somnia. Chloral  should  be  used  with  great  caution.  Gastro-intestinal 
symptoms  must  be  managed  in  accordance  with  general  principles.  If 
of  moderate  intensity,  they  require  no  special  treatment.  Complica- 
tions are  to  be  treated  in  accordance  ^\\ih.  general  therapeutic  indica- 
tions, especial  attention  being  directed  to  the  asthenia  which  is  so 
prominent  and  disastrous  a  tendency  in  grippe. 

The  treatment  of  influenza  demands  the  most  careful  attention  of  the 
physician,  who  must  be  on  guard  to  detect  the  inflammatory  lung  com- 
plications, which  so  often  lead  up  to  a  fatal  issue,  as  early  as  possible. 
The  circumstances  of  the  indi^ddual  case,  the  age  of  the  patient,  the 
nature  of  the  complications,  and  the  effect  of  remedies  must  be  carefully 
taken  into  account.  All  measures  that  tend  to  depress  the  general  ner- 
vous system,  the  functional  activity  of  the  respiration,  or  the  heart 
power  are  to  be  carefully  avoided. 

During  the  convalescence  the  patient  should  be  treated  with  equal, 
even  more,  care  than  those  convalescing  from  other  acute  infectious  dis- 
eases. Rest  in  bed,  a  systematic  diet  of  high  nutritive  value,  strychnine, 
iron,  and  later  change  of  climate,  are  important.  The  patient  should  be 
instructed  as  to  the  liability  of  pulmonary  disorders,  which  may  become 


424  INFLUENZA. 

chronic,  and  in  regard  to  the  necessity  of  limiting  for  a  time  the  appli- 
cations of  his  energy.  The  convalescence  is  often  slow  and  trying,  alto- 
gether out  of  proportion  to  the  severity  of  the  primary  attack.  Influ- 
enza is  a  distressing  affection  even  in  the  milder  cases,  and  so  often 
dangerous  in  its  after  effects  that  it  cannot,  though  a  disease  of  short 
duration,  be  looked  upon  as  a  trifling  malady. 


EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

By  THOMAS  S.  LATIMER,  M.  D. 


Synonyms. — Cereljro-spinal  fever  ;  Spotted  fever  ;  Lepto-meningitis. 

Definition. — A  s^pecitic  infectious  disease  of  microbic  origin,  but 
little  if  at  all  contagious,  characterized  by  inflammation  of  the  lepto- 
meniuges,  with  disturbance  of  function  of  the  whole  cerebro-spinal 
axis,  motorial,  sensory,  and  psychical,  with  strong  tendency  to  a  speedily 
fatal  issue. 

History. — Epidemic  cerebro-spinal  meningitis  has  been  known 
from  the  earliest  years  of  the  present  century,  but  was  first  accurately 
described  by  Viesseux  in  Geneva  in  1805.  It  appeared  in  the  United 
States  in  1806,  and  continued  with  l)ut  little  interruption  for  ten  years 
During  this  time  it  also  made  its  appearance  in  Spain,  Germany,  Italy, 
Algeria,  and  Denmark.  In  1854  it  broke  out  in  Sweden  with  severity, 
causing  4000  deaths.  Slight  epidemics  occurred  in  Germany  in  1822 
but  it  was  not  until  1863  that  it  was  there  of  frequent  occurrence 
V.  Ziemssen,  writing:  in  1874,  savs  that  it  had  then  become  domesticated  in 
Germany.  Since  then  Striimpell  says  there  have  been  more  or  less  ex- 
tensive epidemics  every  year.  It  broke  out  in  the  workhouses  of  Ireland 
in  1846,  and  appeared  in  severe  form  in  Dublin  in  1866-68.  In 
Fagge's  Practice  of  Medicine,  published  in  1886,  it  is  stated  that  Scot- 
land and  England  had  been  almost  exempt  up  to  that  time.  It  was 
first  observed  in  this  country  at  Medfield,  Mass.,  in  1806.  After  this 
scattered  epidemics  of  moderate  severity  appeared  in  various  parts  of 
the  United  States  up  to  1816,  when  the  disease  disappeared,  to  recur  in 
Middletown,  Conn.,  in  1822-23.  Since  then  it  has  been  of  frequent 
recurrence  in  various  parts  of  the  country.  At  Carbondale,  Pa.,  400 
persons  died  from  this  cause  out  of  a  population  of  6000.  In  Pepper's 
Aiiierican  Text-booh,^  a  tabulated  statement,  begun  by  Stille  in  1863 
and  carried  on  to  1883,  and  completed  by  Pepper  up  to  1892,  shows 
that  it  prevailed  continuously  during  this  period  in  Philadelphia  ;  the 
smallest  mortality  for  any  one  year  was  23  in  the  year  1891.  The  total 
mortality'  reported  in  this  city  for  this  period  was  2575.  Numerous 
cases  occurred  in  both  armies  in  the  late  American  war,  but  it  cannot 
be  said  to  have  had  any  widespread  prevalence  in  either. 

Etiology'. — The  essential  cause  of  epidemic  cerebro-spinal  menin- 
gitis is  not  yet  definitely  determined,  though  a  large  body  of  evidence 
tends  to  establish  such  a  relation  with  the  micrococcus  lanceokdus  encap- 
sulatus.  This  organism  is  found  almost  invariably  in  the  exudates, 
meningeal  and  cerebral,  and  in  the  lungs  in  cases  complicated  with 
pneumonia.  Eberth  first  isolated  it  in  1880  in  a  case  of  meningitis 
secondary  to  pneumonia  ;  Bozzolo  and  Leyden  in  1883  ;  Weischelbaum 

^  ^Iti  American  Text-book  of  the  Theory  and  Practice  of  Medicine,  Pepper,  vol.  i.  p.  163. 

425 


426  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

in  1886 ;  Netter  in  the  same  year ;  Goldschmidt  in  1887  ;  Ortman,  Foa, 
and  Bordoni-Uifreduzzi  in  1888  ;  Banti  in  1889  ;  and  Bonome  in  1890. 
Mirto  obtained  it  from  the  exudates  in  1891,  and  inoculated  rabbits 
with  it,  producing  septicaemia.  Klippel  in  1891  and  Ribbert  in  1892 
found  it  in  sporadic  cases.  In  Welch's  laboratory  in  Baltimore  in  3 
recent  cases  the  same  organism  was  found  (Flexner  and  Barker). 

Other  organisms,  however,  have  been  frequently  found  associated 
with  cerebro-spinal  meningitis  ;  thus,  according  to  Flexner  and  Barker, 
in  1889  Netter  found  the  Friedlander  bacillus  in  a  case  of  meningitis 
following  otitis  media.  Mills,  in  a  case  of  pneumonia  associated  with 
meningitis,  thought  he  had  discovered  the  same  organism.  Monti 
in  a  case  of  pleuritis  with  arthritis  obtained  the  micrococcus^  kmceolatus 
in  1889.  Adenot  in  the  same  year  and  Kainen  in  1890  each  isolated  a 
bacillus  which  they  supposed  to  be  the  typhoid  bacillus.  Debove,  in  a 
case  associated  with  peritonitis,  obtained  a  pneumococcus.  Hanot  and 
Luzet  isolated  streptococci  from  the  exudate  from  the  meninges  in  a  case 
of  general  infection  resulting  from  puerperal  fever.  The  staphylococcus 
pyogenes  aureus  was  found  in  a  case  associated  with  otitis,  broncho- 
pneumonia, and  arthritis  by  Le  Gendre  and  Beaussenat  in  1892,  Klip- 
pel in  1892,  in  a  demented  individual  who  died  of  acute  meningitis, 
observed  the  micrococcus  kmceolatus  over  an  area  of  brain  softening 
where  the  exudate  was  most  abundant. 

Boulay  and  Courtois-Suffit  in  1890  isolated  the  mici^ococcus  kmceo- 
latus from  a  case  of  combined  meningitis  and  peritonitis  without  pneu- 
monia ;  and  Bonome  found  the  same  organism — pneumococcus — in  a 
case  of  combined  pericarditis  and  meningitis.  Zorkendorfer,  from 
Chiari's  laboratory,  reports  a  case  of  purulent  meningitis  associated 
with  inflammation  of  the  ethmoidal  cavity  and  suppuration  in  the 
sphenoidal  sinuses,  in  which  diplococci  were  found  in  the  pus  taken 
from  the  sinuses  and  from  the  meninges.  Pure  cultures  of  these  caused 
fatal  septicaemia  in  rabbits,  in  whose  blood  organisms  were  found  not 
distinguishable  from  the  micrococcus  lanceolatus.  Drs.  Flexner  and 
Barker — to  whom  I  am  indebted  for  most  of  the  historical  facts  here 
mentioned — found  the  micrococcus  lanceolatus  in  a  case  of  traumatic 
meningitis  with  no  other  focus  of  infection.  Prudden  likewise  isolated 
it  in  a  case  of  traumatic  meningitis,  a  patient  of  Holt's. 

Streptococci  and  staphylococci  have  also  been  found  by  various 
observers,  and  by  Roux  a  bacillus  resembling  that  of  typhoid  fever ;  by 
Mircoli,  the  bacillus  pyogenes  foetidus.  Netter  clearly  traced  meningitis 
to  the  pneumococcus  in  16  out  of  30  cases  in  which  no  pneumonia  had 
existed.  The  number  of  cases  examined  is  as  yet  too  small  to  warrant 
the  statement  that  the  pneumococcus  lanceolatus  is  the  single  and  only 
cause,  but  the  facts  recited  above  go  far  to  show  that,  although  other 
organisms  are  often  found  and  the  pneumococcus  has  not  invariably 
been  shown  to  be  present,  it  is,  however,  so  much  more  frequently 
present  than  any  other  pathogenic  microbe  that  it  may  fairly  be  consid- 
ered the  causative  agent  in  a  large  proportion  of  cases. 

If,  however,  it  is  admitted  that  this  organism  is  the  specific  cause 
of  epidemic  cerebro-spinal  meningitis,  the  frequency  with  which  it  is 
found  in  sporadic  and  traumatic  cases  makes  it  impossible  to  distin- 
guish the  epidemic  from  other  forms  of  meningitis.     It  is  generally 


ETIOLOUY.  427 

julniittod  that  tlio  clinicnl  ])henomona  arc  nol  widely  dissimilar  in  the 
various  tbrnis  of  nu'iii ileitis,  and  if  this  etiological  lactor  is  not  pecu- 
liar to  the  ei)ideinic  form,  then  all  meiiin<;'e:d  intlammations  are  essen- 
tially the  same,  and  any  tranmatie  or  sj)oradie  ease  may  be  a  [)oint  of 
departure  in  epidemics  of  this  disease. 

The  frequency  with  which  the  inicrococca.s  lancco/dtu.s  is  found  in  the 
mouths  of  healthy  individuals  (<S()  per  cent.,  Netter)  would  indicate  that 
under  certain  conditions — antacid  or  hypoacid  states  of  the  <rastric  secre- 
tion or  other  unknown  conditions — it  may  pass  throut>;h  the  stomach  into 
the  circulation,  and,  ac<[nii-int;-  a  virulence  not  before  possessed,  "ive  rise 
to  meningeal  and  other  intiammations,  thus  becoming  truly  auto-infec- 
tive. Such  an  origin  of  course  does  away  with  the  necessity  for  conta- 
gion or  th(>  introduction  of  the  microbe  with  food  or  drink.  It  is  almost 
uniformly  present  in  health,  and  requires  only  some  alteration  in  the 
condition  of  the  host  to  invest  it  with  virulence.  If  so,  \vc  must  seek 
an  explanation  of  its  epidemic  prevalence  in  the  environment  of  the 
individual.  The  atmosj^heric  conditions,  character  of  the  water  and 
food  supply,  season,  shelter,  clothing,  occupation,  and  any  of  the  many 
conditions  affecting  the  general  health,  are  without  special  bias  until 
the  entrance  of  a  specific  organism  or  a  newly  acquired  virulence  gives  it. 
Of  these  predisposing  causes — predisposing  to  epidemic  prevalence — w^e 
have  comparatively  little  definite  or  positive  information.  It  may  be 
said  in  general  terms  that  extreme  cold  of  long  continuance  ;  bad  food, 
especially  if  in  process  of  decomposition  ;  drinking  water  containing' 
abundant  organic  impurities  ;  breathing  the  foul  air  of  crowded  tene- 
ment-houses ;  insufficient  and  uncleanly  clothing, — may  all  be  conditions 
so  impairing  the  vigor  of  the  individual,  while  favoring  the  multiplica- 
tion of  the  organisms  and  determining  greater  virulence,  as  to  cause 
epidemic  outbreaks  where  otherwise  a  sporadic  case  or  two  only  would 
be  found.  These  conclusions,  however,  which  seem  reasonable  enough, 
cannot  readily  be  sustained  by  any  positive  evidence  at  our  disposal. 

In  the  winter  and  spring  of  1893  an  extensive  epidemic  of  cerebro- 
spinal meningitis  prevailed  in  the  vicinity  of  Lonaconing,  a  mountain 
village  of  about  5000  inhabitants  in  the  coal-mining  region  of  Mary- 
land, wdiich  was  carefully  studied  by  Drs.  Simon  Flexner  and  Lew^ellyn 
F.  Barker  of  the  Johns  JEIopkins  University  staff  in  the  Department  of 
Pathology.  The  well-known  ability  of  these  gentlemen  and  the  pains- 
taking manner  in  which  this  study  was  conducted,  make  their  report 
one  of  the  most  (if  not  the  most)  valuable  recent  contributions  to  the 
study  of  this  disease.  It  will  be  understood  in  what  follow^s  that  w^hen- 
ever  reference  is  made  to  the  Lonaconing  epidemic  it  is  done  on  the  author- 
ity of  their  report  and  that  of  R.  L.  Randolph,  assistant  ophthalmic  and 
aural  surgeon  of  the  Johns  Hopkins  Hospital,  whose  report  is  limited 
to  the  ophthalmological  phenomena  observed  in  this  epidemic. 

The  village  of  Lonaconing  is  situated  in  a  deep  gulch  in  the  Alle- 
gheny Mountains,  through  which  a  muddy  creek  of  considerable  size 
runs.  All  the  streams  in  this  vicinity  are  subject  to  speedy  rise  after 
a  heavy  rainfall  of  even  brief  duration.  The  houses  are  situated  in 
terraces  on  the  side  of  the  valley  and  mountain  through  which  the 
stream  runs.  Tier  above  tier  rise  on  the  side  of  the  mountain  the 
houses   occupied   by  the   miners,  while   in  the  valley  are  situated  the 


428  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

business  and  professional  houses.  Above  the  level  of  the  dwellings  are 
placed  the  privies,  which  must  constantly  pollute  the  soil  about  them, 
and  after  rainfall,  as  indeed  at  all  times,  foul  the  stream  running  through 
the  town.  The  stables  are  quite  close  to  the  dwellings.  On  the  arrival 
of  Drs.  Flexner  and  Barker  the  snow  which  had  recently  fallen  had 
already  begun  to  melt  with  the  effect  thus  described  : 

"  The  water  streamed  down  the  mountain  sides,  carrying  with  it  the 
general  refuse  from  the  yards,  the  material  from  the  cow  stables,  and 
the  excreta  from  the  outhouses  of  the  upper  tiers,  through  the  yards, 
past  the  dw^ellings  situated  below,  and  finally  entering  the  creek,  which 
acts  as  a  huge  sewer  winding  through  the  centre  of  the  town.  On  their 
way  these  polluted  surface  washings  found  no  system  of  drains  for  their 
reception,  and  in  places  crossed  the  common  roadway  in  little  rivulets, 
through  which  the  inhabitants  of  the  town  had  to  drive  and  walk." 

The  water  supply  of  the  village  is  obtained  from  surface  wells  and 
from  cisterns,  and  in  many  instances  the  surface  water  with  its  accom- 
panying filth  was  seen  flowing  directly  into  these  wells,  which  are  in 
constant  use  for  drinking  water.  They  may  be  further  supposed  to  be 
contaminated  by  filtration  of  water  from  the  creek,  which  is  itself  addi- 
tionally fouled  by  slaughter-houses  built  on  its  margin,  from  which  the 
blood  and  other  noxious  matters  find  ready  entrance  into  its  waters. 
In  many  instances  the  houses  of  the  miners  are  overcrowded ;  in  one 
house  in  which  was  a  fatal  case  eleven  persons  slept  in  three  bedrooms. 
The  houses  were  generally  very  close  together.  Many,  however,  were 
commodious,  well  built,  and  not  overcrowded ;  these  possessed  no  im- 
munity, and  the  majority  of  cases  prevailed  in  the  higher  rows.  One 
fatal  case  occurred  in  an  isolated  dwelling  on  a  high  hill  a  quarter  of  a 
mile  distant  from  any  other  dwelling.  A  number  of  cases,  however, 
occurred  in  the  lower  sections,  and  there  were  numerous  sporadic  cases 
more  or  less  distant  from  the  site  of  general  prevalence. 

The  earliest  cases  were  in  two  young  men,  aged  respectively  twenty- 
one  and  twentv-two  years,  who  in  January,  1893,  after  a  dance  in  which 
they  were  overheated,  exposed  themselves  to  extreme  cold,  so  that  "  their 
hair,  wet  with  perspiration,  was  frozen  upon  their  heads."  A  long  and 
cold  drive  to  their  homes  followed,  and  on  the  next  day  they  were  attacked 
with  cerebro-spinal  meningitis.  Immediately  afterward  the  disease  be- 
came epidemic  at  many  different  points  in  the  same  region,  and  prevailed 
continuously  during  the  succeeding  months  up  to  the  middle  of  May. 
Fresh  cases  occurred  with  every  decided  diminution  of  temperature ; 
and  by  the  1st  of  March  68  well  marked  cases  and  40  classed  as  abor- 
tive had  been  recorded.  No  notable  difference  attributable  to  sex  was 
observed,  and  though,  as  usual,  children  were  most  often  attacked,  it 
was  by  no  means  limited  to  them. 

An  outbreak  in  the  neighboring  town  of  Frostburg  ran  the  total 
number  up  to  200. 

In  this  epidemic  it  is  noteworthy  that  such  a  condition  existed  as  is 
favorable  to  the  development  and  spread  of  infectious  diseases  in  gen- 
eral, and  that  there  was  an  actual  prevalence  at  the  same  time  of  scar- 
latina, diphtheria,  and  other  diseases  of  this  class.  It  is  also  shown  how 
close  is  the  relation  to  season,  and  even  to  variations  of  temperature  in 
the  same  season — a  fact  frequently  observed  before. 


ETIOLOGY.  429 

That  external  variations  in  tcmpcratnrc  should  so  dccidcdlv  infliK'nce 
tho  c'j)ideinii-  pi'cvalonce  ol"  this  disease  is  somewhat  renKirkal)le,  as  it  is 
of  course  attended  with  little  or  no  alteration  in  the  temperature  of  the 
medium  in  which  the  or<i:anism  lives.  It  cannot  therefore  materiallv 
affect  its  life  history,  apparently  tendino-  rather  to  produce  such  unknown 
conditions  in  the  host  as  favor  the  development  of  meningeal  inflamma- 
tion without  obvious  increase  in  numbers  or  virulence  of  the  parasite. 

According  to  J.  Lewis  Smith/  statistics  collected  in  Europe  and 
America  show  that  1(36  epidemics  occurred  "in  the  six  months  com- 
mencing with  December ;  only  50  were  in  the  remaining  six  months  of 
the  year."  Hirsch,  who  found  57  epidemics  occurring  in  winter  and 
but  20  in  other  seasons,  thinks  this  tendency  is  rather  a  result  of  the 
crowding  and  bad  ventilation  incident  to  cold  weather  than  to  the  direct 
effect  of  cold.  The  moist  atmosphere  probably  present  from  the  melt- 
ing of  snoAV  and  overflow  of  streams  furnishes  a  favorable  condition 
heretofore  observed  especially  by  WoUf,  who  in  a  series  of  132  cases 
treated  in  Hamburg  in  hospital  came  to  the  conclusion  that  atmos])heric 
moisture  was  a  strong  predisposing  influence.  That  fatigue  associated 
with  exposure  may  be  a  potent  predisposing  influence  is  shown,  not  only 
in  the  two  cases  that  first  occurred  in  the  Lonaconing  epidemic,  l)ut  in 
numerous  other  instances,  notably  in  the  brigade  of  General  Butterfield 
of  the  U.  S.  Army  during  the  late  war,  where,  according  to  Froth- 
ingliam,  it  seemed  to  be  connected  with  exhausting  drilling ;  and  also 
in  the  epidemic  of  1811  in  A^ermont,  where  the  outbreak  in  the  com- 
mand of  General  Dearborn,  which  was  fatigued  bv  exhausting  marches 
and  dispirited  by  defeat,  was  of  especial  severity. 

The  filthv  condition  of  the  drinking  and  cooking  water  at  Lonacon- 
ing  would  favor  the  idea  that  here  the  state  of  the  water  supply  sus- 
tained close  causal  relation  to  this  disease ;  but  the  force  of  this  conclu- 
sion is  impaired  by  the  fact  that  the  occupants  of  the  upper  tiers  of 
houses  suffered  most. 

That  a  crowded  condition  of  many  of  the  houses  in  this  locality 
favored  the  diffusion  and  fatality  of  this  epidemic  is  extremely  probable, 
as  a  like  tendency  has  frequently  been  observed  in  crowded  tenement- 
houses,  barracks,  and  prisons  ;  but  it  has  frequently  prevailed  exten- 
sively in  cleanly  villages  where  there  was  no  crowding  ;  and  it  will  be 
remembered  that  in  the  commodious  and  well  Iniilt  houses  in  Lonacon- 
ing the  occupants  were  not  exempt. 

That  this  disease  is  directly  communicable  from  person  to  person  is 
unlikely  under  ordinary  circumstances.  Attendants  are  not  much,  if  at 
all,  more  liable  to  contract  it  than  others  in  the  same  community,  but  a 
sufficient  number  of  cases,  apparently  traceable  to  personal  contact  with 
the  infected  or  with  clothing,  warn  us  that  this  mode  of  origin  is  at 
least  possible.  Hirsch,  J.  Lewis  Smith,  Kohlman,  and  many  others 
have  reported  cases  that  admit  of  no  other  reasonal)le  explanation  ; 
therefore  the  unaffected  should  receive  the  benefit  of  the  doubt  and  all 
unnecessary  intercourse  Avith  the  affected  should  be  forbidden.  On  the 
other  hand,  no  unnecessary  alarm  need  be  felt  because  of  unavoidable 
association  with  the  contaminated,  since  the  closest  intimacy  has  often 
failed  to  transmit  the  disease.     In  an  epidemic  of  30  cases  occurring  in 

^  J.  Lewis  Smith,  Diseases  of  Children,  p.  363. 


430  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

Cologne  no  two  cases  were  in  the  same  house.  Radzowski  reports  a  case 
in  which  a  woman  through  a  three  weeks'  illness  suckled  her  babe  with- 
out infecting  the  child.  Immunity  is  not  acquired  by  one  attack. 
Gowers  relates  a  case  in  which  a  woman  died  in  one  epidemic  who  had 
recovered  from  a  similar  attack  five  years  before. 

A  very  common  circumstance  is  the  association  of  epidemic  menin- 
gitis with  other  acute  diseases  ;  this  is  especially  the  case  with  croupous 
pneumonia.  In  Erlangen  between  1866  and  1872  no  less  than  14 
instances  of  such  association  were  recorded  (Fagge).  That  this  is  a 
fact  of  especial  significance  as  bearing  on  the  etiology  of  the  disease  is 
quite  clear  when  we  reflect  that  the  pneumococcus  lanceolatus  is  the 
microbe  common  to  both  diseases.  It  is  nevertheless  true  that  other 
organisms  are  found  with  sufficient  frequency  to  compel  the  admission 
that  meningeal  inflammations,  including  the  epidemic  form,  may  be  ex- 
cited by  other  microbes,  and  to  give  some  warrant  to  the  nomenclature 
at  present  not  uncommonly  used.  Grasset,  for  example,  speaks  of  a 
meningeal  pneumococcus,  pneumococcus  meningitis,  of  which  he  recog- 
nizes two  varieties — one  occurring  by  extension  from  inflamed  mucous 
membrane  in  the  ear,  nose,  or  pharynx,  where  the  organism  is  harmless 
in  health,  or  it  may  supervene  in  general  infection  arising  at  some  dis- 
tant point.  Writers  also  speak  of  a  streptococcus  meningitis,  a  typhoid 
bacillus  meningitis,  a  Klebs-Lbffler  bacillus  meningitis,  a  golden  staphylo- 
coccus meningitis,  and  an  influenza  meningitis}  It  would, greatly  simplify 
matters  if  the  facts  warranted  the  statement  that  epidemic  meningitis 
was  peculiar  in  its  etiology  and  arose  only  from  pneumococcus  infection, 
even  though  we  had  to  admit  some  peculiar  state  of  the  body  or  of  the 
microbe  at  the  time  of  epidemic  prevalence  to  account  for  this  circum- 
stance, while  other  forms  of  meningitis  had  varied  modes  of  origin.  We 
must,  however,  reluctantly  admit  that  this  conclusion  is  not  justified  in 
the  present  state  of  our  knowledge. 

Possibly  the  explanation  may  be  found  in  the  manner  in  which 
other  microbes  or  their  toxins  may  be  associated  with  the  pneumo- 
coccus, as  in  the  suggestive  observations  of  E.  Mosny  related  in  La 
Semaine  medicate,  January  4,  1895.  This  observer  instituted  a  series 
of  experiments  in  Straus's  laboratory  in  order  to  determine  the  influ- 
ence on  the  pneumococcus  of  various  microbes  with  which  it  is  usu- 
ally associated  in  cases  of  pneumonia  in  man — viz.  the  staphylococcus 
pyogenes  aureus,  Friedlander's  pneumobacillus,  and  the  streptococcus 
pyogenes.  His  results,  so  far  as  the  staphylococcus  pyogenes  aureus  was 
concerned,  were  that  in  every  case  association  of  living  cultures  of  the 
staphylococcus  aureus  with  living  cultures  of  the  pneumococcus  increased 
the  virulence  of  the  latter  microbe,  and  this  was  esiaecially  marked 
when  both  cultures  were  inoculated  simultaneously  at  points  distant 
from  each  other  under  the  skin  of  both  thighs.  Rabbits  thus  inocu- 
lated died  within  a  day,  while  the  control  animals  lived  a  fortnight. 
Simultaneous  inoculation  in  the  blood  of  the  two  cultures  at  the  same 
point  caused  death  within  three  days  ;  the  control  animals  died  in  five 
days  ;  similar  inoculation  under  the  skin  killed  a  rabbit  in  four  days  ; 
while  in  inoculation  with  the  pneumococcus  alone  the  control  animal 
did  not  die  for  a  fortnight.  Even  twenty  four  hours  after  inoculating 
'  Journal  of  Nervous  and  Menial  Diseases,  Jan.,  1895. 


ETIOLOUY.  431 

■\vitli  the  piK'umocoecus,  inociihitioii  with  livinii-  cultures  of"  the  staphy- 
h)i-oociis  iiu'ivascil  thi-  viriih'iK-e  of"  the  former,  thoii<ih  to  a  h'ss  dejrrce. 
In  all  these  ex[)eriinents  the  piieiiniocoeeus  was  f'oimd  in  a  state  of 
purity  in  the  blood  of  tlu'  heart  and  at  the  point  of  inoculation  when 
this  was  in  the  skin,  while  the  staphylococcus  was  found  only  in  the 
kidney  and  at  the  point  of  inoculation,  never  in  the  blood.  All  this 
points  to  the  conclusion  that  the  virulence  of  pneuniococcus  is  increased 
bv  association  with  the  staphylococcus  or  its  toxins. 

It  would  be  interesting  to  know  the  exact  manner  of  death  in  these 
animals,  and  to  what  extent,  if  at  all,  meningeal  inflammation  existed. 
With  the  pneumococcus  in  a  state  of  purity  in  the  blood  of  the  heart, 
with  added  virulence  derived  from  the  staphylococcus,  we  would  natur- 
ally expect  such  a  result,  unless  we  must  also  have,  to  attain  this  end,  a 
diminished  resistance  on  the  part  of  the  meninges — what  Jacccnid  calls 
the  "  morbid  opportunity."  Otherwise  we  are  entitled  to  a  little  skep- 
ticism as  to  the  potency  of  this  microbe  as  an  excitant  of  meningitis. 

In  the  Academy  of  ^Medicine,  Paris,  May  7,  1895,  Cornil  related 
a  case  of  suppurative  meningitis  distinctly  influenzal,  as  none  of  the 
ordinary  pus-producing  microbes  were  present.  In  this  form  of  men- 
ingitis the  pus  is,  according  to  Cornil,  serous  and  less  opaque  than  in 
the  pneumococcus  or  streptococcus  meningitis. 

The  following  conclusions  seem  fairly  warrantable  from  the  facts 
above  narrated  : 

1st.  ^leniugeal  inflammation,  cerebral  or  spinal,  is  due  to  the  pres- 
ence of  pathogenic  germs.  The  same  organism  is  sometimes  found  in 
sporadic  and  in  epidemic  cases ;  any  sporadic  case  may  therefore  be  a 
centre  of  endemic  or  epidemic  prevalence. 

2d.  The  organism  most  frequently  associated  with  it  is  the  pneumo- 
coccus lanceolatus. 

3d.  Various  other  organisms — streptococci,  staphylococci,  and  bacilli 
— are  present  sufficiently  often  to  jastify  the  belief  that  they  may  also 
be  excitants  of  this  disease. 

4th.  The  epidemic  prevalence  of  cerebro-spinal'  meningitis  is  prob- 
ably due  to  the  influence  of  external  conditions  on  the  individuals 
affected,  rendering  them  more  susceptible  to  the  pathogenic  action  of 
the  infecting  microbe, 

5th.  The  best  known  of  these  external  influences  are  cold,  moisture, 
fatigue,  crowding,  and  foul  water,  yet  it  may  occur  in  the  absence  of 
any  of  these  predisposing  causes  ;  hence  it  may  be  inferred  that  changed 
conditions  in  the  host  may  develop  especial  virulence  in  the  parasite, 
yet  this  cannot  affect  the  propagation  of  the  disease  unless  it  is  assumed 
that  the  virulent  microbe  is  transmissible  when  under  ordinary  circum- 
stances it  is  not.  On  the  whole,  it  seems  more  reasonable  to  conclude 
that  the  host  becomes  more  susceptible,  more  liable  to  meningeal  inflam- 
mation, than  that  the  parasite  becomes  more  virulent ;  there  is  a  dimin- 
ished resistance  rather  than  an  added  force. 

The  mode  of  access  of  the  microbe  to  the  meninges  cannot  be  said 
to  be  positively  determined,  but  it  probably  varies  with  many  circum- 
stances. It  is  almost  always  found  in  the  mouth  and  nose  of  healthy 
individuals  ;  hence  it  is  not  improljable  that  it  frequently  passes  into 
the  ear  by  the  Eustachian  tube,  or  directly  into  the  respiratory  passages, 


432  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

or  directly  through  the  ethmoid  to  the  cerebral  meninges,  where  in  either 
locality  it  may  or  may  not  give  rise  to  inflammation  as  the  conditions 
are  favorable  or  unfavorable,  or  as  it  is  accompanied  or  not  by  other 
micro-organisms,  such  as  streptococci  or  staphylococci,  or  as  it  may 
itself  be  possessed  of  peculiar  virulence  or  not. 

The  occurrence  of  suppurative  otitis  as  a  condition  precedent  to 
meningeal  inflammation  has  so  often  been  noted  as  to  leave  little  room 
for  doubt  that  it  furnishes  a  condition  favorable  to  the  development  and 
access  to  the  meninges  of  this  organism.  "  The  otitis  interna,  i.  e. 
media,  or  whatever  it  may  mean,"  says  Goodhart,  "  forms  a  fructifying 
ground  by  which  the  adjacent  membranes  become  attacked ;  it  forms 
the  open  door  by  which  the  murderer  steals  in,  rather  than  the  weapon 
by  W'hich  the  injury  is  inflicted."  A  nasal  catarrh  or  a  tonsillitis  may 
likewise  furnish  acceptable  conditions.  It  is  scarcely  credible  that  an 
organism  may  be  continuously  present  in  healthy  mouths  and  not  fre- 
quently pass  into  the  air  passages  to  find  at  times  conditions  favorable 
to  the  development  of  its  pathogenic  properties.  It  is  not  therefore 
surprising  that  the  lungs  should  often  prove  the  portal  to  the  brain, 
and  pneumonia  the  primarj^  disease  to  which  cerebro-spinal  meningitis 
is  the  legitimate  successor.  The  pneumococcus  has  been  found  free  in 
the  blood  of  the  heart,  and  so  may  readily  pass  directly  to  the  cerebral 
membranes.  There  is  a  sufficient  number  of  cases  in  which  meningitis 
is  the  primary  disease  to  make  it  extremely  probable  that  the  micrococ- 
cus may  pass  directly  into  the  general  circulation,  and,  finding  other 
organs  and  tissues  more  resistant,  effect  a  lodgement  in  the  cerebral  or 
spinal  meninges,  and,  owing  to  favoring  conditions  but  little  understood, 
produce  disturbance  in  them  alone.  Or,  it  may,  in  consequence  of  the 
effect  upon  the  general  health  by  the  disease  here  established  and  the 
changes  produced  in  the  blood,  render  other  tissues  susceptible,  which 
thus  become  secondarily  involved.  It  is  probable  that  the  alimentary 
canal  is  at  times  the  avenue  by  which  the  blood  becomes  affected,  as 
the  microbes  must  frequently  be  carried  from  the  mouth  into  the  stom- 
ach with  food  and  drink,  esj)ecially  with  the  latter  ;  and  as  simple  fluids 
presumably  do  not  excite  an  active  secretion  of  acid  gastric  juice,  they 
may  escape  digestion  and  be  washed  into  the  intestine,  where  the  con- 
ditions are  more  favorable  to  their  growth  and  development  and  to  their 
entrance  into  the  circulation  by  either  lymph  or  bloodvessels.  Fliigge 
has  called  attention  to  this  possibility  in  vSwallowing  water  infected  with 
a  cholera  bacillus ;  and  the  experiments  of  Ewald,  in  which  he  found 
that  after  water  was  introduced  into  the  stomach  a  portion  passed  on  at 
once,  and  after  a  time  the  rest  passed  over  suddenly  without  becoming 
acid,  tend  to  sustain  this  view.  Some  support  is  also  given  to  it  by  the 
observation  of  Flexner  and  Barker,  who  in  the  vomit  obtained  from  one 
child  sick  of  meningitis  demonstrated  the  absence  of  free  hydrochloric 
acid.  One  case,  however,  proves  nothing,  and  of  course  the  absence  of 
free  hydrochloric  acid  in  a  case  of  meningitis  does  not  show  that  the 
stomach  was  free  from  acid  before  the  attack  :  it  may  have  been  a  result 
of  the  disease,  and  not  a  condition  precedent,  but  the  fact  is  suggestive. 

Xothing  is  known  as  to  the  manner  in  which  the  microbe  leaves  the 
body  or  if  it  has  any  existence  outside  the  body ;  but  if  it  is  admitted 
that  the  disease  has  been  occasionallv  communicated  from  articles  of 


PATHOLOGICAL  AXATO^fY.  433 

clothing  or  pci'r^onal  coiitiu't  with  the  sic-k,  it  tollovvs  that  it  is  contained 
in  some  of  the  excreta  or  in  the  air  breathed  by  the  patient.  That  the 
inicroeoecus  can  live  and  retain  its  virulence  tor  four  months  when  dried 
in  sputum  or  blood  has  been  abundantly  shown.  "  We  have  sh<Avn," 
sav  Flcxner  and  liarker,  '*  that  an  or^-anism  possessing  the  culture  and 
morphological  prupi-rtics  of  the  ntirroajcca.s  (anceoldtn.s  is  thrown  off  witii 
the  dejections  in  some  cases  of  cerebro-spinal  meningitis,  and,  as  in<li- 
cated  bv  tiie  experiments  of  Bordoni-Uli'reduzzi,  Guarnieri,  Xetter, 
Patella,  Xikiforoif,  Sirena  and  Alessi,  and  Kruse  and  Pansini,  the 
organisms  mav  retain  their  vitidity  and  even  virulence  when  dried  in 
sputum,  l)l()od,  etc.,  sometimes  for  four  months."  It  must  be  admitted, 
however,  that  we  have  no  positive  knowledge  of  the  mode  of  access  or 
exit  of  this  organism,  nor  of  its  life  history  outside  the  living  body.   • 

Pathological  Axatomy. — The  most  characteristic  effects  of  cere- 
bro-spinal meningitis  are  naturally  seen  in  the  brain  and  cord  and  their 
membranes.  Tlie  vessels  of  the  pia  mater  are  engorged,  the  sinuses  dis- 
tended, and  the  vessel  walls  thickened.  Effusions,  serous,  plastic,  and 
purulent,  occur  on  the  surface  of  the  convexity,  at  the  base,  and  in  the 
ventricles  and  central  canal.  On  the  convexity  the  sulci  are  tilled  with 
inflammatory  exudates,  in  the  later  stages  purulent  in  character.  The 
meninges  and  entire  cerebral  surface  may  be  bathed  in  pus,  the  mem- 
branes adherent  to  each  other  and  to  the  cerebral  surface,  which  may 
be  infiltrated  and  softened,  S(^  that  efforts  to  separate  them  are  neces- 
sarily attended  with  cerebral  laceration.  The  vessels  of  the  brain  are 
engorged  and  dilated  and  the  ventricles  distended.  The  dura  of  the 
brain  is  but  little  affected,  that  of  the  cord  somewhat  more. 

The  suljarachnoid  space  may  be  filled  with  serum  or  pus,  and  the 
arachnoid  meshes  infiltrated,  especially  in  the  sulci.  This  infiltration, 
serous  or  cellular,  may  be  sufficient  to  render  the  membrane  quite 
opaque.  It  usually  follows  the  course  of  the  vessels,  but  at  times 
occurs  in  scattered  patches.  In  advanced  and  severe  cases  the  mem- 
branes may  be  everywhere  (edematous,  and  the  cerebral  substance  soft- 
ened to  a  considerable  depth.  Even  abscesses,  single  or  multiple,  may 
occur.  The  disease  is  really  a  meniugo-encephalitis  and  myelitis.  Those 
cases  that  run  a  rapid  course  present  but  slight  naked-eye  changes  beyond 
intense  hypersemia,  but  microscopic  examination  almost  always  shows 
extensive  cellular  infiltration.  It  is  probable  that  a  better  chemical 
kncjwledge  will  some  day  demonstrate  the  presence  of  toxic  agents  in 
such  quantity  in  foudroyant  cases  as  to  account  for  the  rapid  develop- 
ment of  fatal  symptoms.  Such  cases  present  in  a  striking  manner  the 
clinical  symptoms  of  acute  toxa?mia.  In  these  eases  the  amount  of 
liquid  effusion  or  of  cellular  infiltration  is  insufficient  to  account  for  the 
sudden  development  of  grave  symptoms  and  their  rapid  progress  to  a 
fatal  issue  on  any  hypothesis  of  pressure  or  other  mechanical  interfer- 
ence witli  the  functions  of  important  parts  of  the  cerebro-spinal  struc- 
ture. The  presence  of  toxins  sufficiently  potent  to  overpower  the  nerve 
centres  must  be  assumed,  and  this  is  no  very  strained  assmiiption,  since 
their  presence  has  been  shown  in  so  many  other  instances ;  but  in  tliis 
particular  disease  the  demonstration  has  not  been  made. 

The  inflammation  invades  both  convexity  and  base,  or  either  alone. 
When  the  base  is  involved  the  cerebral  nerves  are  liable  to  become 

Vol.  I.— 2S 


434  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

aifected  and  optic  and  aural  neuritis  ensues.  The  lymph  spaces  about 
these  nerves  may  be  filled  with  exudate.  Structural  changes  in  the 
nerve  fibres  are  usually  present  in  sufficient  degree  to  account  for  the 
functional  disturbances  in  vision  and  hearing  so  characteristic  of  this 
affection.  At  times  this  may  be  brought  about  by  direct  extension  of 
the  inflammatory  action,  with  swelling  of  the  axis  cylinders  of  the 
affected  fibres,  sometimes  issuing  in  their  complete  destruction,  and 
attended  with  diminution  of  the  white  substance  of  Schwann ;  at  times 
the  transudate  derived  from  other  sources  may  follow  the  course  of 
these  nerves,  and  by  pressure  occasion  degeneration  ;  or  the  vessels  of 
the  nerve  investments  may  be  distended  and  thrombotic.  Suppuration 
of  the  tympanum  leading  to  perforation  occasionally  gives  rise  to 
tinnitus  aurium  and  deafness.  Inflammation  of  the  floor  of  the  fourth 
ventricle  has  been  invoked  to  account  for  these  symptoms,  v.  Ziemssen, 
however,  found  this  condition  without  disturbance  of  auditory  function. 

Fagge  calls  attention  to  the  curious  fact  that  whilst  the  auditory 
nerve  is  frequently  affected  the  facial  nerve  always  escapes.  This  con- 
clusion, however,  is  not  generally  accepted  :  Gowers  says  it  is  probable 
that  inflammation  of  the  membranes  never  damages  the  auditory  nerve 
without  also  affecting  the  adjacent  facial  nerve.  Both  ears  are  usually 
affected  by  inflammation  of  the  labyrinth,  and  deafness,  consequently, 
is  complete.  In  cases  that  recover,  especially  in  the  very  young,  this 
may  result  in  mutism,  even  in  those  who  have  acquired  the  faculty  of 
speech.  Hirsch  thinks  there  is  at  times  a  true  aphasia  immediately 
resulting  from  the  cerebral  affection,  but  v.  Ziemssen  failed  to  observe  it, 
and  I  am  not  aware  that  it  has  been  observed  by  others.  Fagge  states 
that  in  1874  every  one  of  the  inmates  of  the  asylum  for  deaf  mutes  at 
Bamburg  owed  the  defect  to  an  attack  of  epidemic  meningitis. 

The  ventricles  may  be  so  distended  with  a  turbid  serous  fluid  or  pus 
as  to  compress  and  flatten  the  intervening  cerebral  structure  against  the 
cranial  vault.  Very  large  quantities  of  fluid  are  at  times  present,  and 
may  indeed  be  said  to  be  continuous  from  the  meshes  of  the  pia  arach- 
noid through  the  fissures  of  the  convolutions  into  the  ventricles  and 
central  canal  of  the  cord.  Large  serous  or  sero-purulent  accumulations 
in  the  ventricles  are  commonly  associated  with  occlusion  of  Majendie's 
foramen  or  of  the  aqueduct  of  Sylvius.  Small  hemorrhages  occur  in 
the  meninges  and  in  the  substance  of  the  brain  and  cord. 

The  cord  and  its  membranes  present  appearances  in  all  essential  par- 
ticulars identical  with  those  found  in  the  brain  and  its  meninges.  The 
exudates  are  here  most  abundant  at  the  most  dependent  parts. 

It  seems,  however,  probable  that  the  extent  to  which  the  posterior 
dorsal  and  lumbar  regions  of  the  cord  are  affected  is  rather  because  of 
the  greater  abundance  of  subarachnoid  tissue  there  than  because  of  the 
favoring  influence  of  gravitation.  "  The  disease  is  really  one  of  the  sub- 
arachnoid tissue,  involving  on  the  one  hand  the  pia  mater  and  subjacent 
nervous  tissue,  and  on  the  other  the  arachnoid."  ^  According  to  Fagge, 
the  changes  in  the  body  of  the  cord  are  less  marked  than  those  of  the 
brain,  but  this  o^jinion  finds  little  support  in  the  observations  of  Flexner 
and  Barker,  who  in  the  post-mortem  examinations  made  by  them  found 
the  cord  lesions  to  be  of  a  most  marked  character.     In  cases  examined 

1  Trevelyan,  Brain,  1892,  p.  104. 


PATiioiJxncAL  .I.V.I yo.i/)'.  435 

by  tlicm  the  pia  was  butlicil  in  [ni.s  or  s('i-()-[)ii.s,  its  vessels  iiijcftcd  and 
thickened,  the  membrane  infiltrated,  and  the  surface  of  the  cord  cov- 
ered  with   exudate  and   its  structure   infiltrated  witli   cells. 

In  the  anterior  fissure  an<l  at  the  roots  of  origin  of  the  anterior 
nerves  cellular  elements,  hirgely  of  the  small  round  cell  variety,  were 
abundant.  With  tiiese  were  also  found  other  cells  in  small  nnnd)er — 
larue  inclusive  cells,  cells  with  vesicular  nuclei,  and  polynuclear  lenc(j- 
cvtes.  On  the  posterior  aspect  of  the  cord  the  snrfacc  exudate  and  the 
injection  of  l)l()odvessels  and  membranous  infiltration  were  more  decided 
than  on  the  anterior  aspect,  and  the  posterior  fissure  contained  a  lar<>er 
amount.  The  body  of  the  cord  was  invaded  in  like  manner,  but  to  a 
greater  extent  than  in  front.  That  ])art  of  the  cord  at  which  the  pos- 
terior roots  enter  was  especially  the  site  of  cellular  infiltration ;  between 
the  roots  and  the  median  fissures  the  cell  infiltration  was  abundant,  but 
a  uniform  layer  of  cells  may  be  said  to  have  extended  from  the  ante- 
rior lateral  to  the  posterior  lateral  fissure.  The  predominating  cells 
resembled  "  lymphocytes  or  the  mononuclear  cells  of  granulation 
tissue." 

Changes  in  the  ganglionic  cells  of  the  cord  were  not  marked ;  some 
variation  was  observed  in  the  granulation  of  the  cells  and  in  the  clear- 
ness of  the  nuclei  and  nucleoli,  and  especially  in  the  sharpness  of  the 
cell  outline.  There  were  no  well  defined  changes  in  the  axis  cylinders 
of  the  cord  observed  by  Flexner  and  Barker,  owing  possibly  to  some 
difficulty  in  satisfactorily  staining  those  parts.  In  the  nerve  roots, 
how^ever,  swelling  of  axis  cylinders  and  interstitial  changes  also  were 
marked. 

In  both  anterior  and  posterior  roots  the  axis  cylinders  were  swollen 
in  considerable  nnmbers,  though  in  the  anterior  roots  a  large  number — 
the  majority — were  not  affected. 

"  The  normal  axis  cylinders  lie  in  a  space  which  has  apparently  been 
formed  either  by  the  disappearance  in  part  or  the  contraction  of  the 
myelin  sheath,  a  faint  line  of  myelin  being  still  visible  just  inside 
Schwann's  sheath ;  in  some  instances  the  myelin  entirely  fills  the  space 
between  the  axis  cylinder  and  the  sheath  of  Schwann.  On  the  other 
hand,  the  swollen  cylinders,  which  occur  singly  or  in  groups,  always  fill 
the  space  inside  the  myelin  sheath,  being  distinguished  from  the  latter 
by  their  larger  size  and  by  their  staining  properties.  It  is  worthy  of 
note  that  in  those  nerves  in  which  a  cellular  proliferation,  especially 
around  the  veins,  can  be  made  out,  more  axis  cylinders  show  this  change 
than  where  the  cellular  increase  is  not  so  apparent." 

The  vessels  of  the  perineurium  are  engorged  and  hemorrhages  occur 
between  the  bundles.  Cell  proliferation  in  the  interstitial  tissue  is  not 
abundant  in  the  anterior  roots,  but  in  the  posterior  roots  it  is  quite 
marked,  and  at  times  is  so  great  in  the  peri-  and  epineurium  as  to  obscure 
the  fibres.  Other  organs  are  more  or  less  affected,  but  not  in  a  manner 
distinctive  of  the  disease.  Congestion  of  the  kidney,  liver,  spleen,  and 
lungs  with  oedema  not  infrequently  occurs. 

Tiie  lungs  are  at  times  engorged,  oedematous,  or  solidified,  and  the 
pneumococcus  is  found  in  the  exudate. 

The  pleura  and  pericardium  are  now  and  then  inflamed  and  ecchv- 
motic,  and  occasionally  lined  with  purulent  exudate.     Endocarditis  is 


436  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

also  occasionally  present,  v.  Ziemssen  has  found  the  intestine  present- 
ing conditions  analogous  to  those  occurring  in  dysentery. 

Eifusions  into  the  joints,  purulent  or  semi-purulent,  are  not  infre- 
quent. 

Granular  degeneration  of  voluntary  muscles,  especially  of  the  spinal 
muscles,  is  of  common  occurrence. 

Symptoms. — The  period  of  incubation  is  necessarily  uncertain,  if 
indeed  there  is  any  propriety  in  speaking  of  an  incubative  period  in  a 
disease  supposed  to  have  its  origin  in  an  organism  almost  uniformly 
present  in  the  human  body.  Whether  the  organism  begins  to  acquire 
virulent  properties  or  the  body  ceases  to  be  resistant  to  it  cannot  at 
present  be  stated,  since  we  know  so  little  of  the  circumstances  effecting 
the  change.  Nevertheless,  persons  have  been  known  to  develop  symp- 
toms after  association  with  the  infected  or  after  exposure  to  contact  with 
infected  clothing  within  from  eight  to  ten  days. 

The  symptoms  are  necessarily  varied  and  complex,  depending  as  they 
do  on  the  degree  of  toxaemia,  the  extent  and  site  of  the  inflammation, 
and  the  amount  of  inflammatory  exudate,  and  this  irrespective  of  the 
particular  organism  concerned  in  its  production. 

Certain  cases  progress  with  such  rapidity  and  violence  as  to  over- 
whelm the  system  before  the  local  changes  can  exert  marked  influence. 
Others  present  phenomena  of  the  gravest  character,  which  may  be  alto- 
gether ascribed  to  profuse  exudation  in  and  upon  delicate  structures 
within  a  circumscribed  space  surrounded  by  unyielding  walls ;  still 
others  to  the  direct  destructive  metamorphosis  of  the  inflamed  tissues. 

To  what  extent  any  of  the  clinical  features  of  the  disease  are  due  to 
the  local  action  of  the  infecting  organism  cannot  now  be  said,  since  but 
little  is  known  of  this  branch  of  the  subject.  It  may  be  stated,  in 
general  terms,  that  the  psychical  phenomena  are  most  apparent  in  those 
cases  in  which  the  cortex  is  most  implicated,  the  special  sense  disturb- 
ances where  the  base  is  most  involved,  and  the  muscular  and  general 
sensory  disorderly  manifestations  when  the  spine  is  extensively  in- 
vaded. 

The  fact  must  not  be  lost  siglit  of  that  all  the  phenomena  character- 
istic of  this  affection  may  occur  without  any  inflammation  of  the 
meninges  whatever — that  decided  inflammation  of  considerable  extent 
and  with  abundant  purulent  exudation  over  convexity  and  base  may  be 
revealed  post-mortem  in  cases  where  no  clinical  evidence  of  its  existence 
had  been  present,  as  in  a  case  related  by  L.  Emmet  Holt.^ 

Prodromata  are  exceptional,  and  when  present  not  very  characteris- 
tic. Occasional  rigors,  general  malaise,  headache,  back-pain,  vertigo, 
and  loss  of  appetite  furnish  little  if  any  indication  of  the  nature  of  the 
impending  trouble. 

No  elaborate  classification  of  the  varieties  of  the  affection  is  desir- 
able. It  is  sufficient  to  describe  the  ordinary  form,  and  to  note  the 
particulars  in  which  it  may  vary  from  this  form,  and  as  far  as  may  be 
the  condition  causing  or  attending  such  variation. 

TJie  Ordinary  Form. — Prodromata  are  rare  and  slight,  such  as  have 
already  been  referred  to.  It  has  been  thought  that  cerebro-spinal 
meningitis  is  more  likely  to  begin  between  the  hours  of  midday  and 
^  Transactions  of  the  American  Pediatric  Society,  vol.  v.  p.  214. 


sYMP'roMs.  437 

rai(lni<rlit.  Sincic  tlie  t'|)i(leniic  (»l"  187*2,  .'iO  rocordod  cases.  J.  Lewis 
Smith  s;i\s,  wt'iv  almost  without  exception  in  this  particular,  from 
which  he  coMcUides  that  tiie  comlortahU'  sleej)  and  rest  of  the  latter 
part  of  the  niiiht  increases  the  resistance  of  tlie  hody  to  the  disease. 
Although  fatiyiie  is  a  recoiiiiized  factor  in  pre(lisposin<^  to  this  af- 
fection, yet  this  view  seems  somewhat  fanciful,  noi-  is  it  ])racticable  to 
sav  in  anv  iaro-e  nuinhcr  of  cases  at  what  hour  the  disease  begins. 
Rigors  are  occasionally  initial,  but  by  no  nu'ans  characteristically  so. 
Pain  in  the  head  is  an  early  and  continuous  symptom.  It  may  be  ov(!r 
the  l)row  or  at  the  back  of  the  head,  most  frecjuently  in  the  latter  posi- 
tit»n.  The  site  of  the  pain  does  not  necessarily  indicate  the  site  of  the 
inflammation  :  it  may  l)e  upon  one  side,  while  the  inflammation  is  on  the 
other.  Xoi'  does  the  degree  of  pain  have  any  constant  relation  to  the  in- 
tensity or  the  extent  of  inflammation.  It  extends  down  the  ne(^k  and 
back,  and  is  accompanied  by  intense  hy[)ei"{esthesia.  It  is  decidedly  in- 
creased on  motion,  and  is  usually  associated  with  rigidity  of  the  muscles 
of  this  region,  ranging  from  simple  stiffness  to  marked  tetanic  contrac- 
tion, with  extreme  pain  and  decided  0})istliotonos.  Both  the  pain  and 
contracture  in  the  cervical  and  dorsal  region  are  doubtless  due  to  the 
involvement  of  the  ])osterior  nerve  roots,  although  the  contracture  may 
be  in  part  the  direct  effect  of  the  inflammation  of  the  anterior  roots. 

In  perfect  repose  of  body  there  may  be  considerable  periods  of 
immunity  from  pain,  but  any  attempt  at  movement  is  attended  by  its 
recurrence.  The  extreme  extension  of  the  spine  is  in  part  due  to  the 
rigidity,  and  in  part  to  the  desire  of  the  patient  to  relax  the  affected 
muscles.  The  same  condition  and  purpose  doubtless  prompt  the  flexion 
of  the  thighs  on  the  pelvis  and  the  legs  on  the  thighs,  a  position  very 
commonly  assumed  by  the  patient. 

The  arms  are  also  flexed  at  the  elbows  and  on  the  chest.  These 
muscular  contractions  may  be  in  part  due  to  voluntary  effort  to  lessen 
the  tension  of  painful  muscles,  but  is  to  a  greater  extent  reflex,  indicat- 
ing irritation  of  the  sensory  roots  or  perhaps  direct  irritation  of  the 
anterior  roots,  or  to  a  combination  of  these.  A  sense  of  thoracic  con- 
striction with  respiratory  difficulty  is  very  frequently  present  in  cases 
without  pulmonary  complications,  and  serves  to  show  how  independent 
of  volition  the  muscular  phenomena  may  be.  In  this  connection  may 
be  mentioned  Kernig's  sign,  which  he  believes  distinctive  of  this  disease. 
He  observed  a  flexion  contracture  of  the  knee  joint,  which  in  the  sit- 
ting posture  could  not  Avithout  violence  be  straightened  beyond  an  angle 
of  l.")0°  with  the  thigh,  but  which  was  readily  straightened  when  the 
patient  was  in  the  erect  or  recumbent  posture.  It  is  objected  to  the 
])athognomonic  character  of  this  symptom  that  it  may  also  be  observed 
in  chronic  alcoholism,  old  age,  etc.,  but  Kernig  has  examined  several 
thousand  persons  especially  for  it  without  finding  it  in  a  single  instance 
except  in  cerebro-spinal  meningitis.  Pain  in  the  sacral  region  and  loins 
and  in  the  joints  is  not  uncommon.  It  is  much  more  frequent  and 
severe,  however,  in  the  head  and  cervical  and  dorsal  spine.  Whether 
the  pain  be  present  or  not,  muscular  rigidity  commonly  is,  and  is  most 
decided  in  the  same  regions  of  the  spine.  With  the  cephalalgia  vertigo 
is  frequently  associated  or  may  occur  indej^endently  of  it. 

In  children  the  disease  mav  be  ushered  in  with  convulsions  which 


438  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

may  recur  repeatedly  during  its  progress  until  it  finally  ends  in  coma  and 
death.  In  all  severe  cases  convulsions  are  liable  to  occur  in  the  later 
stages,  and  patients  usually  pass  into  a  comatose  condition  before  death. 
The  convulsions  have  no  necessary  relation  to  the  site  of  the  inflamma- 
tion (Gowers).  When  they  are  of  frequent  occurrence  and  the  patient 
remains  in  a  state  of  stupor  in  the  intervals,  they  commonly  indicate  a 
fatal  termination. 

Delirium  is  frequently  present,  and  may  be  active  and  continuous  or 
may  be  succeeded  by  stupor,  which  in  turn  "gives  place  to  active  delirium 
when  the  patient  is  aroused. 

The  tendon  reflexes  are  usually  increased  during  the  period  of  irri- 
tability and  diminished  in  the  later  period.  The  cutaneous  reflexes  are 
exaggerated.  Choreiform  movements  are  occasionally  present,  and  may 
issue  in  a  true  chorea  lasting  for  months. 

With  the  headache  is  heightened  sensibility  in  the  special  sense 
organs,  evidenced  by  intense  photophobia  and  increased  suifering  when 
noises  invade  the  room  of  the  patient.  Aversion  to  light  and  sound  is 
at  times  extreme  in  the  early  stages,  and  gives  place  to  indiflerence  as 
the  products  of  inflammation  increase,  and  the  aflected  nerves  or  their 
centres  become  structurally  more  and  more  impaired  until  their  func- 
tion is  partially  or  completely  abolished.  With  the  photophobia  also 
coincides  the  muscular  rigidity  of  the  eye  muscles,  giving  rise  to  stra- 
bismus, irregular  movements  of  the  globe  and  eyelids,  and  contraction 
of  the  pupils,  to  which  succeed  nerve  and  muscular  degeneration,  with 
paralysis,  ptosis,  dilatation  of  pupils,  and  blindness. 

Nearly  all  cases  of  cerebro-spinal  meningitis  are  attended  with 
marked  and  obvious  changes  in  the  eye.  Besides  the  nervous  and  mus- 
cular symptoms  already  alluded  to,  Ihere  may  be  lesions  of  every  por- 
tion of  the  structure  of  the  orbit.  Keratitis  occurs  in  many  instances, 
giving  rise  to  opacity  of  the  cornea,  followed  by  blindness  (Wilson, 
Niemeyer).  Iritis  and  choroiditis  resulting  in  blindness  are  not  infre- 
quent. Knaj)p  reports  that  in  the  epidemic  of  Rastadt  near  Heidelberg 
from  4  to  5  per  cent,  of  cases  were  affected  with  what  he  considered  a 
hyperplastic  choroiditis  with  consecutive  retinal  detachment  and  iritis. 
Krietmar  and  Salomon  after  an  examination  respectively  of  15  and  6 
cases  aff'ected  similarly — that  is,  with  subconjunctival  injection,  oedema 
of  mucous  membrane  of  eyeball,  hypopyon,  discoloration  of  iris  with 
redness  of  lids  which  lasted  one  or  two  weeks,  leaving  the  eyeball  soft 
and  the  patients  blind — looked  upon  it  as  a  simple  iriclo-choroiditis. 

Randolph  ^  found  the  eyes  more  or  less  aflected  in  nearly  all  cases. 
Engorged  and  tortuous  retinal  veins,  enlarged  papillae,  and  optic  neur- 
itis were  the  conditions  commonly  noticed  by  this  observer.  In  one 
instance  thrombosis  of  the  central  vein  was  seen.  This  condition  has 
been  observed  by  Michel,  who  recognizes  three  varieties,  "complete, 
incomplete,  and  slight"  thromboses.  In  even  the  third  variety  marked 
stasis  occurs,  recognizable  by  the  dark  red  color  of  the  blood  and  the 
tortuosity  of  the  venous  branches.  Age  and  the  associated  atheroma 
seem  to  play  an  important  part.  Michel's  7  cases  ranged  from  eighty- 
one  to  fifty-one  years,  and  were  sometimes  associated  with  cardiac  ven- 

^  Robert   L.   Eandolpli,  A  Clinical  Study  of  Forty  Cases   of  Epidemic  Cerebro-spinal 
Meningitis,  with  reference  to  the  Eye  Symptoms. 


sYMi'ToMs.  4:i9 

triciilar  livpcrtrdpliics.  KiiiWolisiii  nf  tlic  cciiti'Ml  ai'tcrv  <1mc  to  the 
saiiic  i-aiisi's  and  ncciin'iiio-  also  in  elderly  patients  is  nctt  nnenninKtn. 
Popp  re])orts  ")()  eases,  all  over  twenty-one  years  of"a«i-e.  lUaneo  re|»oi'ts 
tVoni  ( Jale/owski's  C'linie  an  averaj^e  a<i;e  of  torty-ei<ilit  yeais.  iJan- 
dolpli  tliinks  his  one  of  the  yonnuest  eases  recorded — twenty  month- — 
and  thinks  it  belonf>;s  to  the  ]»hlebitic  form  as  distinjiuished  from  the 
marantic,  which  is  seen  only  amonj::  elderly  ])ersons.  This  writei-  ealls 
attention  to  the  im|)ortant  fact  that  the  eye  phenomena  may  he  deteeted 
ophthalmoscopically  some  time  hefore  there  is  snhjective  evidence  of  such 
severity  as  to  attract  attention  in  the  midst  of  the  severe  jicneral  ^uft'er- 
ing.  Of  the  35  cases  exainiiicd  by  Randolph,  the  fimdus  was  normal 
in  but  7,  and  of  these  7,  "  1  ha<l  divergent  strabismus  and  dilated  pnpil, 
another  had  marked  nystagmus,  and  still  another  had  greatly  dilated 
j)upils."  In  6  were  optic  neuritis  ;  in  1  retinitis  with  thronil)osis  of 
the  central  vein;  and  in  19  cases  there  were  great  venous  t<»rtuosity 
and  engorgement  with  congestion  of  the  optic  disk.  The  right  eye  was 
much  more  frequently  aftected  than  the  left. 

Randolph  considers  the  conditions  here  noted  as  of  great  gra\ity 
in  prognosis,  far  more  so  than  pano|)hthalmitis,  suppurative  choroiditis, 
and  keratitis — conditions  more  conimonlv  described  by  other  writers. 

The  tongue,  teeth,  and  lips  are  at  times  covered  with  sordes.  Vomit- 
ing is  an  early  severe  and  often  persistent  symptom,  and  appears  to  be 
reflex  in  character  rather  than  due  to  any  direct  lesion  of  the  gastric 
mucosa.  It  is  not  usually  associated  with  decided  nausea,  nor  is  there 
any  especial  tenderness  on  pressure  over  the  stomach.  Difficulty  in 
swallowing  occurs,  and  the  effort  of  swallowing  and  the  l^ody  move- 
ment connected  therewith  mav  bring;  on  vomitino;  and  muscular  con- 
tractions,  and  to  this,  in  part,  is  due  the  apparent  lack  of  appetite  in 
many  cases.  The  desire  for  food  may  be  normal  or  nearly  so,  and  yet 
the  difficult  deglutition  and  the  apprehension  of  tetanoid  seizure  on 
rising  for  the  purpose  of  swallowing  will  cause  children,  who  can  give 
no  explanation,  to  decline  food  in  many  instances. 

The  bowels  are  more  ()ften  constipated,  but  diarrhoea  is  not  infrequent, 
and  occasionally  dysenteric  stools  with  mucus,  blood,  and  tenesmus  are 
present.  In  the  later  period  involuntary  stools  may  occur,  sometimes 
unconsciously,  at  others  with  the  knowledge  of  the  patient. 

Pyrexia  is  irregular,  following  no  definite  curve.  It  is  not  usually 
very  great,  ranging  in  the  neighl^orliood  of  102—103°  F.  or  lower,  and  is 
at  times  subnormal.  Xor  does  the  temperature  bear  any  close  relation 
to  the  severity  of  the  disease.  The  variations  are  abrupt  and  marked 
without  apparent  reason  in  the  severity  of  other  symptoms.  Indeed,  it 
seems  necessary  to  assume  some  direct  eflFect  on  the  heat  centres.  At 
times  there  is  no  fever,  but  this  does  not  alwavs  justify  a  favorable  prog- 
nosis :  just  before  death  it  may  reacli  10S-l()i»°  F. 

Herpes  facialis  is  often  present,  and  a  ])etcc]iial  rash  is  (juite  common. 
One  of  the  most  common  eru])tions  observed  in  the  Lonaconing  series 
was  "  an  indistinct  purplish  mottling  that  appeared  and  disappeared 
almost  under  the  eye."  Many  cases  are  unattended  with  eruptions. 
The  contribution  to  the  study  of  this  disease  by  Flexner  and  Barker 
is  especially  interesting  in  the  careful  study  of  the  blood  whicli  tliey 
M'ere  able  to  make,  a  line  of  investigation  hitherto  almost  neglei-ted. 


440  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

Halle  and  Voii  Limbeck  found  a  leucocytosis  in  suppurative  meningitis, 
and  Riedar  observed  two  cases  of  epidemic  cerebro-spinal  meningitis, 
one  having  20,100  white  corpuscles,  the  other  17,500  to  the  cubic  milli- 
metre. Flexner  and  Barker  thus  epitomize  the  result  of  their  examina- 
tions :  "  In  the  fresh  blood  slide  no  marked  variations  in  size  or  shape 
of  the  red  corpuscles  could  be  made  out ;  in  some  of  the  cases,  however, 
there  was  distinct  pallor  of  the  red  cells.  The  increase  in  the  number 
of  the  leucocytes  was  quite  evident  in  many  cases  in  the  examination 
of  the  fresh  drop  of  blood,  and  a  greater  number  of  white  corpuscles 
appeared  to  be  motile  than  one  sees  under  normal  conditions.  Many  of 
the  leucocytes  presented  a  striking  vacuolation — a  condition  Avhich,  we 
believe,  is  not  uncommon  in  the  leucocytes  dependent  on  other  causes. 
The  blood  platelets  were  present  in  lumps,  but  did  not  appear  to  be 
decidedly  increased  or  diminished  in  numbers." 

As  to  the  number  of  corpuscles  present,  the  average  of  a  number  of 
counts  shows  that  a  diminution  of  the  red  cells  is  not  a  marked  feature 
of  the  disease.  In  some  of  the  advanced  cases,  with  emaciation  there 
was  "  a  moderate  oligocythsemia,  but  in  the  majority  of  instances  the 
full  complement  of  red  corpuscles  was  present.  The  haemoglobin,  how- 
ever, in  all  cases  examined  was  somewhat  diminished  in  amount,  so  that 
the  individual  corjjuscular  holding  in  haemoglobin  (valeur  globulaire) 
was  below  par.  A  well  marked  leucocytosis  is,  we  believe,  a  constant 
phenomenon  in  the  disease  during  its  active  stages.  In  no  case  examined, 
except  in  couA'alescent  patients,  was  it  absent.  The  number  of  white 
corpuscles  varied  in  different  cases  in  our  experience  between  12,000 
and  32,000  to  the  cubic  millimetre.  That  the  degree  of  variation  is 
greater,  however,  there  can  be  little  doubt,  and  it  is  probable  that 
further  investigations  will  prove  that  stilklarger  leucocytoses  may  exist, 
especially  in  cases  of  meningitis  associated  with  complications  in  the 
lungs  or  joints." 

These  changes  in  the  blood  are  not  peculiar  to  meningitis,  but  com- 
mon to  suppurative  inflammations.  No  micro-organisms  were  found 
in  it. 

A  decided  variation  in  the  proportion  of  haemoglobin  was  observed 
in  several  of  these  cases,  amounting  to  from  45  to  74  per  cent.  In  two 
cases  the  percentage  was  45  per  cent,  and  55  per  cent,  respectively,  with- 
out materiak  diminution  of  the  number  of  red  corpuscles,  but  both  had 
shown  chlorotic  symptoms  prior  to  the  meningeal  inflammation,  and 
the  diminished  number  of  red  corpuscles  was  therefore  pro1)ably  not 
dependent  on  it. 

No  characteristic  respiratory  difficulty  occurs  in  epidemic  cerebro- 
spinal meningitis,  though  the  respiration  is  often  irregular,  sighing,  or 
of  the  Cheyne-Stokes  type,  and  in  convulsions  and  coma  presents  the 
peculiarities  that  belong  to  these  conditions.  General  cyanosis  happens 
quite  often. 

Epistaxis  was  of  frequent  occurrence  in  the  Lonaconing  cases. 

The  pulse  jiresents  nothing  so  distinctive  as  its  irregularity.  It  may 
be  quick  and  feeble  or  slow  and  intermittent.  Endocarditis  is  rare,  and 
may  rather  be  considered  a  complication  than  a  symptom. 

Joint  swellings  with  pain  are  frequently  observed  and  seem  to  cha- 
racterize particular  epidemics. 


coMJ'i.K'A'rfoxs  .i.\f>  sFj,)rr.LM  441 

Till-  urinary  I'uiictidii  i-  comiiKiiily  bill  little  di.stiirlx'd.  Polyuria  i.s 
present  at  times.  All»iiinin  may  We  present,  and  occasionally  a  ft'W  casts 
are  I'oiind.  The  urine  is  oi'teu  of  lii<ili  sjM'eifie  <):i'a\'ity  and  contains  an 
excess  of"  phosphate.-.  The  diazo  reaction  was  obtained  hy  Khrlich  in 
st'vere  cases.  There  is  also  at  times  retenti(tn  (»!'  uflne  from  irritability 
of  the  sphincter  or  from  paralysis  of  tiie  detrusor  niuseles. 

Emaciation  is  characteristic  of  this  disease,  and  is  at  times  extreme. 
It  may  be  accounted  for,  in  ])art,  by  the  great  suffering,  loss  of  appe- 
tite, and  vomitino-,  but  is  doubtless  to  a  greater  extent  the  effecrt  of 
troj)Jiie  disturbtinee  due  to  the  central  lesions  and  to  the  direct  influ- 
ence of  the  toxins  upon  the  blood. 

Tile  early  stages  are  characterized  by  syni))toms  of  exaggerated  nerve 
sensibility,  ])ain,  general  hypera^sthesia,  phot()])hobia,  aversion  to  sound, 
irregulai-  and  forcible  muscular  contractions,  delirium,  and  convulsions, 
to  which  succeed  symptoms  of  nervous  exhaustion  or  structural  impair- 
ment, such  as  cessation  or  diminution  of  pain,  indifference  to  light,  with 
dilated  pu])ils,  blindness,  deafness  or  indifference  to  sound,  muscular 
paralysis,  coma,  and  death. 

A  form  of  the  disease  characterized  by  extreme  severity  of  all  symp- 
toms and  rapid  progress  to  a  fatal  issue  is  known  as  fulminant  {menin- 
gitis cerebro-spina/is  siderans,  meningite  fond roij ante).  The  patient 
quickly  becomes  comatose,  and  may  expire  in  twenty -four  hours  or 
less.  These  explosive  cases  can  only  be  explained  by  assuming  an 
overpowering  eff'ect  on  the  nerve  centres  by  the  toxic  agent.  They  are 
the  cases  which  show  the  smallest  amount  of  inflammatory  exudate  and 
but  slight  structural  changes.  To  them  cannot  be  applied  the  statement 
of  Ley  den,  that  the  gravity  in  many  cases  is  due  ratlier  to  the  effects 
of  the  exudate  than  to  the  severity  of  the  infection. 

In  the  Lonaconing  epidemic,  cases  of  this  type  were  relatively  quite 
frequent ;  no  less  than  10  patients  died  within  forty-eight  hours  ;  one 
child  died  in  eight  hours,  and  another  in  ten  hours.  lu  the  less  violent 
cases  death  ensued  in  from  six  to  fourteen  days.  In  Pepper's  Text- 
hook  ^  a  case  is  mentioned  in  which  death  occurred  in  five  hours.  These 
cases  may  be  entirely  without  fever,  or  the  temperature  may  be  sub- 
normal, with  cyanosis  and  a  cold  clammy  skin.  The  symptoms  are 
essentially  the  same  as  in  the  ordinary  form,  except  for  the  rapidity 
with  Avhich  they  develop.  Delirium  is  early  in  appearing  and  quickly 
passes  into  coma.  Rarely  does  any  improvement  occur  and  recovery  is 
almost  unknown. 

Remission  of  nearly  all  severe  symptoms  at  times  takes  place,  and  at 
times  complete  intermission,  so  that  an  intermittent  form  is  recognized. 
After  a  brief  period  of  subsidence  all  the  symptoms  may  return  with 
equal  or  increased  violence,  but  the  intervals  are  not  so  definite  nor 
does  the  fever  pursue  the  same  regular  course  as  in  intermittent  fever. 

Abortive  cases  are  also  recognized  in  w^hich  the  disease  may  be 
ushered  in  with  the  usual  symptoms,  often  of  considerable  severity, 
and  after  a  brief  career  terminate  suddenly  to  recur  no  more.  The 
meningeal  inflammation  in  these  cases  is  probably  slight. 

Complications  and  Sequels. — Severe  cases  are  not  uncommonly 
followed  by  sequelee  of  a  grave  character — blindness  due  to  changes  in 

'  Ail  American  Text-book  of  the  Theory  and  Practice  of  Medicine,  Pepper,  vol.  i. 


442  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

the  optic  nerve  or  its  exhaustion,  or  at  times  to  injury  done  the  cortex 
by  inflammatory  infiltration  or  by  pressure  from  large  exudates.  This 
may  also  result  from  opacities  of  lens  or  cornea. 

Deafness  brought  about  in  like  manner  is  of  frequent  occurrence. 
Paralysis  of  orbital  muscles  with  defective  movements  of  the  eye  or 
permanent  strabismus,  ptosis  or  more  general  paralysis  of  one  arm,  leg, 
or  the  entire  side,  may  ensue.  The  higher  psychical  functions  may 
suifer  such  impairment  as  to  leave  the  patient  permanently  imbecile. 
Children  may  be  left  deaf  and  dumb,  imbecile,  and  paralyzed  for  long 
periods  or  for  life.  Deafness  is  perhaps  the  most  common  of  the 
sequelae,  and  is  often  due  to  destruction  of  the  middle  ear,  and  with  it 
vertigo  may  be  associated  from  involvement  of  the  semicircular  canals. 

Pneumonia  is  frequently  associated  with  meningitis,  and  it  may  often 
be  questioned  which  is  the  primary  disease.  The  same  organism  appears 
to  be  responsible  for  both  the  pulmonary  and  meningeal  affections. 
Bronchitis,  pleuritis,  endo-  and  pericarditis  may  be  occasional  compli- 
cations or  sequelae. 

Malignant  or  infective  endocarditis  stands  in  especially  close  relation 
to  epidemic  cerebro-spinal  meningitis.  Osier  ^  in  103  autopsies  in  acute 
pneumonia  found  1 1  cases  of  malignant  endocarditis,  among  which  were 
5  of  meningitis.  In  14  cases  reported  by  Byron  Bramwell  ^  there  was 
croupous  pneumonia  certainly  in  2,  and  probably  in  7.  Osier  and  Jaccoud 
have  pointed  out  that  in  these  cases  of  endocarditis  there  is  not  always 
a  loss  of  tissue,  but  sometimes  a  proliferation,  and  this  M.  S6e  thinks 
is  peculiar  to  the  pneumococcus  cases,  while  the  ulcerative  form  arises 
from  the  streptococcus.  Trevelyan  ^  holds  the  oj^inion  that  the  same 
organism  under  one  set  of  conditions  may  produce  meningitis,  under 
another  endocarditis,  in  another  pneumonia  or  any  combination  of  these. 
A  persistent  headache,  often  lasting  for  months,  may  be  regarded  as 
among  the  more  common  sequels.  Chronic  hydrocephalus,  indicated 
by  mental  feebleness,  loss  of  control  over  the  sphincters  of  bowel  and 
bladder,  vomiting,  pain  in  head,  back,  and  extremities,  loss  of  con- 
sciousness and  convulsions,  is,  according  to  v.  Ziemssen,  not  rare. 

Some  cases  of  epidemic  meningitis  are  indefinitely  protracted,  con- 
stituting a  chronic  form.  I  am  inclined  to  agree  with  Pepper  that 
these  protracted  cases  are  commonly  due  to  some  persistent  or  progres- 
sive lesion,  such  as  chronic  meningitis,  chronic  hydrocephalus,  or  even 
abscess  of  the  brain. 

Cause  of  Death, — Death  may  occur  in  many  Avays — in  the  ordi- 
nary form  probably  most  often  from  asthenia  due  to  continuous  suf- 
fering, sleeplessness,  inability  to  take  or  retain  food,  or  to  bed-sores  with 
exhausting  discharges.  Death  from  this  cause  may  be  at  a  tolerably 
early  period,  since  the  joint  result  of  the  causes  enumerated  tends  to 
speedy  exhaustion,  or  it  may  be  deferred  many  months. 

Death  may  also  result  from  profound  toxaemia  overpowering  the 
nerve  centres  prior  to  any  sufficient  intracranial  local  results  of  inflam- 
mation. This,  apparently,  is  the  manner  of  death  in  the  foudroyant 
form  when  it  occurs  within  the  first  week  or  ten  days. 

Again,  it  may  be  immediately  due  to  the  mechanical  effect  of  inflam- 

^  Gulslonian  Lectures,  1885.  ^  International.  Journal  of  Medical  Science,  1886. 

3  Trevelyan,  Brain,  part  1,  p.  109,  1892. 


JHACXOSfS.  443 

maU>rv  exudaU's  or  to  the  stnu'lural  cliaiiiics  wroimlit  in  tin-  iiilliinicd 
nervous  clenu'iits  by  tho  spreadinii'  of  the  inHainiiiatinii  inward,  and  not 
till'  iiicrc  |)r('ssure  of"  fluid  ;  but  \vv  cannot  thiid<  this  tlu,'  most  coninutn 
cause  of  death,  or,  at  any  rate,  that  it  liives  sufficient  warrant  to  tlie 
statiMuent  that  death  is  due  to  the  h)cal  intracranial  mischief  rather 
than  to  the  infection  per  sc.  Not  a  few  eases  must  also  die  in  conse- 
quence of  complieations,  such  as  pneumonia,  superadding  pulmonary 
<»bstruction  to  central  respiratory  labor.  A  few  eases  with  nephritic 
com[)lications  may  have  a  fatal  issue  determined  by  addition  of  unemia 
to  the  other  depressing  influences.  Fatal  results  sometimes  occur  many 
months  after  apparent  recovery,  or  patients  may  continue  ailing  many, 
many  months  before  death  ensues.  Hadden's  ease  lasted  over  fif- 
teen months,  and  Striimpell '  re[)orts  a  ease  that  died  after  three  nuaiths' 
illness. 

Diagnosis. — Owing  to  the  extremely  varied  clinical  picture  pre- 
sented by  this  disease,  in  sporadic  cases  it  will  often  escape  recognition, 
but  during  its  epidemic  prevalence,  when  it  is  in  the  thought  ni'  the 
observer,  it  can  usually  be  readily  diagnosed.  A  primary  difficulty 
occurs  in  the  fact  that  all  the  characteristic  symjitoms  may  be  present 
in  the  absence  of  any  meningeal  inflammation  whatever,  as  in  the  case 
of  middle-ear  disease,  and  this  difficulty  is  increased  when  it  is  remem- 
bered that  middle-ear  inflammations  may  excite  meningitis  or  a  primary 
meningitis  may  lead  to  suppurative  otitis.  Time  and  treatment  of  the 
aural  affection  can  alone  resolve  the  doubt  in  such  cases. 

The  positive  indications  of  meningitis  are  sudden  invasion,  pain  in 
head,  cervical,  dorsal,  and  lumbar  regions,  loins,  and  less  often  of  the 
extremities ;  intense  general  hyperaesthesia ;  assumption  of  positions 
relaxing  painful  muscles  ;  great  increase  of  pain  on  movement ;  inability 
to  effect  extension  of  the  legs  in  the  sitting  posture,  which  may  be 
readily  effected  in  the  recumbent  posture;  petechise,  purpuric  spots, 
herpes  labialis,  vomiting,  and  intense  photophobia  with  irregular  move- 
ments of  the  globe. 

Ophthalmoscopic  examination  of  the  eye  will  almost  always  shoA\' 
some  orbital  lesion  even  in  advance  of  subjective  indications.  Engorge- 
ment and  congestion  of  the  optic  disks,  venous  thrombosis,  tortuosity 
of  veins,  descending  neuro-retinitis  (von  Graefe),  are  conditions  fre- 
quently present  and  of  great  value  in  diagnosis,  as  are  also  intolerance 
of  sound,  delirium,  stupor,  irregularity  of  pulse  ;  and,  finally,  blind- 
ness, indifference  to  sound,  paralysis,  and  coma. 

The  disease  is  to  be  differentiated  from  typhoid  fever,  in  which  tlie 
cerebral  symptoms  are  a  prominent  feature.  Typhoid  is  more  gradual 
in  its  invasion,  the  fever  pursues  a  more  definite  course,  the  pulse  is 
more  regular  and  uniformly  rapid,  pain  is  less  pronounced  and  more 
apt  to  be  limited  to  the  first  stage,  vomiting  is  much  less  frequent,  bend- 
ing and  rigidity  of  neck  and  liack  are  rare,  sordes  on  tongue,  lips,  and 
teeth  is  more  often  present  and  usually  in  greater  quantity.  The  rose 
spots  of  typhoid  are  distinctive  when  present.  Ileo-caecal  gurgling  and 
tenderness,  and  after  the  first  week  looseness  of  the  bowels,  are  more 
distinctive  of  typhoid.  Epistaxis  and  intestinal  hemorrhages  are  com- 
mon to  typhoid.     Delirium  is  less  active  usually,  and  stupor  more  con- 

^  Pathological  Societi/  Transaction.-^,  1885. 


444  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

tinuous.  When  hypersesthesia  is  present  in  typhoid  it  is  of  brief  dura- 
tion. Extreme  photoj^hobia  is  rare  in  typhoid,  as  is  also  the  great 
sensibility  to  sound. 

Typhus  fever  resembles  epidemic  meningitis  in  the  abruptness  of  its 
invasion,  the  extreme  headache  and  cervical  pain,  general  hypersesthe- 
sia,  and  rapidly  developing  delirium  and  stupor.  It  diifers  in  the 
briefer  duration  and  commonly  milder  character  of  the  pain  and  mus- 
cular rigidity.  The  hypersesthesia  is  less  :  great  photophobia  is  uncom- 
mon. The  fever  is  more  uniformly  high  in  typhus  and  pursues  a  more 
regular  course.  Typhus  in  this  country  is  more  rare,  is  virulently  con- 
tagious, and  can  commonly  be  readily  traced  to  its  origin.  The  roseo- 
lous  eruption  in  typhus  is  tolerably  constant  to  the  fourth  day,  while 
the  eruption  of  meningitis  may  occur  on  the  first  or  second  day.  Herpes 
rarely  if  ever  occurs  in  typhus. 

Kernig's  sign,  of  which  we  have  no  personal  knowledge,  according 
to  its  discoverer  serves  to  distinguish  cerebro-spinal  meningitis  from  all 
other  aifections. 

Influenza  has  some  points  of  resemblance  to  meningitis,  more  espe- 
cially the  sudden  invasion,  the  head  and  back  pain,  convulsions,  and 
stupor  ;  Ijut  the  absence  or  mildness  of  muscular  rigidity,  the  rarity  of 
delirium  and  coma,  the  presence  of  catarrhs,  the  relative  mildness  of 
the  special  s'ense  symptoms,  and  its  cosmic  prevalence  serve  sufficiently 
to  distinguish  it.  The  cerebral  type  of  influenza  which  most  closely 
resembles  epidemic  meningitis  usually  occurs  as  an  occasional  variety 
during  the  prevalence  of  other  forms. 

.  The  presence  of  the  grip  organism  may  serve  to  establish  the  diag- 
nosis, or,  rather,  we  should  say,  to  establish  the  etiology  of  the  particular 
case,  for  a  true  meningitis  may  exist  differing  in  no  important  particular 
from  that  induced  by  any  other  cause.  Gowers  thinks  that  meningitis, 
especially  the  tubercular  form,  is  not  rarely  confounded  Avith  hysteria, 
from  which  it  may  be  distinguished  in  part  by  the  previous  history  of 
the  case.  Hysterical  attacks  are  rarely  single  and  the  individual  symp- 
toms are  seldom  persistent.  Hysteria  commonly  belongs  to  a  later 
period  of  life,  and  more  especially  to  the  female.  Strabismus  in  hysteria 
is  always  convergent,  associated  with  contracted  pupils,  and  varies  from 
day  to  day.  Strabismus  due  to  organic  disease  is  always  divergent  and 
connected  with  irregularity  of  pupils.  Pyrexia  and  the  existence  of 
trophic  disturbances  of  the  skin  make  for  meningitis. 

The  presence  of  symptoms  distinctive  of  organic  disease,  such  as  the 
ophthalmic  conditions  referred  to,  are  of  far  more  value  in  diagnosis 
than  the  history  of  previous  attacks,  and  go  much  farther  in  favor  of 
meningitis  than  a  history  of  previous  attacks  goes  in  favor  of  hysteria. 

From  other  varieties  of  meningitis  the  epidemic  form  is  not  to  be 
positively  diagnosed  by  the  symptoms  alone.  In  all  forms  of  menin- 
gitis the  direct  structural  results  of  the  inflammation  are  the  same,  and 
the  pressure  effects  of  the  exudate  are  not  different.  So  likewise  in 
ordinary  cases  the  toxic  effects  are  not  clinically  distinguishable.  It  is 
only  in  fulminant  cases,  which  may  be  said  to  be  peculiar  to  the  epi- 
demic type,  that  any  marked  clinical  distinction  exists,  and  this  chiefly 
in  the  sudden  and  violent  manner  in  which  the  symptoms  develop.  Just, 
however,  as  ordinary  epidemic  cerebro-spinal  meningitis  differs  from  the 


PROG  X()S[.<— Tin:.  1  TMKST.  44o 

fulminant  variety  in  the  slowness  ami  relative  mildness  ot"  its  develnj)- 
ment,  so  does  tnbercular  meningitis  nsually  dift'er  from  ordinary  epi- 
demic meningitis  in  the  eomparative  slowness  of  its  a<lvanee.  Jint  it  is 
more  to  be  distinonished  by  the  history  of  tniu-renlosis  in  the  family  and 
other  tnbei'cular  manifestations  in  the  patient,  especially  i)v  the  presence 
of  tnbercular  choi'oiditis,  a  ])revious  history  of  ])lenritis,  or  a  strinnoiis 
condition  of  glands  or  Ixmes. 

Herpes  makes  for  epitleniic  meningitis,  as  it  is  rare  in  tlie  other 
forms.  Next  to  the  recognition  of  other  tubercular  processes  in  the 
patient  or  other  members  of  the  immediate  family,  of  most  value  in  dif- 
ferentiating them  is  the  prevalence  of  an  epidemic  of  meningiti.-.  Mus- 
cular contractures  and  hypenesthesia  are  usually  of  milder  typr-  in  the 
tubercular  form.  It  also  runs  a  more  })rotracted  c(»urse  and  is  more 
assuredly  fatal.  It  is  also  much  more  apt  to  invi^lve  the  base  and  to 
present  symptoms  indicative  of  its  site. 

Smallpox,  scarlet  fever,  rheumatism,  and  other  diseases  arc  men- 
tioned by  writers  as  representing  features  of  similarity,  but  they  are  >o 
unlikely  to  be  mistaken  for  epidemic  meningitis  that  it  is  scarcely  neces- 
sary to  consider  them  in  detail.  Pneumonia  is  at  times  primary  and  at 
times  secondary  to  meningitis,  but  as  it  seems  probable  that  they  have  a 
common  origin  it  matters  little  which  is  the  antecedent  disease.  There 
is  of  course  no  difficulty  in  distinguishing  between  the  iuflammaticiu  of 
the  meninges  and  a  pneumonitis. 

Tetanus  might  possibly  be  confused  with  sporadic  cases  of  meningitis, 
but  the  diseases  are  readily  distinguished  by  the  history  of  injury  in  the 
former,  the  more  violent  muscular  contractions  and  the  consequent 
deformitv,  the  persistent  presence  of  trismus,  the  greatly  exaggerated 
reflexes,  the  diminished  sensory  disturbance,  the  absence  of  photopholna, 
and  the  freedom  from  mental  disturbance. 

PROGNOSIS. — The  progiKJsis  is  always  grave,  and,  though  many  cases 
doubtless  recover,  of  no  case  is  it  possible  to  anticipate  recovery  with 
any  strong  measure  of  proliability.  The  mortality  varies  in  different 
epidemics,  but  is  always  high,  ranging  from  30  per  cent,  to  70  per  cent., 
according  to  v.  Ziemssen  ;  Hirsch  places  it  at  from  20  to  To  per  cent.  In 
the  mild  or  abortive  cases  recovery  may  take  place  in  five  or  six  days. 
But  in  other  forms  it  is  the  more  protracted  cases  that  do  best :  tliose 
that  live  past  the  first  week  have  a  moderately  fair  prospect  of  recovery, 
but  as  it  cannot  be  said  of  any  case,  however  mild  in  the  beginning,  that 
it  will  recover,  so  it  cannot  be  said  even  in  cases  advanced  to  the  stage 
of  coma  that  they  are  quite  hopeless.  In  all,  however,  in  which  the 
onset  is  sudden,  the  symptoms  violent,  the  stupor  persistent,  the  pupils 
dilated,  the  muscles  paretic,  the  pulse  feeble  and  irregular,  the  skin  cya- 
notic, death  may  be  confidently  anticii^ated.  Cases  advanced  to  the 
stage  of  coma  have  recovered,  but  so  rarely  that  this  condition  piay  l)e 
taken  as  of  fatal  significance.  Under  five  and  over  forty  years  are  lui- 
fiivorable  periods.  All  fulminant  cases  die,  or  the  exceptions  are  so  few 
they  may  practically  be  left  out  of  consideration. 

Treatment. — There  is  no  specific  treatment  fin*  epidemic  cerebro- 
spinal meningitis,  and  no  very  effective  symptomatic  treatment.  In  all 
cases  the  patient  should  be  placed  in  a  cool,  darkened,  and  well  ventilated 
room,  from  which  all  visitors  and  noises  are  to  be  rigidly  excluded.    The 


446  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

liead  should  be  shaved  and  the  whole  body  thoroughly  cleansed.  As  the 
possibility  of  contagion  must  be  admitted,  articles  of  dress  worn  by  the 
patient  and  the  bed  linen  should  be  disinfected  before  being  sent  to  wash. 
Other  prophylactic  measures  are  of  small  value,  although  it  is  of  course 
desirable,  as  in  all  other  infectious  diseases,  to  avoid  all  forms  of  unclean- 
liness,  overcrowding,  improper  food,  drinking  foul  water,  and  all  things 
tending  to  impair  bodily  vigor. 

It  is  important  to  avoid  exposure  to  extreme  cold  when  overheated 
and  exhausted  by  excessive  exercise,  especially  on  the  part  of  those 
Avhose  duties  bring  them  into  close  association  with  the  affected. 

In  the  early  stage  remedies  supposed  to  lessen  the  circulation  in  the 
affected  parts  by  producing  vasomotor  contraction  of  their  bloodvessels, 
such  as  ergot  and  belladonna,  have  been  thought  effective.  The  use  of 
mercury,  both  internally  and  externally,  has  had  many  advocates,  but 
does  not  hold  a  very  high  place  in  the  estimation  of  modern  practitioners 
except  in  cases  associated  with  syphilis.  It  is,  I  believe,  more  frequently 
used  than  openly  advocated.  It  is  still  held  to  be  of  value,  however, 
by  competent  observers,  v.  Ziemssen  commends  it,  and  Pepper  thinks 
it  of  service  in  the  treatment  of  sequelae.  It  may  be  doubted  whether 
it  has  any  proper  place  in  the  management  of  this  affection. 

Bloodletting,  both  general  and  local,  has  been  extensively  practised 
and  is  still  not  without  advocates.  Striimpell  thinks  the  local  abstraction 
of  blood  of  undeniable  value,  however  difficult  to  explain.  Pepper  also 
thinks  venesection  may  be  useful  in  well  selected  cases  of  sthenic  type, 
considerable  pyrexia,  and  in  the  early  stage  in  healthy  adults.  Even  in 
delicate  and  young  subjects  he  holds  the  local  abstraction  of  blood  or  dry 
cupping  at  times  advisable.  Many  others  entertain  similar  views.  The 
writer  is  inclined  to  the  opinion  that  the  abstraction  of  blood  in  any  way 
or  at  any  period  of  life  is  of  more  than  doubtful  utility  in  this  disease  : 
although  it  is  better  borne  by  the  adult  than  in  childhood,  it  is  harmful 
at  all  periods  of  life,  and  the  cases,  if  any,  in  which  it  may  be  useful 
are  of  such  extreme  rarity  that  its  use  as  a  therapeutic  measure  had 
better  be  abandoned. 

Of  like  value  are  blisters  to  the  scalp  and  along  the  spine.  Proba- 
bly of  little  or  no  real  value,  they  undoubtedly  add  much  to  the  suffer- 
ing of  the  patient.  If  useful  at  all,  they  can  only  be  so  in  the  first 
stage,  before  any  extensive  exudation  or  destructive  structural  meta- 
morphosis has  occurred.  Escharotics  of  all  kinds  are  for  similar  rea- 
sons objectionable.  They  are  capable  of  little  good,  they  are  directly 
painful,  and  unquestionably  add  to  the  hyperffisthesia  and  to  the  pain 
and  muscular  spasm  produced  by  movements  and  manipulation.  German 
authorities  still  recommend  the  antiphlogistic  measures  of  the  past — in 
fulminant  cases  blisters,  mercurial  inunctions,  calomel  by  mouth,  vene- 
section, leeches,  and  cups.  In  the  opinion  of  the  writer  such  measures 
are  hurtful  in  by  far  the  larger  proj)ortion  of  cases,  however  judiciously 
selected. 

An  occasional  brisk  cathartic,  especially  in  the  beginning  of  the  dis- 
ease, is  often  serviceable,  and  at  no  time  harmful  if  used  with  ordinary 
discretion.  Xow  and  then  a  case,  apparently  in  the  last  stage,  may  be 
profited  by  full  catharsis,  as  in  Cases  72  and  75  of  Abercrombie's  series 
of  simple  meningitis,  where  even  after  the  induction  of  profound  stupor 


TREA  TMKNT.  447 

severe  niii'iiation  was  tnllnwcd  Itv  rcfoNcrv  >rciiiiiiiil\'  •''"'  t<»  the  remcdv. 
SiU'li  r(iiiark:il)U'  ctt'octs,  however,  arc  not  to  be  anticipated,  and  tlie 
mea.-iire   is   nndonbtedly  eai)able  of  harm  in  enfeebled  snl)jeets. 

("ahibar  bean,  recommended  by  N.  S.  Davis,  is  entitled  to  f'nrther 
trial  ;  as  yet  bnt  little  evidence  of  its  efficiency   is  ottered. 

In  a  disease  in  which  we  know  of  no  means  of  destroying  the 
organism  producing  it,  nor  any  of  neutralizing  its  toxins,  which  runs 
a  rapid  course  to  a  fatal  issue  in  a  large  proportion  of  cases,  it  would 
seem  most  advisable  to  limit  our  efforts  to  the  relief  of  symptoms,  the 
maintenance  of  strength,  and  to  those  topical  measures  which  are  under 
other  circumstances  found  to  limit  the  amount  of  inflammatory  transu- 
dation. 

All  of  these  purposes  are  in  a  measure  accomplished  by  anodynes, 
of  which  opium  and  its  derivatives  are  best.  The  most  troublesome 
symptoms  are  pain,  hypertesthesia,  muscular  spasm,  vomiting,  sleepless- 
ness, and  all  of  these  are  more  effectually  combated  by  the  hypodermic 
iujeetittn  of  morphine  than  by  any  other  means.  In  the  later  stages, 
■when  coma  supervenes,  neither  this  nor  any  other  measure  is  likely  to 
be  of  any  use,  and  it  is  only  at  this  period  that  there  is  danger  in  the 
discreet  use  of  this  agent.  It  is  a  conservator  of  strength,  since 
nothing  conduces  to  speedy  exhaustion  more  than  continuous  suffering, 
loss  of  sleep,  and  inability  to  take  and  retain  food.  So  far  as  any  drug 
does,  it  lessens  the  amount  of  inliaramatorv  exudate,  and  in  those  cases 
in  which  the  jirogress  of  the  case  is  uninfiueuced  by  it,  it  more  than  any 
other  ay;ent  solaces  the  last  hours  of  the  sufferer. 

Of  equal  or  perhaps  greater  value  is  the  coincident  use  of  cold  to  the 
head  and  spine.  To  be  useful  it  shoidd  be  thoroughly  used,  and  the 
best  results  are  to  be  had  from  the  early  and  almost  continuous  applica- 
tion of  ice  to  these  parts.  This  measure  likewise  lessens  pain,  dimin- 
ishes transudation  and  the  migration  of  leucocytes,  overcomes  muscular 
spasm,  relieves  vomiting,  especially  if  ice  is  also  kept  in  the  mouth  and 
occasionally  swallowed,  and  conduces  to  sleep.  This  measure  may  be 
advantageously  associated  with  the  application  of  warmth  to  the  extremi- 
ties ;  and,  since  its  good  effect  is  probably  largely  due  to  the  diminution 
of  cereliral  and  spinal  hyperj^mia,  we  may  reasonably  expect  that  coin- 
cident lowering  of  the  general  Ijlood  pressure  by  the  administration  of 
such  agents  as  nitroglycerin  will  materially  favor  this  end. 

As  the  general  temperature  is  not  usually  very  high,  and  lifting  or 
other  manipulation  of  the  patient  is  very  painful  and  likely  to  produce 
muscular  spasm,  the  use  of  cold  bathing  is  contraindicated  ;  moreover, 
by  inducing  contraction  of  the  cutaneous  vascular  area  it  would  tend  to 
heighten  the  blood  pressure  in  internal  organs.  Applications  of  ice  to 
the  head  and  spine  as  directed  are  far  less  troublesome,  less  painful, 
more  efficient,  and  probably  unattended  by  the  ill  effect  referred  to. 

Cold  douches  to  the  head  or  the  use  of  a  Leiter's  coil  where  ice  can- 
not be  had  may  be  advantageously  emjiloyed,  but  they  are  not  of  the 
same  efficiency  as  the  continued  application  of  ice. 

Aufrecht  ^  reports  a  case  of  cerebro-spinal  meningitis  with  low  tem- 
perature treated  with  hot  baths,  40"^  C,  with  immediate  remission  of 
symptoms  and  subsequent  recovery.     His  patient  was  a  man  twenty- 

^  Die  Therapie  der  Gegenuart,  Jan.,  1895. 


448  EPIDEMIC  CEREBROSPINAL  MEXINGITIS. 

five  years  of  age,  in  whom,  at  the  end  of  the  third  week  of  illness, 
benumbed  sensorium,  constant  delirium,  and  persistent  opisthotonos 
existed.  The  pulse  was  rapid,  but  the  fever  had  subsided.  "  After  the 
somnolence  had  lasted  ten  days,  in  view  of  the  frequent  pulse  and  low 
temperature  it  was  decided  to  use  the  hot  baths.  There  were  criven 
from  the  loth  to  17th  of  April  twelve  baths  at  40°  C.  of  ten  minutes' 
duration  each.  After  the  first  baths  improvement  began.  Graduallv 
the  sensorium  cleared  up,  pain  and  opisthotonos  diminished,  incontin- 
ence of  urine  and  fseces  disappeared,  the  abducens  nerve  assumed  its 
normal  function,  and  the  power  of  speech  returned.  Upon  discontinu- 
ing the  treatment  nocturnal  headache  and  delirium  reappeared,  where- 
upon three  more  baths  were  given,  after  which  all  symptoms  of  disease 
vanished."  ^  This  very  interesting  case  suggests  a  wider  field  of  useful- 
ness for  hot  baths  than  within  the  clinical  limitations  mentioned.  That 
hot  baths  may  be  useful  in  the  absence  of  fever,  with  feeble  pulse,  clouded 
sensorium,  and  headache,  need  surprise  no  one ;  but  remembering  the 
great  hypersemia  in  all  stages  of  this  disease  of  the  vessels  of  the  brain 
and  cord,  the  extent  of  the  inflammatory  exudate  within  the  cranium 
and  spinal  column,  and  the  not  infrequent  congestion  of  other  internal 
organs,  it  would  be  perfectly  rational  to  expect  benefit  in  other  cases  in 
which  the  temperature  was  not  very  high,  even,  or  perhaps  most,  in  the 
early  stage  of  this  infection.  Hyperj)yrexia  rarely  occurs  in  this  disease 
except  just  before  death. 

Indeed,  high  temperature  is  not  a  characteristic  of  cerebro-spinal 
meningitis,  and  may  in  many,  if  not  most,  cases  be  ignored  if  measures 
Avhich  might  add  to  the  pyrexia  tend  to  the  relief  of  other  more  im- 
portant conditions  ;  and  probably  nothing  is  more  important  than  the 
diversion  of  blood,  if  it  can  be  effected,  from  the  engorged  cerebral  and 
spinal  vessels,  and  no  measure  seems  better  calculated  to  effect  this  than 
the  measure  under  consideration.  It  may  also  be  serviceable  by  favor- 
ing the  elimination  through  the  sweat  glands  of  toxic  agents ;  and  also, 
by  lessening  nephritic  hyperemia,  increase  the  functional  activity  of 
the  kidneys  with  a  like  result.  It  would,  moreover,  in  the  judgment 
of  the  writer,  be  rational  to  associate  this  with  the  application  of  ice  to 
the  head  and  over  the  carotid  arteries  ;  and,  if  the  reasoning  is  just, 
these  measures  are  especially  applicable  to  the  early  stage  of  the  affec- 
tion before  injury,  mechanical  or  other,  is  done  to  the  important  struc- 
tures implicated. 

Other  remedies  of  anodyne  and  hypnotic  properties,  such  as  potas- 
sium bromide,  chloral  hydrate,  sodium  bromide,  bromoform,  phenacetin, 
and  chloroform,  are  at  times  useful,  but  none  of  them  are  so  potent  for 
good  as  morphine  in  cases  where  it  is  well  borne.  The  writer  has  seen 
phenacetin  give  the  most  marked  relief  to  the  painful  symptoms  and 
induce  quiet  and  restful  sleep  in  other  forms  of  meningitis,  and  should 
be  inclined  to  expect  similar  benefit  in  the  epidemic  form.  Iodide  of 
potassium  has  long  enjoyed  some  repute  as  a  sorbefacient  in  this  affec- 
tion. In  syphilitic  cases  and  in  subacute  and  chronic  cases,  after  the 
subsidence  of  acute  symptoms,  it  may  be  of  some  value,  but  in  the 
career  of  the  disease  it  can  be  of  little  service.  Its  value  at  any  time 
when  syphilis  does  not  complicate  the  trouble  has  doubtless  been  exag- 
^  Journal  of  Nervous  and  Mental  Disease,  March,  1895. 


TREA  TMENT.  449 

gerated.  The  use  of  (|iiiiiiii('  lias  Ix'cii  advocated,  but  it  is  of  doiihtful 
advantage,  nor  is  there  any  reason  to  snppose  it  more  usefnl  in  tli<'  inter- 
mittent oases  than  in  others. 

To  maintain  tlic  8tren<;th  of  the  })atient  earefnl  attention  shonld  be 
given  to  the  food.  It  shonld  always  he  licjnid,  and  shonld  he  adminis- 
tered at  short  intervals.  If  the  vomiting  makes  it  diffienlt  to  retain  the 
food,  advantage  may  be  taken  of  an  administration  hyjxxlei'mieally  of 
morphine  to  give  a  somewhat  larger  (jnantity  than  at  other  times.  The 
use  of  ehloral  hydrate  by  enemata  will  often  I'elieve  this  symptom  for  a 
time  and  enable  the  patient  to  retain  food,  lleetal  feeding  may  also  be 
practised  with  advantage,  in  which  case  the  food  should  always  be  pep- 
tonized. The  writer  is  skeptical  as  to  the  benetit  of  forced  feeding  in 
troubles  of  this  kind.  The  use  of  a  stomach  tube  is  very  likely  to  in- 
duee  efforts  at  vomitino-.  The  struyo'le  necessarv  for  its  introdnetion 
nuist  add  to  the  pain  in  head  and  back,  produce  severe  muscular  con- 
tracture, and  in  the  young  and  timid  convulsions  may  be  excited.  The 
free  use  of  water  at  such  temperature  as  best  suits  the  patient,  if  it  can 
be  retained,  is  always  desirable.  With  little  children  the  white  of  an 
ogg  may  often  be  given  mixed  with  water,  slightly  sweetened  and  acid- 
ulated with  lemon,  without  exciting  opposition,  to  the  manifest  advan- 
tage of  the  patient.  Animal  broths  in  all  forms  may  alternate  with 
milk  and  eggs.  The  administration  of  stimulants  may  become  needful, 
especially  when  food  is  badly  assimilated.  At  times  a  little  champagne 
iced  or  brandy  and  ice  will  quiet  the  stomach,  and  enable  food  to  be 
retained  better  than  anything  else.  When  they  add  to  the  excitement 
of  the  patient,  increase  the  pain  and  delirium,  or  notably  heighten  the 
fever,  it  is  best  to  omit  them.  Milk  punch  by  stomach  or  bowel  is  a 
good  form  in  which  to  give  alcoholic  stimulants.  At  all  times  when 
there  is  great  depression  and  a  feeble  heart  they  may  be  tried,  subject 
to  the  above  conditions. 

In  cases  that  recover  convalescence  is  often  j^rotracted  and  requires 
the  careful  supervision  of  the  attendant.  Stimidants  may  be  required, 
but  if  food  is  taken  in  fair  quantity  and  ajipears  to  be  well  digested  and 
assimilated,  alcohol  may  be  advantageously  dispensed  with.  Active  exer- 
cise is  commonly  impracticable,  but  passive  exercise  in  the  open  air  and 
sunshine  should  be  enjoined  as  soon  as  it  can  be  borne  without  distress. 
Massage  of  paralyzed  muscles  and  of  stiff  and  painful  joints  will  Ijc  of 
service.     With  this  electrical  stimulation  may  be  associated  to  advantage. 

Various  drugs  are  recommended  during  this  period,  such  as  mercury 
and  potassium  iodide  to  favor  absorption  of  inflammatory  products,  iron, 
cod-liver  oil,  bitter  tonics,  etc.  Good  food  when  it  can  be  digested  and 
assimilated  is  the  only  real  tonic,  and  drugs  of  this  class  are  only  val- 
uable in  so  far  as  they  favor  these  ends.  It  is  to  be  feared  that  in  the 
majority  of  instances  they  are  more  likely  to  disturb  the  stomach  and 
impair  digestion  than  to  improve  it.  Perhaps  a  few  drops,  not  above 
five  or  ten,  of  the  muriated  tincture  of  iron,  with  a  slight  excess  of 
hydrochloric  acid,  especially  in  cases  where  this  acid  is  shown  to  be 
deficient  in  the  gastric  secretion,  taken  directly  after  meals,  will  at  times 
prove  of  value.  But  so  far  as  drugs  are  concerned  it  may  be  said  with- 
out reservation  that  no  drug  that  disturbs  the  stomach  can  at  this  time 
be  other  than  harmful,  and  no  matter  what  the  supposed  indications  for 

Vol.  I.— 29 


450  EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

its  use  it  should  be  withheld.  With  these  may  be  classed  even  those 
peptonized  and  other  artificially  digested  foods  which  offend  the  taste 
and  nauseate  the  patient.  Sapid  foods  that  "  make  the  mouth  water " 
also  excite  the  gastric  secretion,  and  are,  other  things  being  equal,  most 
easily  digested.  There  can  be  little  doubt  that  enjoyment  of  food  has 
much  to  do  with  its  proper  digestion,  or,  at  any  rate,  food  that  offends 
the  taste  or  has  merely  lost  its  savor  by  reason  of  sameness  is  less  likely 
to  be  promptly  digested.  As  much  variety  should  therefore  be  secured 
as  is  practicable.  It  is  much  to  be  feared  that  lack  of  suitable  season- 
ing is  too  often  a  characteristic  of  sick-room  diet.  Insipidity  in  food 
with  defective  taste  in  the  invalid  is  an  unhappy  conjuncture.  As  there 
is  no  local  inflammatory  trouble  in  the  alimentary  canal,  in  these  cases 
there  can  be  no  reason  why  pungency  in  food  should  be  objected  to  if  it 
accords  with  the  patient's  taste. 


ERYSIPELAS. 

By  GEORGE  DOCK,  M.  D. 


Synoxyms  :  Rose,  St.  Anthony's  fire ;  f^rysipele  (Frencli) ;  Erv- 
sipel,  Rothlauf  (Gorman),  etc.     The  etymology  is  uncertain. 

Definition. — Erysipelas  is  an  acute  infectious  disease  characterized 
by  a  peculiar  inflammation  of  the  skin,  with  fever  and  other  general 
symptoms,  and  caused  by  the  streptococcus  of  Fehleisen. 

EtioloCtY  and  PATHOLOCrY. — Formerly  considered  a  so-called  gen- 
eral disease  caused  by  alterations  in  the  body  fluids,  especially  bile  (Galen 
to  writers  of  the  nineteenth  century^),  with  a  local  manifestation,  we 
now  know  that  erysipelas  is  of  bacterial  origin,  beginning  as  a  localized 
infection  and  producing  general  symptoms  as  the  result  of  the  local  dis- 
ease. Very  early  in  the  history  of  bacteriology-  bacteria  were  found 
in  erysipelatous  lesions,  but  their  constant  occurrence  was  first  shown  by 
Koch.^  About  the  same  time,  and  independently,  Fehleisen^  not  only 
demonstrated  the  presence  of  the  organisms,  but  by  cultures  and  sub- 
sequent inoculations  showed  their  causal  relation.  The  inoculations 
included  seven  on  human  beings,  the  subjects  of  inoperable  malignant 
disease,  and  justified  by  the  clinical  observation  that  erysipelas  acquired 
in  the  ordinary  way  in  such  cases  seemed  sometimes  to  have  exerted  a 
favoral)le  influence. 

The  streptococcus  of  Fehleisen  was  supposed  at  first  by  its  discoverer 
and  others  to  be  sid  generis,  and  it  was  not  until  several  years  after  the 
first  announcement  of  Fehleisen,  when  the  value  of  the  independent 
researches  of  Rosenbach,  Passet,  and  Garre  on  pyogenic  streptococci 
could  be  realized,  that  the  specific  nature  of  Fehleisen's  organism  was 
seriously  questioned.  Since  then,  as  the  result  of  an  enormous  amount 
of  experimental- and  much  clinical  work,  the  belief  has  gained  accept- 
ance that  the  streptococcus  of  erysipelas  is  identical  with  the  strepto- 
coccus pyogenes  of  Rosenbach,  and  cannot  be  distinguished  from  the 
streptococci  found  in  suppurative  lesions  of  the  most  diverse  kinds — 
e.  g.  phlegmon,  puerperal  peritonitis,  certain  anginas,  etc. 

A  discus-sion  of  the  various  observations  and  experiments  for  and 
against  the  specific  nature  of  the  erysipelas  organism  is  quite  outside  the 
object  of  the  present  article.     Much  confusion  has  been  thrown  around 

'  E.  (J.,  "There  are  a  number  of  reasons  which  make  it  extremely  probable  that  the 
connection  between  the  skin  and  mucous  membrane  of  the  alimentary  canal,  between  the 
perspiration  and  the  secretion  of  bile,  between  the  solar  plexus  and  the  cutaneous  nerves, 
is  effective  in  the  production  of  erysipelas"  (Reil,  Fieherlehre,  vol.  ii.,  1804). 

-  Nepveu,  Des  Bacteries  dans  PErysipele,  Paris,  1870;  Hueter,  Deutsche  Zeitschrift  fur 
Chirurgie,  1868,  i.  p.  i. ;  Cenlmlhlatt  fur  die  med.  Wissenschaften,  1868,  Xo.  35. 

^  "Zur  Untersuchung  von  pathogenen  Mikro-organismen,"  MittheUungen  aus  dem  Kais. 
Gcsundheitsamf,  1881,  Bd.  i.  S.  38. 

*  Fehleisen,  "  Aetiologie  des  Erysipels,"  Berlin,  1883,  Verhandlungen  der  Wiirzburger 
med.  GeselUehaft,  1881. 

451 


452  ERYSIPELAS. 

the  subject  by  failing  to  adhere  closely  to  the  generally  admitted  clinical 
and  anatomical  features  of  erysipelas.  By  ignoring  these  features  yari- 
ous  authors  haye  thought  to  haye  produced  erysipelas  ^yith  cultures  of 
different  species  of  micro-organisms,  when  in  reality  the  change  pro- 
duced was  not  erysipelas  at  all.  The  idea  that  erysipelas  in  man  has  in 
certain  cases  been  produced  by  other  organisms  than  the  streptococcus 
of  Fehleisen  (staphylococci,  typhoid  bacilli,  etc.)  has  two  j^ossible  sources 
of  fallacy.  One  of  these  is  that  the  supposititious  erysipelas  is  not  a 
real  erysipelas.  This  was  no  doubt  the  case  with  the  experimental 
bacillary  erysipelas  of  rabbits  described  by  Koch.  The  other  souix-e  of 
fallacy  is  the  fact  that  the  organisms  cultiyated  from  erysipelatous  lesions 
may  have  been  recent  arrivals  there. 

The  old  idea  that  the  erysipelas  cocci  can  l^e  recognized  h\  the  results 
of  inoculations  in  animals  has  been  almost  entirely  abandoned  by  all 
who  have  carefully  examined  the  matter.^  Whatever  the  future  may 
reveal  in  regard  to  the  relation  of  the  streptococci  found  in  various  dis- 
eases, we  can  at  present  assume  that  under  ordinary  conditions  erysipe- 
las in  man  is  always  caused  by  streptococci  morphologically  similar  to 
the  common  streptococci  of  suppuration. 

For  obtaining  these  organisms  in  pure  cultures  various  methods  are 
used.  The  usual  method,  and  the  old  one,  is  to  remove  a  piece  of 
affected  skin  with  the  most  rigid  antiseptic  precaution  and  place  it  in 
sterilized  bouillon.  This  is  of  course  a  method  which  cannot  be  used 
very  frequently,  and  as  a  substitute  that  of  Achalme  ^  is  preferable  : 
After  carefully  disinfecting  the  skin  a  thin  layer  of  collodion  is  rapidly 
dried  over  the  part  to  be  examined  ;  a  sterilized  lancet  is  then  passed 
rapidly  through  the  collodion  into  the  deep  layer  of  the  skin.  The  first 
drops  of  blood  are  removed  by  the  aid  of  a  sterilized  pipette.  The  skin 
is  then  squeezed  so  as  to  press  out  a  dro})  or  two  of  serum,  which  is 
received  in  a  sterilized  pipette.  From  this  tuljes  of  nutrient  media  are 
inoculated.  It  is  necessary-  to  use  a  good  deal  of  serum,  because  even 
in  that  from  the  most  active  seat  of  the  disease  the  microbes  may  be  rare. 
Cultures  from  different  cases  of  erysipelas,  or  from  the  same  case  in 
different  media,  give  results  which  differ  slightly,  as  can  be  seen  from 
the  descriptions  of  various  observers.  On  the  whole,  grown  under 
similar  circumstances  the  cultures  show  unmistakable  resemblances. 

In  gelatin  the  colonies  grown  at  the  ordinaiy  temperature  become 
visible  in  from  thirty-six  to  forty-eight  hours.  In  the  depths  C)f  the 
gelatin  they  appear  as  small,  opaque,  white  specks,  round  and  sharply 
circumscribed.  Those  on  the  surface  are  somewhat  larger  and  almost 
hemispherical.  Examined  with  a  moderate  power,  the  margins  are  seen 
to  be  slightly  irregular.  The  centre  of  the  colony  is  milk-white,  the 
border  somewhat  translucent.  From  the  fact  that  the  gelatin  is  never 
liquefied,  the  streptococci  can  be  distinguished  from  the  vdiite  staphylo- 
coccus which  may  grow  in  the  culture  as  the  result  of  contamination 
from  the  skin.  In  agar  or  serum  at  35°  C.  the  colonies  grow  more 
rapidly  and  are  more  translucent. 

Grown  in  bouillon,  the  medium  becomes  turbid  in  about  twelve  hours, 

^  KMrih,  Arheiten  aus  clem  Kais.  Gesundkeitsamt,  1891,  vii.  389;  Von  Lingelsheiin, 
Zeitschrift  fur  Hyqiene,  xii.  .308. 

2  Achalme,  "'Sur  I'Erysipele,"  Paris  Thesh,  1892. 


'    ETIOLOGY  AND  PATHOLOGY.  45;5 

but  clears  ii]>  in  three  or  loiir  days,  and  tlie  cocci  ihcii  loi'ni  a  j^ranidar 
sediiiieiit  oil  the  hottom. 

J 11  milk  the  strej)t(>cucciis  causes  a  local  coagulation  in  the  course  of 
several  days,  followed  more  or  less  rapidly  by  complete  coagulation  and 
subse([uent  retraction  of  the  clot,  leaving  the  serum  clear. 

Examined  alive  in  liquid,  the  streptococcus  shows  only  Brownian 
movement. 

The  sti'e|)tococcus  of  ervsij)elas  stains  readily  with  the  usual  aniline 
tlyes,  and  fiintly  with  carmine  or  litematoxylin.  It  is  not  decolorized  by 
the  methods  of  Gram  and  Weigert. 

The  appearance  of  the  organism  differs  slightly  according  to  the  soil 
in  which  it  is  grown,  but  in  general  it  forms  short  chains  of  from  six  to 
eight  cocci  on  solid  media.  In  liquid  media  the  chains  may  contain  as 
many  as  thirty  to  forty  cocci.  They  measure  from  .3  to  .6  micromilli- 
metres  in  diameter.  The  chains  often  contain  pairs  in  closer  apposition 
(diplococcus  forms).  In  old  cidtures  the  cocci  show  considerable  varia- 
tion in  size,  and  also  in  intensity  of  staining. 

The  stre])tococcus  of  erysipelas  grows  well  in  the  air,  but  it  also 
grows  anaerobically.  According  to  Achalme,  it  grows  better  without 
access  of  air.  Lubinski  ^  could  see  no  difference  in  the  appearance  of 
the  colonies  grown  under  both  conditions.  Both  observers  say  that 
vitality  and  virulence  are  well  preserved  in  anaerobic  cultures.  Ac- 
cording to  Achalnie,  the  streptococcus  grown  anaerobically  shows  more 
marked  action  than  otherwise,  so  that  he  claims  it  is  really  a  facultative 
aerol)c. 

The  streptococcus  grows  best  in  alkaline  media.  It  produces,  how- 
ever, an  acid  reaction  in  the  medium,  which  is,  according  to  Achalme, 
less  marked  than  that  produced  by  streptococci  from  pus,  although  this 
observer  also  claims  that  attenuated  cultures  of  erysipelas  cocci  produce 
an  acid  reaction  more  rapidly  than  virulent  ones.  The  acidifying  power 
varies  much  wdth  the  medium  in  which  the  organisms  are  cultivated. 
The  nature  of  the  acid  formed  is  not  known. 

The  erysipelas  coccus  is  sensitive  to  extremes  of  heat  and  cold  and  to 
variations  in  its  culture  soils,  but  wdth  care  in  the  selection  of  the  cul- 
ture and  the  soil  may  be  kept  alive  for  long  periods  ("  almost  unlimited," 
Achalme). 

Both  experiments  in  vitro  and  clinical  observations  go  to  show  that 
the  organisms  may  remain  latent  for  long  periods,  and  then  as  the  result 
of  some  change  in  the  environment  which  favors  their  activity,  or  in 
consequence  perhaps  of  the  disappearance  of  some  substance  which  inter- 
feres with  them,  they  may  become  active.  In  consequence  of  this  quality 
certain  auto-infeetions  may  be  explained. 

The  virulence  of  the  streptococcus  of  erysipelas  varies  extremely — 
in  fact,  quite  as  much  as  that  of  the  similar  cocci  found  in  other  diseases. 
Cultures  may  be  attenuated  and  their  virulence  restored,  although  the 
latter,  or  even  the  preservation  of  a  fixed  degree  of  virulence,  is  a  matter 
of  great  difficulty. 

In  experimenting  with  cultures  of  erysipelas  cocci,  rabbits  oifer  the 
best  medium,  and  in  them  all  the  degrees  of  intensity  of  the  reaction 
may  be  observed  wdth  cultures  of  different  degrees  of  virulence.     Thus 

^  Cenlralhlatt  fiir  Bakteriologie  unci  Parasitenkunde,  Bd.  x\ri.  No.  19,  189-t. 


454  ERYSIPELAS. 

in  the  most  severe  cases  there  is  a  general  sepsis  without  local  lesion 
either  from  inoculation  in  a  vein  or  in  the  skin.  In  the  descending 
scale  of  virulence  we  have  fatal  sepsis  following  more  or  less  severe 
local  lesion  ;  localized  erysipelas ;  mild  redness  and  swelling  of  the 
skin.  Finally,  cultures  may  be  so  attenuated  as  to  produce  no  local 
alteration. 

According  to  numerous  experiments,  putrefaction  is  a  powerful  assist- 
ing source  of  virulence  in  a  streptococcus  culture — a  fact  which  has  an 
important  bearing  on  puerperal  erysipelatous  infection.  The  symbiosis 
of  the  streptococci  is  doubtless  of  great  importance.  Roger  made  the 
interesting  observation  that  injections  of  filtered  cultures  of  micrococcus 
prodigiosus  with  very  weak  cultures  of  streptococcus  produced  a  severe 
infection.  Clinically,  mixed  infection  of  streptococcus  and  other  bac- 
teria is  not  uncommon,  but  so  far  as  erysipelas  is  concerned  reliable  data 
are  scanty. 

The  mode  in  which  the  organisms  produce  the  phenomena  of  the  dis- 
ease is  by  no  means  so  definitely  known  in  the  case  of  erysipelas  as  in 
tetanus,  diphtheria,  and  some  other  diseases.  Manfredi  and  Traversa^ 
who  were  the  first  to  experiment  with  soluble  products  of  the  cocci,  were 
able  to  produce  only  transitory  nervous  symptoms.  Achalme  had  a 
similar  experience.  Roger  thought  he  obtained  a  soluble  toxic  substance 
from  erysipelas  cultures,  the  action  of  which  was  not  in  proportion  to 
the  dose  employed.  Roger  asserted  that  by  heating  this  substance  at 
110°  C.  it  acquired  vaccinating  qualities.  Courmont^  holds  that  the 
streptococcus  produces  a  slowly  acting  predisposing  substance,  with  last- 
ing eiFects,  but  one  that  acts  indirectly.  Brieger  and  Wassermann^ 
found  the  urine  in  a  case  of  erysipelas  with  nephritis  very  fatal  to 
mice.  Stern  ^  found  that  the  serum  of  vesicles  in  cases  at  the  height 
of  the  disease  was  much  more  fatal  to  mice  than  blood  serum  of  normal 
subjects. 

Numerous  experiments  in  the  treatment  of  malignant  disease  by 
injections  of  erysipelas  or  streptococcus  toxins  have  shown  that  the 
serums  or  filtrates  usually  produce  the  general  symptoms  of  erysipelas. 
The  experiments,  however,  have  added  little  to  our  knowledge  of  the 
erysipelas  poison. 

Although  the  streptococcus  is  the  cause  sine  qua  non  of  erysipelas,  it 
is  evident  there  must  be  other  factors.  First  among  these  is  individual 
predisposition,  the  real  nature  of  w^hich,  however,  we  do  not  yet  under- 
stand. That  the  various  causes  of  temporary  or  permanent  weakness 
of  the  tissues  favor  the  occurrence  of  the  disease  we  can  easily  believe. 
So  alcoholism,  exposure,  overwork,  exhausting  disease,  even  hunger 
and  fatigue,  come  in  play. 

A  very  important  factor  is  the  existence  of  a  solution  of  continuity 
of  the  skin  or  a  mucous  membrane.  Operations,  wounds  of  all  kinds, 
accidental  lesions,  injuries  received  at  post-mortem  examinations,  acne 
and  other  skin  diseases,  sores  or  abrasions  of  the  eye,  mouth,  nose,  or 
pharynx,  boring  the  lobe  of  the  ear  for  earrings,  operation  wounds  of 
the  nose,  throat,  or  mouth,  cautery  wounds,  tracheotomy  incisions, 
leech  bites,  the  umbilical  cord  or  stump,  the  uterus  post-partum,  may 

^  Berne  de  Med.,  1890,  No.  10,  p.  843.  ^  Qhariie  Annalen,  Bd.  xvii. 

^  Congress  fiir  innere  Med.,  xii.  p.  286. 


ETIOLOGY  AND  PATHOLOGY.  455 

i'lirnisli  the  jxtints  oi"  entrance  of  tlic  ^cniis.  The  old  division  of  ery- 
sipelas into  traunititic  or  surgical  and  non-traninatic  ("  idio])atliic  ")  or 
medieul  ery8ij)elas  is  i'ullinii;  into  deservetl  disnse,  or  when  used  at  all 
the  terms  are  applied  in  a  different  sense  from  the  original  one.  In  the 
old  sense  idiopathic  cases  were  due  to  an  internal  alteration  becoming 
localized  in  the  skin,  surgical  cases  to  the  entrance  of  a  "  contagium." 
It  is  reasonable  to  sup[)ose  in  many  cases  that  even  if  no  wound  can  be 
seen  there  is  nevertheless  one  present,  however  small,  in  the  skin  or  a 
neighboring  mucous  membrane  (throat,  nose).  We  must,  however, 
admit  that  diminished  vitality  of  the  covering  epithelium  may  suffice 
for  the  entrance  of  the  germ  without  solution  of  continuity,  or  that  in 
certain  circumstances  infection  may  take  place  through  physiological 
wounds,  such  as  the  tonsils.  For  such  cases  the  term  "  cryptogenetic  " 
is  preferable  to  "medical"  or  "idiopathic."  From  what  Ave  now  know 
of  the  bacteria  of  erysipelas  we  may  suppose  that  the  organisms  are 
often  present  in  or  on  the  body,  but  lack  the  assisting  causes  necessary 
for  the  development  of  the  process.  Among  these  causes  may  be  men- 
tioned putrefaction  or  the  presence  of  certain  micro-organisms  as  already 
mentioned. 

Disturbances  of  the  circulation  around  the  point  of  entry  are  im- 
portant assisting  causes.  This  has  long  been  known  to  clinicians  and 
has  been  demonstrated  experimentally.  Roger  ^  found  that  when  strep- 
tococci were  inoculated  into  both  ears  of  rabbits  and  the  superior  cer- 
vical ganglion  of  one  side  destroyed,  the  local  reaction  was  favored  on 
that  side.  He  also  found  that  section  of  a  sensitive  nerve  assisted  the 
infection,  Aprojws  of  this,  Guinon^  raises  the  interesting  question 
whether  nervous  affections,  such  as  hysterical  hemiansesthesia,  ex- 
ophthalmic goitre,  etc.,  have  any  effect  on  the  course  of  erysipelas. 
Ochatin^  and  Von  Lingelsheim*  varied  these  experiments,  producing 
hypergemia  by  section  of  nerves,  and  also  by  the  use  of  collodion  or 
adhesive  plaster  and  injecting  cultures  of  erysipelas  cocci.  They  found 
not  only  that  the  process  was  more  severe  in  the  hypersemic  ear,  but 
that  even  cultures  of  mild  virulence  could  produce  severe  lesions. 

Filehne^  has  shown  that  by  raising  the  temperature  of  inoculated 
animals  the  infection  runs  a  more  rapid  and  more  favorable  course. 

Contagion,  or  the  acquisition  of  the  disease  from  another  known 
case,  does  not  occupy  as  important  a  position  in  regard  to  erysipelas  as 
it  did  in  the  preantiseptic  days.  In  fact,  in  surgical  wards  now  the 
disease  is  hardly  ever  seen  to  spread,  and  when  it  does  some  error  in 
technique  can  usually  be  discovered.  It  has  been  thought  that  erysipelas 
is  contagious  in  the  sense  that  it  may  be  acquired  "  through  the  air." 
This  is  possibly  only  when  the  germs  themselves  are  transported  in  that 
medium,  and  its  actual  occurrence  is  always  doubtful.  An  interesting 
case  of  indirect  contagion,  which  also  illustrates  the  resistance  of  the 
organisms,  is  reported  by  Stumpf.*"  A  woman  had  a  boy  infant,  born 
in  1888.  He  acquired  erysipelas  and  died.  In  1889  a  girl  child  Avas 
born  and  remained  healthy.     In  1890  another  boy  was  born.     He  was 

^  Comptes  rendus  de  la  Societe  de  Bioloc/ie,  1890,  p.  222. 

^  Traite  de  Medecine,  tome  ii.  ^  Arch,  de  Med.  exper.  et  d'Anat.  path.,  iv.  2. 

*  Zeitschrift  fib-  Hygiene,  xii.  ^  Proc.  Physiolog.  Soc,  Cambridge,  Aug.  11,  1894. 

^  Deutsche  med.  Woch.,  March  17,  1892,  p.  231.' 


456  ERYSIPELAS. 

washed,  and  tlie  shirt  worn  by  the  first  child,  which  had  not  been  used 
in  the  mean  time,  was  put  on  him.  Thirteen  days  later  he  developed 
erysipelas,  with  a  relapse  and  ultimate  recovery. 

Erysipelas  is  influenced  to  a  certain  extent  by  atmospheric  condi- 
tions. In  this  country  it  is  most  frequent  in  the  early  spring.  Low 
temperature  and  moisture  and  rapid  changes  in  temperature  aid  in  its 
production.  According  to  the  investigations  of  Anders,^  the  number 
of  cases  increases  from  August  to  April  (in  Philadelphia),  and  then 
decreases.  One  half  of  all  the  cases  occur  in  February,  March,  April, 
and  May.  These  relations  are  not  always  the  same  in  other  places  and 
times. 

Erysipelas  is  most  frequently  observed  in  early  middle  life. 

Notwithstanding  the  greater  exposure  to  wounds  on  the  part  of  men, 
the  temporary  predisposition  furnished  by  the  puerperal  condition 
makes  the  relative  proportion  of  the  sexes  less  unequal  than  might  be 
supposed.  Anders  puts  the  proportion  of  men  and  women  affected  as 
three  to  two. 

Pathological  Anatomy. — Even  during  life  the  lesion  of  ery- 
sipelas exhibits  the  cardinal  signs  of  inflammation.  After  death  the 
redness  and  swelling  are  diminished,  especially  the  former.  The  micro- 
scopic alterations  in  the  tissues  have  been  carefully  studied  in  pieces 
excised  during  life,  controlled  by  the  examination  of  experimental  le- 
sions in  animals.  Our  knowledge  of  the  changes  is  due  largely  to 
the  investigations  of  Vulpian,  Volkmann  and  Steudener,  Renaut,  Till- 
manns,  Ranvier,  Cornil,  and  others,  though  the  researches  of  Fehleisen 
have  thrown  a  light  on  them  which  former  investigators  could  not  give. 
Recently  Unna  has  published  the  results  of  his  observations,  which  fill 
out  important  lacunee.  Following  Fehleisen,  the  lesions  are  described 
as  in  three  zones.  The  outer  zone  is  beyond  the  raised  margin  of  the 
erysipelatous  area.  Microscopically,  this  zone  shoAvs  masses  of  cocci  in 
the  lymph  spaces,  but  no  alterations  in  the  tissues.  This  zone  passes 
into  the  middle  one,  corresponding  to  the  advancing  margin  of  inflam- 
mation. It  is  characterized  by  the  evidences  of  inflammatory  reaction 
in  the  tissues.^  The  vicinity  of  the  streptococcus  colonies  contains 
numerous  small  cells,  and  some  of  these  cells  contain  cocci.  In  the 
third  zone  cocci  are  few  or  absent,  but  there  are  traces  of  inflammation 
in  the  stage  of  retrogression  or  absorption.  According  to  Unna,^  the 
process  affects  the  skin  and  subcutaneous  tissue  simultaneously,  but 
heals  more  rapidly  in  the  skin,  and  seldom  reaches  the  height  it  does 
in  the  deeper  tissue.  In  the  subcutaneous  tissue  he  finds  that  the  cocci 
are  not  confined  so  especially  to  the  outer  zone  as  in  the  skin — a  differ- 
ence which  he  suggests  is  due  to  more  favorable  conditions  for  the 
growth  of  the  cocci  in  the  deeper  tissue.  This  corresponds  to  a  more 
severe  process  in  the  subcutaneous  tissue. 

In  the  inflammatory  areas  vascular  changes  are  marked.  The  veins 
and  capillaries  are  distended  with   blood.      The    leucocytes    are    not 

^  Journal  of  the  American  Medical  Association,  July  22,  1893. 

^  In  erysipelas  lymphangitis  is  jiart  of  the  process,  yet  lymphangitis  and  erysipelas 
are  not  identical,  either  clinically,  anatomically,  or  etiologically.  Lymphangitis  may  be 
produced  by  various  kinds  of  bacteria,  as  shown  by  the  researches  of  Fischer  and  Levy 
(Deufsches  Archivfilr  C'hirurgie,  xxxvi.,  1893,  H.  4  u.  5). 

^  Hislopathologie  der  Hautkrankheiten,  Berlin,  1894. 


VATlloLoaiCAL  ANATOMY.  457 

arranged  especially  aloii*;-  the  walls  iA'  the  vessels,  hut  (»ften  form  small 
jii'oups  in  the  vessels.  Thev  are  distinetly  increased  in  these  parts.  The 
caj)illariGs  often  contain  rows  of  leucocytes,  thouj^h  according  to  Unna 
diiipedesis  is  not  a  constant  occurrence.  The  arteries  are  dilated  in 
some  places,  and  ix'sides  an  increased  ])ro])oition  of  lencocvtes  contain 
much  ('oaii'ulati'd  tihrin.  In  other  places  the  arteries  are  narrow,  hut 
j)luuii('d  with  lihrinous  thromhi,  containiuii:  leucocytes.  In  some  of  the 
veins  (.-eutral  thrombi  are  to  be  seen,  evidently  })ropagated  from  those  in 
the  arteries  or  capillaries.  There  is,  then,  a  paralysis  of  the  vessels, 
especially  of  the  veins,  with  slowing  of  the  current,  adhesion  of  leuco- 
cytes, and  intravascular  formation  of  tibrin,  es})ecially  in  the  arteries. 

The  Ivmph  spaces  and  lymph  vessels  are  distended  with  lymph  con- 
taining streptococci  in  chains  and  masses.  The  leucocytes  are  found  in 
greater  numbers  as  the  process  advances.  In  many  places  in  the  lymph 
vessels  there  are  firm  white  thrombi. 

The  vascular  changes  are  by  no  means  the  only  ones  of  importance. 
The  connective  tissue  breaks  down  and  liquefies,  or  becomes  fibrillated 
or  converted  into  a  pnlpy  mass.  The  elastic  tissue  degenerates.  The 
spindle  cells  of  the  skin  break  down  and  their  nuclei  disappear.  The 
striped  and  smooth  muscular  fibres  of  the  skin  undergo  a  fate  similar  to 
the  other  tissues. 

The  epithelial  tissues  suffer  also.  The  swelling  of  the  papillse  loosens 
their  connection  with  the  overlying  tissue.  When  the  papilhe  break 
down  the  epithelium  follows,  the  nuclei  lose  their  staining  capacity,  the 
protoplasm  becomes  indistinct  and  stains  less  readily.  According  to 
Unna,  the  epithelial  cells  do  not  swell,  but  the  degenerated  and  partly 
necrotic  epithelium  is  raised  in  tofo  from  the  papillary  layer,  forming 
thus  blebs  or  vesicles.  In  the  contents  of  the  vesicles  cocci  are  rare  in 
the  beginning,  but  fibrin  and  leucocytes  are  always  present.  Later, 
bacteria  of  various  kinds  can  be  found  in  the  vesicles.  Sometimes  the 
leucocytes  are  so  abundant  in  the  contents  of  the  vesicles  that  the  liquid 
is  turbid  or  opaque,  or,  in  other  words,  purulent.  Occasionally  vesicu- 
lar degeneration  of  the  epithelial  cells  takes  place,  as  described  by  Cor- 
nil,  but  this  is  not  the  cause  of  the  gross  vesicular  lesions,  which  are 
due  to  the  oedematous  infiltration  of  the  papillary  layer  of  the  skin 
already  described. 

In  contrast  to  the  marked  changes  in  the  surface  epithelium,  that  of 
the  sweat  glands  and  hair  follicles  is  often  little  or  not  at  all  affected. 
In  severe  cases  the  hair  follicles  undergo  changes  similar  to  those  in  the 
surface  epithelium. 

Erysipelatous  inflammation  of  the  skin  may  be  described  as  a  sero- 
fibrinous inflammatioM,  but  it  may  and  sometimes  does  pass  on  into  a 
suppurative  or  necrotic  form. 

In  the  deep  tissues  erysipelas  causes  changes  of  a  different  kind, 
especially  when  the  subcutaneous  tissues  are  well  developed.  The  lymph 
vessels  and  lymph  spaces  in  the  coats  of  the  large  vessels  in  the  septa 
of  the  adipose  tissue  form  the  paths  of  the  cocci,  which  are  present  in 
these  parts  in  enormous  numbers.  Usually  the  cocci  do  not  penetrate 
farther  than  the  adventitiae  of  the  vessels.  The  vessels  themselves  do 
not  contain  thrombi,  as  do  those  in  the  skin,  but  the  fat  lobules  and 
their  capillaries  contain  large  masses  of  fibrin.     There  are  also  large 


458  ERYSIPELAS. 

numbers  of  leucocytes  which  break  down,  forming  pus  in  the  septa  of 
the  fat  tissue.  This  process  often  extends  deep  into  the  muscular 
tissue. 

The  process  in  the  deeper  tissue  is  therefore  a  fibri no-purulent  inflam- 
mation, although  not  recognizable  clinically  as  purulent.  In  fact,  in  the 
majority  of  cases  which  seem  to  be  su])erficial  the  deep-lving  pus  is 
absorbed  without  being  discovered.  It  is  when  the  pus  makes  itself 
known  clinically  that  the  term  phlegmonous  may  be  applied.  (In  addi- 
tion to  this  there  is,  of  course,  occasional  phlegmon  formation  as  the 
result  of  a  complication  to  be  mentioned  later.) 

In  the  healing  of  erysipelas  the  cocci  die,  and  they  as  well  as  the  leuco- 
cytes and  thrombi  are  removed  from  the  areas  in  which  they  were.  As 
blood  begins  to  flow  through  the  vessels  the  epithelium  is  renew^ed, 
forming  a  layer  which  desquamates  at  first,  but  ultimately  becomes 
permanent.  Finally  the  muscles,  connective  tissue,  and  elastic  fibres 
are  regenerated. 

As  is  well  known,  erysipelas  is  one  of  the  diseases  in  which  Metch- 
nikoff  asserted  the  importance  of  phagocytosis.  Perhaps  most  investi- 
gators, however,  consider  that  in  ervsipelas  phagocytism  in  the  manner 
originally  described  by  Metchnikoff  is  not  so  important  as  the  latter 
claimed.  That  the  leucocytes  frequently  contain  cocci,  in  different 
stages  of  degeneration  very  often,  is  admitted,  but  the  general  belief  is 
that  the  cocci  have  been  seriously  affected  before  becoming  the  prey  of 
the  phagocytes.  In  the  healing  of  erysi])elas  macrophages,  containing 
leucocytes,  fibrin,  cocci,  and  unrecognizable  debris,  can  be  seen. 

The  earliest  claims  to  the  discovery  of  germs  of  erysipelas  include 
accounts  of  bacteria  in  the  blood.  Later  observers  are  unanimous  in 
holding  that  as  a  general  thing  the  cocci  do  not  enter  the  blood  circula- 
tion, notwithstanding  the  fact  that  they  are  frequently  carried  con- 
siderable distances  in  the  lymph  vessels.  Even  if  they  enter  the  blood 
by  Avay  of  the  lymphatics,  they  must  do  so  so  rarely  and  in  such  small 
numbers  that  they  are  disposed  of  in  the  blood  without  setting  up  other 
processes. 

That  the  cocci  can,  and  in  rare  cases  do,  enter  the  general  circulation 
was  shown  first  by  the  observations  of  Von  Noorden  and  PfuhL 
Sudakow  ^  examined  5  cases  of  ervsipelas  with  reference  to  this  point. 
He  found  cocci  in  2  cases  in  both  blood  and  sweat.  In  one  case  the 
blood,  in  another  the  SAveat  only,  contained  the  organisms.  Aclialme " 
was  unable  to  cultivate  organisms  from  large  quantities  of  l:)lood 
in  18  cases  of  ervsipelas  of  moderate  severity.  On  the  other  hand^ 
in  .3  fatal  cases  he  was  able  to  cultivate  them  from  the  blood  (in  the 
heart),  and  in  2  cases  he  found  cocci  in  the  urine. 

The  probability  of  the  cocci  setting  up  metastatic  processes  by  way 
of  the  blood  depends  partly  on  their  virulence,  partly  no  doubt  on  the 
numerous  accidents  to  which  they  become  exposed  when  they  leave  the 
lymph  spaces,  in  the  plasma  or  in  the  bodies  of  the  leucocytes,  and  are 
carried  toward  the  blood  circulation.  Here  they  are  either  disposed  of  or, 
under  favorable  circumstances,  produce  lesions  which  will  be  considered 
under  Complications  (p.  467).  A  diminution  of  the  red  blood  corpuscles 
in  the  active  stage  of  the  disease  was  noticed  by  early  investigators  in 

^  Centralblatf  fiJ.r  Bakteriologie  u.  Parasitenkimcle,  1893,  ii.  p.  817.         ^  Loc.  cit.,  p.  236. 


SYMPTOMS.  4-59 

that  field,  but  tloes  not  .scom  to  be  constant.  An  increase  of  leucocytes, 
especially  the  polynuclear  neutrophile  eelLs,  amounting  to  as  much  as 
two  or  three  times  the  normal,  is  perhaps  a  constant  occurrence.  An 
increase  of  lihrin  has  l)een  observed  by  many  since  it  was  first  noticed 
by  Andral  and  Gavarvet. 

Inflammation  of  the  r('i;ionary  lymphatic  vessels  and  glands  occurs 
in  the  course  of  erysipelas  as  part  of  the  disease,  but  is  marked  only  in 
cases  of  unusual  severity  or  as  a  complication.  Occasionally  lymph 
glands  some  distance  from  the  skin  lesion  are  affected,  sometimes  very 
early  in  the  disease.  Other  anatomical  alterations  play  a  subordinate 
part  in  erysipelas,  and  ^vill  be  considered  under  the  head  of  Com- 
plications (p.  467). 

Symptoms. — The  stage  of  incubation  of  erysipelas  is  either  without 
symptoms  or  has  those  common  to  many  other  infectious  diseases — 
malaise,  anorexia,  lassitude ;  in  some  cases  an  indefinite  feeling  of 
exhilaration,  perhaps  from  slight  fever,  can  sometimes  be  recalled  by 
the  patient.  The  duration  of  this  stage  is  variable.  According  to 
observations  of  Widal  and  ]S[etter  and  of  Echalier^  in  patients  who 
acquired  erysijjelas  by  exposure  to  other  known  cases  the  incubation 
was  respectively  two,  six,  ten,  thirteen,  and  fourteen  days.  In  Fehlei- 
sen's  experiments  on  men  the  duration  varied  from  fifteen  to  seventy- 
two  hours,  which  corresponds  to  the  period  usual  in  animal  inoculations 
(one  to  three  days).  Cases  without  a  discoverable  wound  sometimes 
seem  to  have  a  longer  period  of  incubation  than  others. 

The  first  striking  symptom,  which  is  rarely  absent,  is  a  chill. 
Usually  the  chill  is  sudden  and  severe,  resembling  the  chill  of  malarial 
intermittent  fever  or  of  croupous  pneumonia  or  the  severe  chills  of 
septic  infection,  to  which,  indeed,  the  erysipelatous  chill  has  a  close 
affinity.  It  may  last  for  only  a  few  minutes  or  from  one  to  two  hours. 
The  usual  duration  of  the  chill  is  less  than  half  an  hour,  with  cold 
skin,  cyanosis  of  the  lips  and  extremities,  chattering  of  the  teeth,  and 
trembling.  From  the  severity  and  the  duration  of  the  chill  an  idea  of 
the  severity  of  the  disease  may  be  formed. 

During  the  chill  nausea  and  vomiting  usually  occur.  The  vomitus 
is  not  peculiar,  but  when  vomiting  is  severe  bile  is  often  present,  and  so 
keeps  up  the  tendency  to  perpetuate  the  term  "  bilious  erysipelas." 

After  the  chill,  or  sometimes  shortly  before  it,  the  temperature  rises, 
usually  rapidly,  reaching  102°  F.  or  more  according  to  the  severity  of 
the  case.  The  pulse  is  frequent  in  proportion  to  the  rise  of  temperature, 
but  full  and  strong.  Nausea  and  a  feeling  of  discomfort  in  the  epigas- 
trium, with  loss  of  appetite,  continue.  The  tongue  is  slightly  swollen, 
with  a  yellow  coat.  There  is  continued  malaise.  Headache  is  a  common 
symptom.  With  some  or  all  of  these  symptoms  a  day  or  more  may 
elapse  before  the  disease  in  the  skin  becomes  visible.  It  was  this  period 
between  the  appearance  of  the  general  symptoms  and  those  in  the  skin 
that  seemed  so  convincing  of  the  dyscrasic  nature  of  the  disease  at  a 
time  M'hen  the  nature  of  infection  was  so  much  less  understood  than  it 
is  now. 

During  this  period  the  diagnosis  is  usually  in  doubt,  or  if  there  are 
marked  cerebral  symptoms  the  case  may  be  considered  one  of  typhoid 

1  Paris  Thesis,  1890. 


460  ERYSIPELAS. 

fever.  Occasionally  careful  examination  or  the  jjatient's  own  account 
discloses  tenderness  or  swelling  of  the  lymphatic  glands  supplied  by  the 
part  aifected.  In  some  cases  tenderness  of  the  lymphatics,  less  fre- 
quently swelling,  precedes  the  inflammation  of  the  skin  by  several  days. 
In  cases  beginning  in  the  nose  epistaxis  often  occurs,  either  spontan- 
eously or  from  blowing  the  nose. 

Before  the  inflammation  appears  the  patient  almost  always  has  a 
.sensation  of  fulness  or  tension,  sometimes  a  prickling  or  itching  in  the 
part  aifected.  When  the  infection  takes  place  in  the  nose  there  may  be 
an  unusual  sense  of  fulness  and  pain,  beginning  very  soon  after  the 
chill  and  followed  by  the  usual  symptoms  of  coryza.  When  the  inflam- 
mation begins  in  a  visible  w^ound  the  latter  sometimes  becomes  paler 
before  the  special  process  appears. 

The  characteristic  erysipelatous  lesion  varies  in  color  from  a  yellow^- 
ish  pink  to  a  bright  or  deep  red  color.  In  anaemic  or  cachectic  persons 
the  color  is  paler.  Pressure  causes  the  color  to  pale,  showing  a  yellow- 
ish tint  in  the  anaemic  parts,  but  it  immediately  resumes  its  previous 
tint  when  the  pressure  is  removed.  The  surface  of  the  skin  is  usually 
shining,  V>ut  finely  or  coarsely  granular  according  to  the  texture  of  the 
skin  in  the  part  affected.  The  appearance  of  the  surface  has  been  well 
compared  to  that  of  an  orange.  The  characteristic  feature  of  the  ery- 
sipelatous patch  is  the  abrupt  margin  by  which  it  is  sharply  marked  off 
from  the  sound  skin.  The  distinctness  of  the  margin  and  the  elevation 
of  the  inflamed  surface  vary  in  different  cases,  depending  partly  on  the 
thickness  of  the  skin.  The  margin  sometimes  is  regular,  sometimes  zig- 
zag, and  again  not  at  all  distinct.  This  is  especially  so  when  erysipelas 
affects  skin  previously  the  seat  of  an  ordinary  inflammation  or  skin 
which  is  rugous,  as  that  of  the  scrotum.  Sometimes  the  margin  can  be 
recognized  more  easily  by  touch  than  by  sight.  An  additional  aid  to 
its  detection  is  that  by  examining  the  affected  area  through  a  glass  plate 
with  pressure.  This  method  of  examination,  "  diascopy "  of  Unna,^ 
€an  be  practised  with  a  microscopic  slide  or  a  watch-glass,  or  by  the 
more  complicated  method  of  Liebreich,  called  by  him  "  phaneroscopy." 

The  affected  skin  feels  hard,  brawny,  like  congealed  skin  or  that  of 
a  cadaver.  It  cannot  be  pinched  up  in  a  fold  except  with  difficulty. 
Pressure  increases  the  pain.  The  inflamed  part  not  only  gives  the  sub- 
jective sensation  of  heat,  but  is  actually  warmer  than  the  normal  skin. 

On  the  surface  of  the  inflamed  area,  except  in  the  mildest  cases, 
vesicles  or  bullae  appear  as  the  process  reaches  its  height.  By  coales- 
cing these  form  large  areas  more  or  less  elevated,  filled  with  a  fluid 
which  is  at  first  clear,  later  turbid.  The  epidermis  over  the  vesicles 
easily  becomes  broken,  and  the  serum,  often  mixed  with  blood  or  pus, 
dries  on  the   surface. 

The  erysipelatous  patch  enlarges  by  spreading  in  waves  or  irregular 
lines,  "  like  an  oil  drop  on  paper."  The  extension  is  rarely  symmetri- 
cal or  even  on  all  sides,  but  may  spread  on  one  side  while  remaining 
stationary  or  receding  on  others.  The  spreading  takes  place  by  stages. 
Sometimes  it  can  be  seen  that  the  process  is  arrested  tempor- 
arily w^here  the  skin  is  firmly  attached  to  the  deep  tissues,  as  at  the 
naso-labial  fold,  the  margin  of  the  hairy  scalp,  Poupart's  ligament,  etc. 

1  Unna,  Berliner  klin.  Wochenschr.,  No.  42,  1893. 


SYMl'TUMS.  4(U 

The  swellini»:  involves  not  only  the  skin,  but  also  the  subcutaneous 
tissue,  thus  adclint>;  greatly  to  the  detbnnity.  Tlie  ju'ocess  is  greatest 
where  the  skin  is  loosely  attaelied,  as  in  the  eyelids,  li])s,  scrotiun,  and 
external  genitals.  The  (edematous  swelling  in  these  parts  adds  much 
to  the  distortion   eharaeteristie  of  the  (^lisease. 

Tile  tenij)erature,  which  rises  rapidly  after  the  chill,  reaching  a  height 
of  104°  or  105°,  remains  elevated  as  long  as  the  infianimatory  process 
is  active.  The  temperature  is  usually  remittent,  with  a  morning  fall 
of  one  or  more  degrees.  Usually  the  remissions  are  more  marked  in 
mild  or  favorable  cases,  and  in  these  the  temperature  may  be  inter- 
mittent. (This  has  no  necessary  relationship  with  malarial  infection, 
though  it  was  formerly  looked  on  as  showing  a  malarial  origin  of  the 
disease.)  On  the  other  hand,  very  severe  cases  may  show  marked 
remissions,  as  in  one  under  my  observation  in  Avhich  the  temperature 
showed  a  daily  diiference  on  successive  days  of  3°,  3.4°,  5°,  5.5°,  4.2°, 
4.6°  F.  Complications,  especially  internal  complications,  have  a  tendency 
to  increase  the  temperature,  and  relapses  are  almost  always  preceded  by 
a  sadden  rise.  If  death  occurs  in  hyperpyrexia,  the  temperature  some- 
times continues  to  rise  post-mortem.  In  rare  cases,  sometimes  otherwise 
severe,  there  is  no  elevation  of  temperature  at  all — afchrlle  eri/sipcld^:. 

The  pulse  follows  the  course  of  the  temperature  during  the  height 
of  the  disease,  with  certain  limitations.  In  cachectic  persons  it  is  rela- 
tively frequent.  In  cases  with  jaundice  it  has  been  observed  to  be 
relatively  slow. 

The  other  symptoms  are  usually  severe  in  proportion  to  the  eruption 
and  fever.  Prostration,  loss  of  appetite,  coated  tongue,  and  constipa- 
tion are  almost  always  present.  In  severe  cases  delirium  is  common, 
usually  of  a  mild  kind.  In  others  there  is  apathy,  stupor,  or  even 
coma.  In  the  most  severe  cases  the  typhoid  condition  comes  on,  with 
sordes  on  the  lips  and  tongue — the  latter  being  dry — trembling,  delirimn 
and  sometimes  convulsions  or  coma. 

The  urine  usually  contains  albumin,  hyaline  casts,  and  increased 
numbers  of  leucocytes,  and  sometimes  red  corpuscles  and  renal  epithe- 
lium. 

At  the  height  of  the  disease  the  local  symptoms  are  marked.  As 
the  redness  and  swelling  invade  new  areas,  with  their  characteristic  sub- 
jective sensations  of  intolerable  tension  and  itching,  the  parts  earlier 
affected  become  pale  and  less  tense,  although  subcutaneous  inflammation 
and  oedema  cause  the  swelling  to  remain  for  some  time.  The  duration 
of  the  swelling  and  redness  in  any  one  part  varies  much  in  ditferent 
cases.  Sometimes  the  whole  process  is  over  in  a  few  hours ;  again,  it 
may  take  a  week  or  more  to  reach  the  stage  of  resolution,  even  without 
complications. 

In  recovery  the  swelling  subsides,  the  temperature  falls,  the  pidse 
often  becomes  abnormally  infrequent.  The  gastric  symptoms  subside, 
appetite  improves,  and  convalescence  is  usually  rapid  in  uncomplicated 
cases.  The  fall  of  temperature  often  precedes  the  other  symptoms  of 
recovery.  It  is  nsually  rapid  and  marked  in  cases  which  recover 
promptly,  slow  or  irregular  in  others.  Yet  there  are  exceptions  to  this, 
and  severe  relapses  or  complications  sometimes  follow  in  cases  with 
marked  crises.     The  losses  of  epidermis  from  vesicles,  scratching,  or 


462  ERYSIPELAS. 

treatment  are  restored.  Desquamation,  usually  in  fine  scales,  sometimes 
in  patches,  continues  for  some  time.  The  affected  skin,  especially  that 
of  the  nose  and  face,  often  remains  hypersemic  for  a  long  time.  The 
hair  falls  out  when  the  scalp  has  been  aifected,  but  soon  grows  again. 
The  new  hair  is  apt  to  be  curled  or  darker  than  before,  but  soon  resumes 
its  former  appearance.  In  parts  where  the  skin  is  loose,  as  in  the  eye- 
lids, oedema  is  likely  to  persist  for  some  time. 

Recurrences. — Erysipelas  is  one  of  the  acute  diseases  in  which  recur- 
rence takes  place — a  fact  which  gave  much  trouble  to  those  who  sup- 
posed that  infection  always  produced  immunity,  but  at  the  same  time 
wished  to  include  erysipelas  among  the  exanthemata.  Relapses  may 
occur  in  convalescence,  beginning  in  the  same  point  as  the  original  dis- 
ease or  elsewhere.  They  are  usually  not  so  severe  nor  of  as  long  dura- 
tion as  the  primary  attack,  but  they  do  not  always  become  successively 
milder,  as  has  been  supposed.  Attacks  occurring  after  long  intervals 
are  also  likely  to  be  less  severe  than  the  first  one,  thus  giving  support 
to  the  idea  that  a  sort  of  immunity  is  produced,  but  to  this,  too,  there 
are  exceptions. 

Some  individuals  seem  extremely  disposed  to  recurring  erysipelas,  as 
in  the  subjects  of  so-called  menstrual  erysipelas,  first  described  by  Hoff- 
mann in  the  last  century.  Hirtz  and  Widal  ^  have  reported  the  case  of 
a  woman  of  fifty  who  had  erysipelas  every  month  at  the  time  the  menses 
had  usually  occurred.  As  an  example  of  the  number  of  recurrences 
which  can  take  place,  the  same  observers  report  the  case  of  a  woman 
who  for  four  years  was  free  from  the  disease  only  two  months.  Admit- 
ted to  hospital  for  nephritis,  she  had  in  the  next  three  months  twenty 
distinct  attacks  of  erysipelas  on  the  face  and  thighs.  The  latter  began 
in  a  chronic  eczema.  Some  of  the  attacks  were  afebrile ;  in  one  the 
temperature  was  above  40.5°  C.  for  a  week.  The  blood  contained  viru- 
lent streptococci  in  both  mild  and  severe  attacks.  Critzman  ^  reports 
the  case  of  a  woman  who  from  the  age  of  thirty  to  thirty-five  had  ery- 
sipelas almost  regularly  at  the  time  of  menstruation.  A  piece  of  excised 
skin  in  one  attack  showed  streptococci  of  Fehleisen. 

Recurrences  may  be  explained  by  a  retention  of  the  germs  in  the 
body  in  a  latent  form,  which,  according  to  experiments  in  vitro,  may 
last  for  long  periods.  The  following  observations  show  a  not  infrequent 
mode  of  recurring  erysipelas  :  A  man  with  an  old  wound  of  the  right 
orbit  was  admitted  to  my  wards  with  severe  angina.  On  the  fourth 
day,  M'hen  the  angina  had  subsided  and  the  temperature  reached  99°  F., 
the  patient  had  a  chill,  with  a  rise  of  temperature,  soon  followed  by 
severe  erysipelas  of  the  face,  beginning  around  the  orbital  wound.  The 
temperature  reached  105°  F.  every  day  for  four  days,  notwithstanding 
full  doses  of  salol,  and  then  fell  slowly  with  disappearance  of  the  ery- 
sipelas. A  purulent  discharge  from  the  right  frontal  sinus  was  treated 
locally  in  the  eye  ward.  Two  days  after  complete  disappearance  ery- 
sipelas began  again,  but  subsided  rapidly  under  the  use  of  ichthyol. 
Six  days  later  another  attack  came  on,  beginning,  as  had  the  others,  at 
the  wound.  This  attack  was  quite  severe  and  lasted  a  week.  Ichthyol 
was  used  as  before.     I  then  had  an  opening  made  into  the  left  frontal 

1  La  Bulletin  medicale,  1891,  No.  101,  p.  1163. 

2  Arch.  gen.  cle  Med.,  1892,  Jan.,  p.  24. 


SYMPTOMS.  463 

.sinus,  with  penuaueiit  drainage  and  tlu)rou<;li  irrigatioa,  and  tlie  patient 
made  a  eomplete  recovery. 

Varkitio)it<  in  the  Cour,se  of  fhc  Lord!  LcHion. — The  erysipelatous 
lesion  varies  much  in  its  course,  a|)pearance,  and  intensity  in  different 
cases.  Various  terms  have  been  applied  to  those  varieties,  most  of" 
which  suffer  from  havint;'  been  used  in  different  senses  by  different 
writers.     I  shall   mention  only  the  commonest. 

The  term  fixed  erysipelas  is  given  by  some  writers  to  mild  cases 
which  remain  localized  in  the  vicinity  of  the  point  of  origin.  Others 
applv  the  same  term  to  an  inflammation  whi(;li  occurs  especially  around 
chronic  ulcers.  This  latter  is  not,  as  a  rule,  identical  with  true  ery- 
sipelas. 

JIi(/r((ti)i</,  aiiibidaiit,  or  ivanderinr/  erysipelas  is  spoken  of  when  the 
disease  tends  to  spread  by  continuity  from  the  point  of  origin  in  one  or 
more  directions.  This  is  the  typical  course  of  the  disease,  but,  as  the 
extent  varies  greatly,  some  writers  apply  the  term  only  when  the  disease 
affects  large  territories,  receding  at  one  end  while  it  advances  at  the 
other.  The  progress  of  the  disease  sometimes  follows  definite  lymphatic 
paths,  but  often  no  such  course  can  be  recognized.  Sometimes  it  fol- 
lows the  lines,  called  Langer's,  of  the  minute  fissures  of  the  epidermis. 

Erratic  erysipelas  is  a  term  given  by  many  to  a  form  resembling  the 
one  just  described,  but  differing  in  the  fact  that  the  areas  are  not  con- 
tinuous. Sometimes  several  foci  develop  about  the  same  time.  This  has 
also  been  called  multiple  erysipelas.  Both  this  and  the  preceding  form 
may  affect  parts  in  which  the  eruption  has  wholly  or  partly  subsided. 

Erysipelas  is  sometimes  called  serpiginous  when  the  lesion  is  both  ex- 
tensive and  irregular. 

Variations  in  the  Character  of  the  Local  Lesion. — Erysipelas  varies  in 
intensity  from  a  slight  redness  and  swelling  in  the  outer  layers  of  the 
skin  to  the  most  severe  inflammatory  affection.  Besides  these  degrees 
there  are  certain  varieties  which  need  mention.  In  many  cases  the 
names  given  to  these  are  superfluous,  although  sometimes  convenient  in 
practice. 

(Edematous  erysipelas  is  spoken  of  when  oedema  is  a  predominant 
feature.  This  is  almost  always  the  case  in  certain  parts  of  the  body,  as 
the  scrotum  and  the  eyelids.  It  is  also  likely  to  be  marked  in  the  sub- 
jects of  heart  or  kidney  disease.  In  phlegmonous  and  gangrenous 
erysipelas  oedema  usually  appears  early. 

"  Bullous  or  pemphigoid  erysipelas  only  differs  from  the  ordinary  form 
in  the  greater  size  of  the  vesicular  lesions,  which  occur  in  all  but  the 
mildest  cases. 

Under  the  old  term  white  erysipelas,  formerly  applied  to  the  oedema- 
tons  variety,  Achalme  describes  a  case  in  which  all  the  symptoms  and 
signs  of  erysipelas  were  present  but  redness.  Streptococci  were  found 
in  great  numbers  in  the  deep  lymphatics.  Notwithstanding  Achalme's 
remarks,  it  seems  that  such  cases  have  more  resemblance  to  lymphangitis 
than  to  erysipelas,  although  the  distinction  is  not  a  very  important  one. 

Hemorrhages,  usually  of  small  size,  occur  in  most  cases  of  severe 
erysipelas.  In  some  cases  they  are  so  marked  as  to  lead  to  the  use  of 
the  term  petechial,  hemorrhagic,  or  ecchymotic.  Extensive  hemorrhages 
occur  especially  in  cachectic  persons  and  are  of  bad  prognostic  import. 


464  ERYSIPELAS. 

Juhel-Renoy  ^  gave  the  name  erysipele  a  type  2ietechial  couperosique  to 
certain  cases  which  are  always  severe  and  frequently  fatal. 

In  the  section  on  Pathological  Anatomy  (page  456)  the  fact  was  men- 
tioned that  in  every  severe  erysipelas  suppuration  occurs.  In  most 
cases  suppuration  or  phlegmon  formation  in  the  ordinary  clinical  sense 
does  not  occur.  In  some  cases  suppuration  becomes  manifest  in  differ- 
ent degrees,  so  that  circumscribed  phlegmon  or  abscess,  diffuse  phlegmon, 
or  purulent  oedema  can  be  distinguished.  These  all  fall  under  the  name 
plilegmonous  erysipelas.  Although  these  processes  can  be  produced  by 
the  intensity  of  the  action  of  the  erysipelas  coccus,  they  may  be,  and 
sometimes  are,  due  to  mixed  infection  with  some  other  pyogenic  germ. 
Like  other  suppurative  diseases,  they  are  less  frequent  now  than  formerly. 

The  phlegmonous  complication  usually  develops  in  the  end  of  the 
first  or  beginning  of  the  second  week.  Sometimes  it  develops  slowly 
without  marked  local  signs ;  again,  the  skin  becomes  more  indurated 
and  darker,  the  pain  is  more  severe,  the  lymphatic  vessels  in  the  vicin- 
ity are  red  and  hard,  the  parts  feel  full.  Often  there  are  repeated 
chills,  with  increase  of  fever,  nausea,  and  vomiting,  and  increased  pros- 
tration. As  the  process  continues  the  pain  becomes  less  severe,  but  the 
general  symptoms  are  more  marked,  and  usually  the  common  signs  of 
sepsis  are  present,  including,  in  severe  cases,  the  typhoid  state.  The 
abscesses  may  oj)en  spontaneously,  but  frequently  this  is  delayed,  so  that 
when  an  opening  does  occur  the  quantity  of  pus,  sloughs,  and  debris 
evacuated  is  usually  large.  The  number  of  abscess  foci  may  be  large, 
as  many  as  sixty-nine  having  been  counted  in  a  patient  who  recovered. 

Gangrenous  erysipelas  often  develops  with  the  phlegmonous  variety 
or  aj)pears  as  a  terminal  phenomenon  in  it.  In  some  cases  it  is  no  doubt 
due  to  secondary  infections,  but  it  is  of  most  importance  when  it  occurs 
especially  as  a  primary  affection  in  old  persons,  drunkards,  or  persons 
with  atheroma,  diabetes,  or  chronic  nephritis.  Gangrenous  erysipelas 
occurs  most  frequently  where  the  skin  is  loose,  as  on  the  eyelids,  scrotum, 
and  labia.  In  such  cases  the  skin  soon  becomes  dusky ;  the  vesicles 
which  form  contain  reddish  serum  which  soon  dries,  turning  brown  or 
black.  The  epidermis  itself  often  becomes  black  and  dry.  The  swell- 
ing and  induration  are  often  not  marked.  Usually  sloughs  of  various 
sizes  form  in  all  parts  of  the  affected  skin.  In  a  few  days  these  sepa- 
rate, leaving  ulcers  with  necrotic  surfaces.  In  gangrenous  erysipelas 
general  symptoms  are  severe.  The  typhoid  condition  is  almost  always 
present,  the  pulse  weak  and  irregular.  Death  usually  occurs  in  a  few 
days. 

The  typhoid  condition  is  not  an  unusual  feature  in  severe  erysipelas, 
so  that  the  attempt  to  make  a  special  form  of  the  disease,  typhoid  ery- 
sipelas, is  not  warranted.  The  presence  of  the  symptoms  making  up 
that  condition  is  not  necessarily  of  fatal  augury. 

The  term  bilious  erysipelas  has  been  handed  down  from  a  time  when 
bile  played  a  more  important  part  in  the  causation  of  disease  than  it  does 
now,  and  sometimes  the  bilious  vomiting  of  the  early  stages  leads  to  the 
application  of  the  term.  It  should  be  used,  if  at  all,  for  those  cases  in 
which  there  is  a  marked  "  bilious  "  condition,  with  epigastric  pain,  con- 
stipation, or  diarrhoea,  an  icteric  hue  of  the  skin  and  sclerse,  and  bile 
1  Archives  gen.  de  Med.,  Jan.,  1894. 


ERYSIPELAS   OF  .S77.V7.|/,    llKdIONS.  465 

coloi'iiiii'  matU'i'  in  the  urine.  I'liis  ilcpeiids  on  an  intoxii-atiitn  oi'  an 
inHainniation  involving-  tlic  l)ik'  ducts.  It  is  inijxirtaiit  to  distiniiuisli 
tliis  iVoni  oases  of  ensipelas  coui[)lieated  by  general  sepsis,  in  wliieh  the 
jaundice  is  due  partly  at  least  to  destruction  of  red  blood  corpuscles. 

Erysipelas  of  Special  Regions. —  The  Face. — The  coninionest  and 
at  the  same  time  the  most  important  seat  of  erysipelas  is  the  face.  This 
is  true  esj)eeially  of  "medical"  erysipcslas.  The  predilection  is  readilv 
explained  by  the  i>;reater  exposure  to  wounds  and  also  to  the  miero- 
ori>anisnis.  Corresponding:;  to  the  most  common  seat  of  inoculation,  the 
local  lesion  usually  ap])ears  first  in  or  on  the  nose,  from  which  it  spreads 
in  ditlerent  directions,  and  often  so  symmetrically  that  at  a  certain  stage 
the  area  of  intitimmation  has  a  shape  somewhat  resembling  that  of  a 
butterHy  with  the  wings  spread.  In  mild  cases  it  extends  no  farther 
than  the  middle  of  the  cheeks  and  is  limited  to  the  skin.  In  other  cases 
the  disease  passes  down  to  the  angles  of  the  jaws,  np  to  the  scalp,  and 
back  to  the  ears.  Often  the  progress  is  temporarily  arrested  where  the 
skin  is  firmly  attached  to  the  deej^  tissues,  as  at  the  naso-hibial  fold  and 
the  margin  of  the  hairy  scalp.  For  a  similar  reason  the  chin  is  sel(h)m 
affected  as  severely  as  other  parts  of  the  face.  In  all  but  the  mildest 
cases  the  subcutaneous  tissues  are  also  affected.  The  eyelids  soon  become 
swollen,  and  so  thickened  that  they  cannot  be  opened.  The  nose  is 
broad  and  shapeless  ;  the  lips  are  swollen  and  their  motion  painful ;  the  ears 
form  large  swollen  masses  ;  the  nares  are  occluded  ;  the  mouth  and  tongue 
are  dry;  the  tongue  is  red  or  brown,  sometimes  fissured  and  l)lecding. 
Ill  other  cases  the  inflammation  passes  down  the  neck  and  surrounds  it. 
In  such  cases  the  scalp  is  usually  invaded  from  different  directions.  This 
is  accompanied  by  the  most  severe  pain,  although,  owing  to  its  texture, 
the  swelling  is  not  so  great  as  in  other  parts  of  the  body.  From  the 
swelling  of  the  skin,  aided  by  that  of  the  deep  tissue,  the  vesiculation 
and  scabbing,  the  swelling  of  the  eyelids,  between  which  purulent  secre- 
tions trickle,  the  swelling  of  the  nares,  causing  the  patient  to  breathe 
through  the  thickened  lips,  the  aspect  of  the  patient  is  most  repulsive. 
When  the  scalp  is  invaded  the  symptoms  usually  reach  their  acme.  All 
the  general  symptoms  of  the  disease  are  present,  and  headache,  restless- 
ness, and  delirium  are  rarely  absent.  The  nervous  symptoms  are  often 
so  severe  that  meningitis  is  suspected.  Formerly,  in  fact,  it  was  thought 
that  the  inflammation  often  passed  down  the  veins  into  the  cranial  cavity, 
but  this  rarely  happens.  The  nervous  symptoms  are  readily  explained 
on  the  ground  of  intoxication,  as  held  by  Todd  long  ago,  or  fever,  and 
are  often  as  serious  even  when  the  scalp  is  not  involved  or  when  the 
local  disease  is  at  the  opposite  end  of  the  body. 

The  duration  of  erysipelas  of  the  face  varies  as  that  in  other  parts, 
from  a  day  to  one  or  two  weeks,  usually  lasting  about  a  week. 

Uri/sipelas  of  the  bodi/  and  extremities  occurs  most  frequently  as  a 
complication  of  surgical  diseases.  It  does  not  require  special  consider- 
ation, as  the  general  and  local  symptoms  are  similar  to  those  already 
described. 

Erysipelas  of  the  3Iucoux  Membranes. — Erysipelas  affecting  the  mu- 
cous surfaces  is  sometimes  called  interna/  erysipelas.  In  these  parts 
the  disease  may  be  primary  or  secondary.  As  the  structure  of  many 
of  the  mucous  membranes  resembles  closely  that  of  the  skin,  it  may  be 

Vol.  I.— 30 


466  ERYSIPELAS. 

admitted  that  they  offer  favorable  localities  for  the  activity  of  the  ery- 
sipelas coccus,  but  the  real  nature  of  many  so-called  primary  cases  of 
erysipelas  of  the  mucous  membranes  may  be  questioned. 

The  Nose,  Mouth,  and  Pharynx. — Judging  from  the  frequency  with 
which  erysipelas  first  appears  on  the  nose,  it  would  seem  that  the  nasal 
mucous  membrane  is  often  the  starting  point  of  the  disease.  This  is  no 
doubt  true,  and  yet  it  must  be  remembered  that  the  infection  may  take 
place  in  the  nose  without  setting  up  the  characteristic  lesion  at  the"  point 
of  entrance,  just  as  infection  may  take  place  in  a  wound  in  the  outer 
skin  and  the  disease  begin  some  distance  from  it.  The  disease  usually 
begins  like  a  coryza,  with  dryness  followed  by  increased  secretion,  and 
is  soon  attended  by  unusual  pain  and  the  other  symjDtoms  of  erysipelas. 
Very  often  erysipelas  begins  during  an  ordinary  attack  of  coryza,  the 
latter  furnishing  the  necessary  conditions,  and  the  first  suspicion  of  the 
existence  of  more  severe  disease  is  caused  by  the  chill,  followed  by  the 
other  general,  and  finally  the  local,  symptoms  of  erysipelas. 

The  occurrence  of  erysipelas  of  the  pharynx  has  been  observed  for  a 
long  time  as  an  isolated  affection  and  in  epidemic  form.  It  is  usually 
supposed  that  the  "  black  tongue  "  which  attracted  so  much  attention 
during  the  middle  of  this  century  was  erysipelas.  It  seems  much  more 
likely  that  these  were  for  the  most  part  cases  of  dij)htheria,  possibly 
streptococcus  diphtheria. 

Erysipelas  of  the  pharynx,  including  the  tonsils,  may  be  primary  or 
secondary.  Infection  may  take  place  in  the  latter  by  way  of  the  mouth, 
nose,  and  lachrymal  ducts,  or  even  by  the  ear.  In  any  case  the  diagnosis 
can  only  be  made  when  erysipelas  appears  on  the  skin.  AVithout  that 
the  most  accurate  term  that  could  be  given  (in  case  of  bacteriological 
examination)  Avould  be  streptococcus  angina. 

The  local  symptoms  are  those  of  an  angina,  varying  from  a  mild 
catarrhal  to  a  diphtheritic,  phlegmonous,  or  gangrenous  inflammation. 
Generally  the  lymphatic  glands  at  the  angle  of  the  jaws  are  unusually 
swollen  and  tender.  The  other  symptoms  are  those  of  erysipelas  in 
other  locations,  but,  as  remarked  above,  it  is  only  when  cutaneous 
erysipelas  is  present  that  the  diagnosis  can  be  made.  In  any  event, 
the  throat  affection  should  be  treated  as  an  angina  after  its  kind  in  each 
case. 

Erysipelas  of  the  mouth  is  much  rarer  than  that  of  the  pharynx.  It 
is  usually  secondary  and  requires  no  special  description.  The  stomatitis 
which  develops  in  many  cases  of  erysipelas  hardly  deserves  the  specific 
term. 

Chantemesse  anclWidal  claim  that  inflammation  of  the  submaxillary 
glands  (angina  of  Ludwig)  is  of  erysi])elatous  origin,  having  found 
streptococci  in  the  exudate  in  that  condition.  I  have  seen  Ludwig's 
angina  as  a  complication  of  erysipelas. 

The  Larynx. — Erysipelas  of  the  larynx,  which  was  described  long 
ago  by  English  physicians,  may  be  primary  or  secondary.  The  latter 
is  recognized  by  the  appearance  of  the  lesion  elsewhere.  The  former  is 
of  more  importance  on  account  of  the  belief  that  many  cases  of  so-called 
idiopathic  oedema  of  the  glottis  are  erysipelatous.  It  is  also  thought 
that  many  cases  of  phlegmon  of  the  larynx  are  erysipelatous.     Massei  ^ 

^  Das  primdre  Erysipel  des  Kehlkopfs,  German  translation  by  Yincenz  Meyer,  1886- 


COMPLICATIONS  AND  SEQUKLM  467 

and  l)(.'la\an'  drscrxe  credit  lor  calliiii;- altciitinii  to  tlic  .siil)j('('t.  \'ir- 
cliow  soon  lifter  predioted  that  many  acute  cases  of  (edema  of  the  o;h)ttis 
would  prove  to  be  ervsipehitous,  as  tlie  anatomical  conditions  in  both 
diseases  are  similar.  Biondi  and  others  have  found  streptococci  which 
could  not  be  distini>-uished  from  those  of  Fehleisen.  The  ((Uestion  of 
nosoloiiv  need  not  be  discussed  here.      Massei  trives  the  fojlowini'-  dis- 

.  .  .  ^ 

tiniiuishiiii:-  features  of  the  disease:  Marked  swellinti;  of  the  mucous 
membrane,  developing  almost  constantly  in  the  glandular  tissue  at  the 
base  of  the  tongue,  soon  spreading  to  the  epiglottis  and  aryepiglottic 
folds  ;  rapid  ]xissage  of  the  swelling  from  one  ])art  to  the  other,  witli 
sudden  ajipearance  and  disappearance  of  dyspuwa ;  high  fever  in  the 
beginning.  Ilerzfeld-  calls  attention  to  the  phlyctente  on  the  epiglottis, 
some  of  Avhich  disappear,  while  others  break  down  and  form  superficial 
ulcers.  This  condition,  which  Massei  also  describes,  was  noticed  by 
Gottstein  in  primary  oedema  of  the  larynx.  Herzfeld  thinks  these  spots 
are  due  to  a  mild  subepithelial  exudate,  and  are  not  true  vesicles.  Pain 
in  the  prelaryngeal  region  is  a  marked  symptom.  Massei  ascribes  it  to 
inflammation  of  the  prelaryngeal  ganglia. 

Erysipelas  of  the  lower  respiratory  passages,  the  lungs,  and  pleura 
are  important  chiefly  as  complications.  Many  cases  described  under 
that  name  have  been  cases  of  streptococcus  infection  which  are  not 
definitely  entitled  to  the  term  erysipelas. 

The  (roiifal  JIucous  Membranes. — Although  admitted  as  possible  by 
some  writers,  erysipelas  of  the  urethra  of  man  must  be  exceedingly  rare. 
Achalme  could  not  cultivate  the  specific  organisms  in  normal  urine  even 
w'hen  made  alkaline,  and  obtained  no  results  from  the  injection  of  one 
c.c.  of  a  virulent  culture  in  the  bladders  of  rabbits. 

In  the  female,  on  the  contrary,  erysipelas  of  the  genitals  is  of  great 
importance  on  account  of  its  association  with  the  puerperal  state.  As 
this  subject  does  not  belong  to  internal  medicine,  it  cannot  be  further 
considered  here. 

Traiisinission  of  ErysipelcLS  from  the  Mother  to  the  Foetus. — The  possi- 
bility of  this,  which  has  no  doubt  occurred,  depends  on  the  circulation 
of  the  germs  in  the  blood,  a  matter  which  has  been  mentioned  in  an 
earlier  part  of  this  article.  Although  abortion  is  not  rare  in  pregnant 
women  with  erysipelas,  such  patients  rarely  have  pyaemia,  which  would 
almost  necessarily  follow  in  case  the  organisms  could  reach  the  fcetus 
in  a  virulent  condition.  The  abortion  must  therefore  be  due  to  other 
causes  than  fcetal  erysipelas. 

Erysipelas  of  the  newborn  occasionally  occurs  by  infection  of  the 
cord  or  stump,  and  begins  on  the  abdominal  wall.  It  also  occurs  in  the 
newborn,  as  in  later  life,  in  accidental  wounds,  excoriations  (nose,  vulva 
in  intertrigo),  and  skin  diseases.  It  sometimes  complicates  circumcision 
Avhen  performed  without  aseptic  precautions.  Many  cases  of  so-called 
erysipelas  of  the  newborn  are  really  cases  of  sepsis,  usually  produced 
by  streptococci,  but  often  complicated  by  other  organisms. 

Complications  and  Sequel.^:. — The  complications  of  erysipelas 
are  due  either  to  unusual  localization,  or  to  unusual  severity  of  the  essen- 
tial disease,  or  to  secondary  infections.     Many  of  them  are  almost  con- 

1  Neiv  York  Medical  Journal,  Sept.  12,  1885,  p.  284. 
^  Arch,  fiir  path.  Anat.,  Bd.  133,  p.  176. 


468  ERYSIPELAS. 

stant,  and  might  be  considered  as  ordinary  phenomena  of  the  disease ; 
such  is  albuminuria.     Others  are  rare. 

Erysipelas  affecting  the  eyelids  is  sometimes  followed  by  suppurative 
conjunctivitis,  keratitis,  iritis,  detachment  of  the  retina,  and  even 
destruction  of  the  bulb.  Glaucoma  has  been  observed  as  a  late  sequel. 
In  other  cases  inflammation  aflFects  the  orbital  connective  tissue  and  pro- 
duces exophthalmos,  thrombosis  of  the  sinuses,  infection  of  the  men- 
inges, or,  as  a  late  complication,  optic  atrophy. 

The  ear  complications  of  erysipelas  have  been  well  described  by 
Haug.^  The  afPection  is  usually  secondary.  Primary  erysipelas  of  the 
ear  has  followed  boring  the  ear,  itching  diseases  of  the  ear,  or  removal 
of  impacted  cerumen.  Usually  the  internal  ear  is  not  affected,  except 
by  temporary  hypersemia.  In  the  external  canal  erysipelas  causes 
swelling,  with  vesicles.  Necrosis  does  not  often  occur,  but  suppuration 
sometimes  does.  Eczema  may  follow.  Usually  the  disease  does  not 
pass  the  tympanic  membrane,  but  in  severe  cases  otitis  media  occurs, 
and  even  abscess  of  the  mastoid  antrum.  Sometimes  suppuration  of 
the  mastoid  cells  occurs  without  perforation  of  the  tympanic  membrane. 
Erysipelas  rarely  affects  the  ear  by  extension  from  the  pharynx. 

Parotitis  occurs  in  some  cases  in  which  the  mouth  or  pharynx  has 
been  involved.     It  frequently  goes  on  to  suppuration. 

Empyema  of  the  antrum  of  Highmore  occasionally  follows  erysip- 
elas of  the  face. 

The  coated  tongue,  vomiting,  and  other  evidences  of  gastric  disorder 
so  common  in  erysipelas  are  usually  explicable  by  the  intoxication  and 
fever.  In  rare  cases  inflammation,  exudation,  and  ulceration  of  the 
mucous  membrane  of  the  duodenum  occur,  with  streptococci  in  the 
lesions  examined  post-mortem.  In  other  cases  diarrhoea  with  bloody 
stools  has  been  observed,  leading  to  the  supposition  of  an  erysipelatous 
enteritis.  In  many  cases  it  is  probable  the  enteritis  is  septic,  not  neces- 
sarily due  to  specific  organisms.  Rendu  has  reported  an  interesting 
case  "in  which  facial  erysipelas  spread  into  the  mouth  and  pharynx,  and 
after  several  days,  during  which  the  patient  had  severe  gastro-intestinal 
symptoms,  appeared  at  the  anus. 

Ucke  ^  has  reported  a  case  of  secondary  erysipelas  of  the  stomach. 

Erysipelas  is  a  comparatively  common  complication  of  wounds  and 
ulcers  in  or  near  the  anus. 

The  liver  is  often  enlarged,  the 'seat  of  parenchymatous  degeneration 
and  sometimes  of  necrotic  foci. 

The  spleen  undergoes  similar  changes,  and  an  enlargement  of  that 
organ  has  been  looked  on  as  an  important  diagnostic  sign.  Frequently, 
however,  the  spleen  cannot  be  felt. 

Albuminuria  is  an  almost  constant  symptom  in  erysipelas,  occurring 
in  about  two  thirds  of  cases  of  all  degrees  of  severity ._  Usually  the 
albuminuria  lasts  but  a  short  time  in  the  height  of  the  disease,  and  the 
amount  of  albumin  is  small.  Hyaline  casts,  an  increased  number  of 
colorless  corpuscles,  and  red  blood  corpuscles  occur  at  times  in  the  urine 
even  in  mild  cases.  Usually  the  lesion  causing  these  symptoms  is  due 
to  intoxication,  but  some  observers  have  found  organisms  in  the  urine 

1  Prager  medieinisehe  Wochensehrift,  1893,  No.  37. 

2  Centralhlatt  Jixr  allg.  Path,  und  path.  Anat.,  p.  473,  1894. 


COMPLICATE L\S  AND  SEQUELAE.  469 

similar  to  those  in  the  skin.  In  nirc  rases  nephritis  occurs,  with  large 
quantities  of  albumin,  epithelial  and  blood  easts,  and  free  blood  cor- 
puscles in  considerable  numbers.  Salinger'  has  seen  uriciiiia  in  such  a 
case.  A'arious  lesions,  such  as  diffuse  nephritis,  glonierulo-nejdiritis, 
and  septic  interstitial  nephritis,  have  been  observed.  As  a  geneial 
thing,  the  ne})hritis  ot"  erysij)elas  docs  not  become  chronic.  Nephritis 
is  sometimes  absent  in  the  most  severe  cases  of  erysipelas. 

Pericarditis  is  comparatively  rarely  observed,  though  no  doubt  some- 
times overlooked,  as  it  is  in  other  diseases.  It  has  been  observed  in 
different  forms,  from  peric^arditis  without  effusion  to  suppurative  inflam- 
mation with  streptococci  in  the  exudate. 

Endocarditis  is  much  more  frecpient,  and  usually  occurs  in  the  later 
stages  of  the  disease.  It  usually  affects  the  mitral  valve.  The  symp- 
toms, physical  signs,  and  outcome  of  erysipelatous  endocarditis  are  like 
those  of  other  cases  of  infective  endocarditis.  Accidental  systolic  mur- 
murs are  comparatively  frecpient. 

Mvocarditis  has  been  observed  in  erysipelas  as  in  other  infectious 
diseases.     The  changes  are  both  proliferative  and  degenerative. 

Endarteritis  and  degeneration  of  the  intima  and  media  of  the 
arteries  have  an  importance  chiefly  anatomical. 

Pleurisy  and  ])neumonia  are  rare  C(^mplications  of  erysipelas,  found 
most  frequently  in  cases  with  general  sejisis.  Cases  of  pneumonia  in 
which  the  local  lesion  seemed  to  vary  during  life,  and  in  which  the 
lesions  post-mortem  were  irregular  or  serpiginous,  have  been  called  ery- 
sipelatous. The  peculiarities  mentioned,  however,  do  not  demonstrate 
the  speciflc  nature  of  the  cases,  as  they  are  sometimes  present  in  true 
croupous  pneumonia,  and  there  is  no  advantage  in  applying  the  term 
erysipelatous  unless  the  clinical  relationship  is  evident,  and  very  little 
even  in  that  case. 

Peritonitis  occurs  very  rarely,  either  as  part  of  general  infection  or 
by  extension  from  the  female  genitals. 

Inflammation  of  the  meninges  or  brain  is  rare  in  erysipelas.  Occa- 
sionally the  former  occurs  from  the  extension  of  inflammation  from  the 
orbit  or  along  one  of  the  cranial  nerves.  It  is  sometimes  due  to  organ- 
isms other  than  the  specific  streptococcus. 

Peripheral  neuritis  is  a  very  rare  complication. 

Various  affections  of  the  joints  occur  in  erysipelas.  When  the  skin 
is  involved  over  a  joint  an  effusion  in  the  latter  sometimes  occurs  from 
the  extension  of  inflammation  to  the  serous  membrane  of  the  joint. 
Sometimes  this  serous  effusion  seems  to  be  due  to  obstruction  of  the 
lymph  circulation.  In  other  cases  suppuration  takes  place  in  the  joint 
as  part  of  a  general  septic  condition.  Occasionally  there  is  a  mon- 
arthritis  from  the  localization  of  micro-organisms  in  a  single  joint.  In 
some  of  these  cases  pure  cultures  of  streptococci  have  been  found.  In 
an  interesting  case  observed  by  Galliard,'  in  which  the  right  knee 
became  inflamed  on  the  sixth  day  of  a  facial  erysipelas,  the  pus  in  the 
joint  contained  both  staphylococci  and  streptococci.  As  a  rare  occur- 
rence multiple  arthritis  with  the  characteristics  of  acute  rheumatism  has 
been  observed. 

1  Medical  Xewff,  .July  4,  1891. 

^  CentrulblaU  fur  Bakteriologic  unci  Pavasiteiikunde,  1893,  ii.  p.  436. 


470  ERYSIPELAS. 

Serous  eiFusions  and  inflammations  take  place  sometimes  in  the 
sheaths  of  tendons. 

One  of  the  late  sequels  of  erysipelas,  especially  that  of  the  face  and 
scalp,  is  seborrhoea.  A  not  uncommon  consequence  of  repeated  attacks 
of  erysipelas  is  chronic  dermatitis.  In  some  of  these  cases  a  chronic 
hyperplasia  of  the  subcutaneous  tissue  takes  place,  with  dilatations  of 
lymphatics,  which  is  spoken  of  as  elephantiasis.  As  a  rare  sequel  of 
recurrent  erysipelas  Tenneson  and  Darier  have  observed  lymph  varices 
of  the  cheeks  and  mucous  membrane  of  the  mouth.  They  explain  the 
condition  as  due  to  obliteration  of  lymph  vessels  or  sclerosis  of  lymphatic 
glands. 

Abscess  of  the  superficial  lymphatic  glands  is  a  common  occurrence 
in  erysipelas,  and  hardly  needs  detailed  description. 

Diagnosis. — Difficult  or  usually  impossible  before  the  local  lesion 
is  developed,  after  that  the  diagnosis  can  almost  always  be  made  by 
inspection.  When  the  general  symptoms  only  are  present,  one  should 
exclude  as  many  other  conditions  as  possible  by  the  complete  examina- 
tion, and  withhold  the  diagnosis  or  simply  make  one  covering  the  most 
distinct  local  condition.  As  in  all  other  cases,  the  examination  of  the 
pharynx  should  never  be  neglected,  and  when  the  general  symptoms  are 
present,  with  pharyngitis,  the  possibility  of  erysipelas  should  not  be 
forgotten.  Whenever  there  is  a  known  wound  or  abrasion,  still  more, 
exposure  to  other  cases,  the  symptoms  of  the  onset  should  at  once 
excite  the  suspicion  of  erysipelas.  This  is  true  also  of  coryza,  in 
which  chill,  fever,  vomiting,  etc.  occur  without  signs  of  other  infectious 
disease.  The  examination  of  the  lymphatics  of  the  head  and  neck 
should  not  be  neglected. 

When  the  eruption  has  appeared,  it  is  usually  unmistakable,  but 
there  are  enough  anomalous  cases  to  make  a  careful  examination  neces- 
sary always.  The  elevated  redness,  the  increased  consistence  of  the 
skin,  the  margin,  which  the  patient  often  describes  as  spreading  or 
which  can  be  seen  to  spread  from  hour  to  hour,  the  fulness,  itching,  or 
tickling  in  the  skin,  the  tenderness  in  the  enlarged  lymphatic  glands  in 
the  vicinity,  and  the  history  of  the  onset,  usually  make  matters  clear. 
But  sometimes  some  of  these  signs  are  absent  or  equivocal,  and  a  dif- 
ferential diagnosis  must  be  made.  Usually  a  want  of  definiteness  of 
the  margin  causes  the  greatest  difficulty.  This  allows  confusion  be- 
tween erysipelas  and  numerous  forms  of  erythema  and  dermatitis,  such 
as  those  from  exposure  to  the  sun,  from  irritating  drugs,  or  from  pois- 
onous plants  or  animals.  In  most  of  these  the  redness  is  not  so  clearly 
outlined,  the  swelling  if  present  is  very  superficial,  the  margin  does  not 
extend  in  so  characteristic  a  manner.  Finally,  the  general  symptoms 
are  absent.  In  the  case  of  dermatitis  from  poisonous  plants  or  animals 
a  history  can  usually  be  obtained.  The  appearance  in  many  of  these 
cases  is  like  that  of  erysipelas,  but  the  swelling  is  not  so  deep. 

Lymphangitis  and  erysipelas  have  a  close  relationship,  and  in  ery- 
sipelas it  is  often  possible  to  make  out  distinctly  the  existence  of  inflamed 
lymph  vessels.  In  lymphangitis  without  erysipelas  the  absence  of  the 
characteristic  elevation  with  progressing  boundaries  is  important.  Red- 
ness over  a  considerable  area  may  be  present,  but  is  likely  to  be  irreg- 
ular in  its  outlines  and  uneven  in  intensity  of  tint,  or  even  with   areas 


PRoaxosfS.  471 

of  miuirt'c'tcd  skin  in  it.  In  .simple  lyni[)luingitis  the  temperature  is 
not  so  high  tis  in  erysipehis,  and  the  symptoms  of  the  onset  are  nsually 
not  so  (listinct,  thmioh  sometimes  present. 

It  is  (lillieiilt  to  dislinii'iiish  between  ervsipelas  and  dill'iisc  [thieaiiion 
of  the  skin.  The  latter  mav  have  an  abrupt.  mar<iin,  but  this  is  not  so 
elevated  and  st)  distinet  to  the  touch  as  in  erysipelas.  The  redness  is 
usual ly  duskier  than  in  erysipelas,  and  the  swelling  greater.  The  gen- 
eral symptoms  e(^me  on  more  gradually,  as  a  ruk',  but  may  be  very 
severe. 

Urticaria,  mumps,  and  eczema,  all  of  which  have  been  mistaken  for 
erysipelas,  can  be  distinguished  by  careful  attention  to  the  local  and 
general  features  of  the  ditferent  diseases. 

The  condition  described  by  Rosenbach  as  eri/xipe/oid,  sometimes 
called  migrating  or  chronic  erysipelas,  can  hardly  be  mistaken  for  ery- 
sipelas if  care  be  taken.  This  disease  oc(!urs  especially  on  the  Avrists 
and  hands  of  cooks,  hucksters,  fishermen,  and  others  \vlio  handle  irri- 
tating substances.  It  nsually  begins  in  the  fingers  as  an  infiltration 
with  redness,  and  extends  very  slowly  toward  the  wrists,  often  reaching 
them  only  at  the  end  of  a  week  or  later.  It  subsides  slowly  without 
suppuration.     Fever  is  absent. 

Erysipelas  of  the  mucous  membranes  can  only  be  distinguished  as 
such  when  its  relation  to  erysipelas  of  the  skin  is  evident.  The  distinc- 
tion between  erysipelas  of  the  larynx  and  the  so-called  idiopathic  cede- 
ma  of  the  glottis  is  a  matter  of  theoretical  interest  and  does  not  aifect 
the  treatment. 

Prognosis. — The  prognosis  in  erysipelas  varies  widely  in  different 
eases.  The  mild  nature  of  most  cases  of  facial  erysipelas  has  made 
that  disease  a  favorite  among  those  who  claim  to  work  miracles  in  medi- 
cine.    On  the  other  hand,  erysipelas  is  at  times  extremely  fatal. 

In  making  a  prognosis  one  can  be  guided  to  a  certain  extent  by  the 
fact  that  a  sporadic  case  is  usually  more  favorable  than  one  developing 
in  an  epidemic.  The  previous  condition  of  the  patient  is  of  great 
importance.  Even  the  most  severe  cases  are  recovered  from  by  persons 
previously  in  good  health.  All  temporary  or  long-standing  conditions 
of  debility,  as  convalescence  from  acute  disease,  drunkenness,  atheroma, 
advanced  malignant  disease,  etc.,  are  unfavorable.  Cases  of  chronic 
nephritis  are  usually  extremely  unfavorable  subjects  for  erysipelas. 
Erysipelas  in  the  first  month  of  life  is  almost  always  fatal.  After  that 
time  the  danger  decreases,  but  in  old  age  it  is  again  pronounced. 

In  any  case  it  is  unsafe  to  predict  as  to  the  probable  time  of  recovery, 
and  even  when  the  temperature  falls  and  the  local  process  ceases  relapses 
must  be  looked  for.  Erysipelas  of  the  mucous  membranes  is  more 
dangerous  than  that  of  the  skin,  and  the  danger  is  greater  as  the 
inflammation  proceeds  toward  the  deeper  parts,  as  the  larynx.  Ery- 
sipelas of  the  scalp  is  in  most  cases  dangerous  simply  because  it  occurs 
in  severe  cases.  The  occurrence  of  unequivocal  symptoms  on  the  part 
of  the  central  nervous  system  must  be  looked  for  and  used  accordingly. 
Gangrenous  and  hemorrhagic  erysipelas  are  unfavorable ;  suppuration, 
when  tending  to  be  circumscribed,  is  not  so  unfavorable.  In  both  the 
gangrenous  and  phlegmonous  forms  even  the  most  extensive  destruction 
mav  be  recovered  from. 


472  ERYSIPELAS. 

Treatment. — In  the  treatment  of  erysipelas  two  leading  indications 
must  be  kept  in  view :  the  prevention  of  infection  in  others  and  the 
treatment  of  the  patient.  As  regards  the  former,  erysipelas  is  not  so 
dangerous  to  others  as  most  of  the  acute  exanthemata,  as  predisposition 
is  not  so  marked  and  infection  at  a  distance  is  more  rarely  observed. 
At  the  same  time,  the  erysipelas  cocci  have  considerable  power  of 
resistance,  and  local  or  temporary  predisposition  is  at  any  time  possible. 
The  infectious  material  is  therefore  to  be  destroyed  as  near  as  possible 
to  its  source,  and  the  patient  is  to  be  treated  to  that  end  as  any  septic 
surgical  case  should  be.  In  hospitals,  erysipelas  patients  should  be  iso- 
lated, or  at  least  separated  from  all  others  Avith  wounds  or  diseases  of 
the  skin  or  mucous  membranes.  Dressings  from  such  cases  should  be 
burned  at  once  after  removal ;  clothing  and  bedclothing  should  be  disin- 
fected. Instruments  used  on  them  should  also  be  disinfected.  Physi- 
cians and  attendants  should  avoid  getting  secretions  and  discharges  on 
their  persons  and  clothing,  disinfect  their  hands  after  examinations,  and 
take  special  pains  to  avoid  infection  of  wounds  on  their  own  persons. 
The  existence  of  coryza  or  acute  pharyngitis  furnishes  a  source  of 
danger  during  the  care  of  an  erysipelas  case,  and,  although  a  certain 
amount  of  risk  is  unavoidable,  much  can  be  done  by  cultivating  the 
habit  of  keeping  the  hands  away  from  the  mouth  and  nose.  The  great- 
est care  must  be  taken  by  those  who  treat  cases  of  erysipelas  and 
obstetric  or  surgical  cases,  but  if  proper  disinfection  is  practised,  it  is 
possible  to  treat  all  of  these  at  the  same  time. 

As  regards  the  patient,  the  indications  are  to  hasten  the  natural 
tendency  to  recovery,  to  relieve  painful  or  dangerous  symptoms,  and 
to  prevent  or  mitigate  complications.  Although  one  may  entertain  the 
hope  that  some  uiore  sj)ecific  method  of  treatiug  erysipelas  will  ulti- 
mately be  discovered,  our  best  methods  at  present  are  the  outcome  of 
clinical  experience. 

Marmorek^  early  in  1895  devised  a  method  for  obtaining  an  anti- 
toxic streptococcus  serum.  This  serum  has  been  extensively  used,  espe- 
cially in  France,  in  erysipelas  and  scarlatina-diseases  in  which  the  prog- 
nosis is  proverbially  uncertain,  so  that  the  results  must  be  accepted  with 
caution.  Many  adverse  results  have  been  observed,  and  the  experiments 
of  Aronson^  and  Petruschky -''  are  opposed  to  those  of  Marmorek,  but 
indicate  the  need  of  further  investigation. 

Ervsipelas  is  a  favorite  subject  for  therapeutic  novelties,  and  an 
immense  amount  of  ingenuity  has  been  expeuded  in  devising  methods 
of  treatment,  the  very  multiplicity  of  which  shows  how  far  they  are 
from  realizing  the  claims  made  for  them,  although  the  natural  tend- 
encv  to  recovery  gives  favorable  material  for  each  method.  The 
Avritcr  believes,  however,  that  among  the  newer  methods  of  treatment 
there  is  one  at  least  of  value,  although  not  committing  himself  to 
all  of  the  theories  which  have  been  announced  in  explanation  of  the 
results  obtained.  This  method  consists  in  the  routine  use  of  ichthyol 
on  the  skin,  as  proposed  first  by  Unna,  and  since  then  used  with  satis- 
faction to  a  greater  extent  than  any  other  contemporary  method.  The 
iron  and  quinine  of  tradition  are  no  doubt  useful,  especially  on  account 

'  Annaks  d'lnsiitut  Pasteur,  1895.  ^  Berliner  klin.  Wochenschr.,  1896,  No.  32. 

»  Centrulblati  fiir  Bukt,  etc.,  1896,  Bd.  xx.  Nos.  4,  5. 


Tin: ATM  EST.  47:> 

of  the  :ilcoh(tl  ill  tlic  jircparatioii  of  iron  iniivorsally  used,  but  in  iii<».<t 
oases  aleoliol  is  not  neeessarv,  and  when  it  is  ean  he  jiiven  more  ration- 
ally in  a  h'ss  emnplex  mixture.  That  iron  and  (|uinine  liave  any  etti- 
eaey,  as  ehiinied  hy  some,  in  promoting"  heahng-  hy  [diagoeytosis,  is  alto- 
gether problematiial. 

Tlu'  general  eare  of  the  })atient  should  he  earried  out  on  the  lines 
followed  in  other  aeiite  diseases.  The  ])atient  shoidd  Ik'  in  bed,  in  a 
well  aired  rooni,  not  too  warm.  The  room  should  be  darkened  if  the 
eyes  are  aff'eeted.  Cleanliness  of  the  patient,  his  clothinir,  and  his  sur- 
roundings are  essential. 

The  diet  should  be  mild,  but  in  quantities  as  large  as  the  patient  can 
digest,  consisting  hirgely  of  milk,  with  thin  soups  and  gruels,  albumen 
water,  etc.  If  the  patient  is  seen  early  enough,  the  symptoms  of  tiie 
onset  must  be  treated.  A'omiting  shoidd  be  encouraged  by  drinking 
tepid  water  until  the  stoniaeh  is  empty,  and  then,  if  it  continues  ha 
checked,  by  bismuth  and  lime  water,  carbonated  water,  bits  of  ice,  or  a 
mustard  plaster  over  the  epigastrium.  It  is  usually  advisable  to  give 
a  mild  calomel  purge,  followed  by  a  saline,  in  the  beginning  of  tlie 
disease. 

After  careful  examination  of  the  patient,  and  especially  of  the  local 
disease  and  the  treatment  of  wounds  or  ulcers  on  surgical  principles,  the 
ichthvol  is  applied.  It  is  used  most  frequently  in  comljination  with 
vaseline,  in  the  proportions  of  20  to  30  per  cent.  This  form  is  to  be 
preferred  in  the  majority  of  cases,  but  in  delirious  or  unruly  patients 
more  adhesive  preparations  can  be  used  with  advantage.  I  have  found 
the  followino;  formulte  useful  : 

Unna's  Icldhyol  Varnish. 

^.  Ichthyol,  grm.  40.0  ; 
Starch  powder,  40.0  ; 

Albumen  ieg^),  1.5  ; 

AVater  to  make  100.0.— M. 


Or, 


Ichthyol  Traumaticm  {Juhd-Renoy). 

R.   Ichthyol, 

Traumaticin,  equal  parts. — M. 


Before  applying  the  ichthyol  the  skin  must  be  cleaned  with  soap  and 
Avater.  The  ichthyol  is  then  rubbed  or  brushed  over  the  skin  at  least 
three  quarters  of  an  inch  from  the  red  margin,  and  covering  a  strip 
about  that  width  all  around  the  lesion,  then  covering  over  the  inflamed 
part. 

The  astringent  action  of  the  remedy  is  very  soon  evident.  I  have 
convinced  myself  it  is  much  more  marked  than  that  of  vaseline  alone. 
In  favorable  cases  the  redness  and  swelling  lessen,  no  extension  takes 
place,  and  the  general  symptoms  subside.  If  the  margin  advances,  the 
ichthyol  must  be  applied  beyond  it ;  usually  it  is  not  necessary  to  apply 
it  more  than  twice  a  day.  It  should  be  kept  applied  until  the  tempera- 
ture has  been  normal  for  two  days,  except  in  very  mild  cases,  and  always 
reapplied  as  soon  as  a  fresh  eruption  occurs. 


474  ERYSIPELAS. 

The  application  of  the  drug  is  sometimes  painful,  though  not  to  be 
compared  with  that  from  nitrate  of  silver.  Almost  always  the  improve- 
ment in  local  and  general  conditions  is  so  striking  that  the  patient  is 
willing  to  put  up  with  the  superficial  pain  and  the  unpleasant  odor  of 
the  remedy. 

It  is  probable  that  ichthyol  owes  its  efficacy  to  its  astringent  and 
counterirritant  properties,  although  according  to  AbeF  it  has  a  pecu- 
liarly marked  action  on  erysipelas  cocci.  It  is  therefore  comparable 
to  nitrate  of  silver  and  iodine,  to  both  of  Avhich  it  seems  undoubtedly 
superior,  Ichthyol  also  resembles  in  its  action  the  constricting  methods 
recommended  in  the  treatment  of  erysipelas,  but  is  much  more  conve- 
nient and  simple  than  most  of  these. 

In  regard  to  its  antiseptic  properties,  as  used  in  erysipelas,  ichthyol 
does  not  prevent  abscess  of  the  skin  and  lymphatic  glands.  Abel  advises 
that  only  freshly  made  preparations  be  used,  as  in  the  dilute  form  it  does 
not  remain  free  from  bacteria. 

In  simple  cases  of  erysipelas,  even  of  the  most  severe  kind,  internal 
treatment  is  not  necessary.  The  condition  of  the  heart  and  urine  must 
be  carefully  watched.  If  the  pulse  becomes  weak  or  irregular  or  the 
heart  sounds  show  indications  of  weakness,  whiskey,  strychnine,  or  small 
doses  of  quinine  should  be  given. 

In  cases  with  prostration  beef  tea,  eggnog,  and  other  stimulants 
should  be  given  as  required. 

Symptoms  of  nephritis  must  be  treated  as  for  an  independent  disease. 

Old  or  cachectic  persons  and  hard  drinkers  must  be  given  stimulating 
food  and  medicine  from  the  beginning. 

For  high  temperature  quinine  in  full  doses  or  phenacetin  can  be  used. 
Cold  bathing  or  sponging  is  often  beneficial. 

For  delirium  the  ice  cap  should  be  used,  and  if  necessary  bromide  of 
potassium,  with  or  without  chloral  to  produce  sleep. 

Complications  must  always  be  looked  for,  especially  when  the  case 
does  not  show  signs  of  improvement  within  three  or  four  days.  When 
found,  complications  must  be  treated  as  independent  diseases,  the  external 
ones,  like  abscess  and  gangrene,  on  surgical  principles. 

It  is  in  the  latter  cases  only  that  the  more  heroic  methods  of  treat- 
ment are  to  be  used.  Such  are  injections  of  antiseptics  or  incisions 
with  antiseptic  compresses.     In  ordinary  cases  their  use  is  uncalled  for. 

When  erysipelas  extends  into  the  scalp,  the  hair  should  be  cut  short 
for  convenience  of  applying  remedies.  As  the  hair  will  be  lost  in  any 
event,  there  can  be  no  objection  to  this.  In  other  cases  the  hair  need 
not  be  cut.  Ichthyol  used  on  the  scalp  should  be  diluted  with  water 
or  oil. 

For  the  nasal  or  pharyngeal  complications  of  erysipelas  antiseptic 
sprays  and  douches  are  to  be  used.  Erysipelas  of  the  larynx  is  treated 
by  cold  externally,  ice  pills,  scarification,  and,  if  necessary,  tracheotomy. 

After  recovery  from  erysipelas  the  affected  parts  must  be  thoroughly 
cleaned.  Abscesses  or  ulcers  must  be  thoroughly  treated,  in  order  to 
remove  all  possibility  of  relapse  by  infection  from  such  lesions. 

Kelapses  should  always  lead  to  careful  examination  for  some  such 
source  of  infection.     Next  to  these,  the  clothing  or  furniture  may  harbor 

^  Centralblatt  fiir  Bakteriologie  und  Parasitenkunde,  Bd.  xiv.,  1893,  No.  13. 


TREATMENT.  475 

the  specific  baetcM-ia.  Disiufcction  dl"  tlic  room  should  tlicreloiv  he 
practisc'(h 

In  I'ouvah'sc'c'iK'c  remcchcs  to  increase  apju'titt;  and  (Uii;('stioii  are  ()i"teii 
inchcated.     Frequently  iron  is  useful  in  this  stage. 

The  use  of  erysipelas  cocci  or  their  products  in  the  treatment  of 
malitiuant  and  infectious  diseases  belongs  rather  to  the  domain  of  experi- 
mental ])atliologv  and  therapeutics  than  to  practical  medicine.  From 
the  results  of  Fehleisen,  C'oley,  Emmerich,  tind  others,  wlio  have  experi- 
mented in  the  matter,  it  is  clear  tiiat  live  cultures  should  not  be  used, 
since  there  is  a  chance,  though  small,  of  dangerous  accident. 


PYiEMlA. 

By  I.  E.  ATKINSON,  M.D. 


Defixitiox. — Pysemia  (ttuou,  pus,  and  al/m,  blood)  is  a  disorder 
dependent  upon  the  presence  in  the  blood  and  tissues  of  pyogenic 
organisms  derived  from  a  suppurative  or  infected  centre  in  the  body, 
and  is  characterized  by  inflammation  of  veins,  thromboses,  embolisms, 
and  metastatic  abscesses,  accompanied  by  fever.  It  manifests  itself  by 
irregular  chills,  remitting  or  intermitting  fever,  sweating,  and  the  devel- 
opment of  secondary  centres  of  inflammation  and  suppuration. 

Etiology. — The  connections  between  external  suppurations  and 
internal  inflammations,  and  the  ultimate  eflPects  of  the  poisoning  of 
wounds,  whether  from  putrefaction  or  otherwise,  were  recognized  in 
very  remote  times.  The  crude  ideas  of  pathology  prevailing  give  no 
reasonable  explanation  of  the  causation  of  secondary  inflammation  and 
abscess  formation.  Toward  the  end  of  the  last  century  Jolm  Hunter 
declared  that  pus  gained  admission  to  the  blood  through  inflammation 
of  veins,  and  ascribed  the  symptoms  of  what  is  now  known  as  pytemia 
to  phlebitis.  The  theory  that  general  purulent  infection  was  dependent 
upon  phlebitis  gradually  gained  acceptance,  and  "  pus  in  the  blood  "  was 
held  to  be  the  pathogenetic  factor.  This  theory  led  to  the  introduction 
of  the  term  "  pyaemia  "  by  Piorry — a  term  that  now  serves  to  designate  a 
special  form  of  blood  infection,  though  with  a  significance  different  from 
the  original  conception.  Virchow,  denying  the  presence  of  pus  in  the 
blood  and  agreeing  with  Cruveilhier  that  thrombosis  was  the  initial  lesion 
in  pyaemic  processes,  made  the  first  great  advance  toward  a  correct  know- 
ledge of  their  pathology.  While  erroneously  asserting  that  coagulation 
of  blood  in  veins  preceded  inflammation  of  their  walls,  he  described  the 
disintegration  of  thrombi  thus  formed,  the  detachment  of  parts  of  these 
and  their  escape  into  the  venous  circulation,  the  impaction  of  these 
particles  in  branches  of  the  arterial  system  of  too  narrow  calibre  to 
transmit  them,  and  the  subsecpient  inflammation  and  suppuration  of 
the  tissues  surrounding  these  embolisms.  Today  these  are  considered 
the  essential  pathological  change  of  pyaemia  ;  but  the  etiological  basis 
of  those  changes  remained  unrecognized — indeed,  could  not  be  recog- 
nized— until  the  discovery  of  the  influence  of  micro-organisms  in 
pathogenesis  enabled  research  to  be  prosecuted  along  the  right  line. 
Since  the  discovery  by  Klebs  in  1870  that  pyemic  processes  are  invari- 
ably associated  with  the  presence  of  definite  micro-organisms  the 
dependence  of  these  processes  upon  micro-organisms  has  been  abun- 
dantly proven,  and  it  is  now  known  that  they  are  those  that  excite  sup- 

47" 


478  PYuEMIA. 

purative  inflammation.     These  micro-organisms    of  pus  are    of  many- 
varieties,  but  those  almost  constantly  found  are  staphylococcus  pyogenes 
aureus  and  streptococcus  pyogenes,  the  former  most  frequently  the  cause 
of  circumscribed  abscess  formation,  the  latter  of  rapidly  spreading  sup- 
puration.   As  causes  of  pyaemia  these  two  micro-organisms  occur  in  about 
equal  proportion,  and  one  or  the  other  will  be  found  in  nearly  ever}^  case. 
There  are,  however,  other  micro-organisms  which  occasionally,  though 
rarely,  determine  pysemic  manifestations ;  thus,  the  bacillus  of  typhoid 
fever  "  has  been  found  in  pure  culture  in  osteomyelitis  of  the  ribs,  in 
acute  purulent  otitis  media,  in  abscess  of  the  soft  parts,  in  the  pus  of 
empyema,  and  in  localized  fibro-peritonitis  either  during  its  course  or 
as  a  sequel  of  typhoid  fever."  ^     Likewise  the  bacterium  coli  commune, 
the  micrococcus  lanceolatus,  gonococcus,  and  others  are  occasionally  dis- 
covered in  suppurative  processes  in  remote  regions  of  the  body.     Prac- 
tically, however,  pysemia  depends  upon  staphylococcus  pyogenes  aureus 
or  streptococcus  pyogenes.    Senn  reports  from  the  observations  of  Baser 
and  others  46  cases  of  pyaemia,  in  22  of  which  staphylococcus  was  found, 
and  in  21   streptococcus ;  in  3  both  organisms  were  present.     Experi- 
mental research  has  definitely  shown  that  these  bacteria  are  the  actual 
causes  of  pyaemia.     A  pure  culture  of  staphylococcus  pyogenes  aureus 
injected  into  a  vein  of  a  rabbit  will  be  followed,  pretty  certainly,  by 
typical  and  fatal  pyaemia  within  three  days.     If,  however,  the  culture, 
sometimes  indeed  in  considerable    quantity,  be  injected  into  the    sub- 
cutaneous cellular  tissue  of  animals,  pyaemia  is  by  no  means  certain  to 
follow,  and  if  injected  into  the  abdominal  cavity  of  the  dog,  if  care  be 
taken  to  avoid  injury  and  the  introduction  of  other  foreign  substances, 
large  amounts  of  culture  fail  to  produce  any  reaction.     If,  however,  the 
culture  be  introduced  into  the  abdominal  cavity  along  with  the  bits  of 
potato  upon  which  they  have  grown,  or  if  the  intestines  be  injured  so 
as  to  disturb  the  circulation,  fatal  peritonitis  will  ensue  (Halsted).     It 
often  happens  that  pure  cultures  of  pyogenic  bacteria  disappear  after 
their  introduction  into  the  body  without  producing  any  noticeable  reac- 
tion, but  if  they  are  introduced  into  the  circulation  along  with  minute 
particles  of  some  indifferent  substances,  such  as  pith  or  cinnabar,  or  if 
the  endothelium  of  the  heart  or  of  the  bloodvessels  is  mechanically 
injured,  typical  pyaemia  with  metastatic  abscess  will  ensue.    The  healthy 
tissues  of  animals  have  then  the  power  to  resist  and  destroy  pathogenic 
organisms  to  a  considerable  degree.     If  introduced  in  small  quantity 
into  the  blood,  bacteria  may  be  attacked  and  destroyed  by  the  leucocytes 
of  the  healthy  body. 

It  is  probable  that  pus  organisms  gain  admission  to  the  circulation 
very  commonly,  in  the  presence  of  local  suppuration,  without  injurious 
effects,  and  it  has  been  shown  that  in  septicaemia  progressiva  unlimited 
numbers  may  exist  in  the  body  without  the  development  of  pyaemia. 
So  long  as  the  epithelium  of  the  bloodvessels  remains  intact  conditions 
for  pyemia  do  not  exist.  It  is  true  that  when  progressive  septicaemia 
is  unusually  protracted  bacteria  become  implanted  in  the  vascular  walls, 
and  excite  such  changes  in  these  by  their  toxic  products  that  thrombotic 
phlebitis  is  set  up  and  conditions  for  the  development  of  pyaemia  estab- 
lished ;  or  the  pus  organisms  may  so  modify  the  red  blood  corpuscles, 

^  Abbott,  Principles  of  Bacteriology,  2d  ed.,  p.  231. 


ETIOLOGY.  479 

in  rabbits  at  least,  as  has  been  sliowii  hy  Kocli,  as  to  briii*^  about  primary 
coagulation  and  the  subsequent  formation  of  embolic  abscesses  from  the 
arrest  of  these  coagula  in  small  arterial  trunks. 

However  it  may  occur,  injury  to  the  walls  of  the  bloodvessels  is 
essential  to  the  production  of  i)yiomia.  As  was  first  clearly  shown  by 
Virchow,  the  essential  basis  of  py;omia  in  man  is  thrombosis  and  the 
dissemination  of  the  disintegrated  thrombus  in  the  circulation,  where  its 
fragments  arc  carried  along  in  the  blood  stream  until  they  hnally  obstruct 
arteries  too  small  to  transmit  them,  and  form  embolisms  which  become 
centres  for  metastatic  abscess  formation.  But  simple  thrombosis  cannot 
result  in  pvjcmia,  and  the  embolisms  caused  by  its  detached  fragments 
cannot  determine  metastatic  abscess.  Even  the  thrombosis  and  embolism 
caused  bv  aseptic  solid  foreign  substances,  such  as  cinnabar,  powdered 
charcoal,  wax,  etc.,  are  incapable  of  inducing  suppurative  changes. 
Hemorrhagic  infarctions  and  circumscribed  necrosis  may  result,  but 
nothing  more.  Pvogenic  organisms  must  pervade  the  thrombi  and 
emboli  in  order  that  pvismia  may  develop. 

Simple  stasis  of  blood  in  a  vessel  is  not  sufficient  to  bring  about 
coacrulation.  So  lone:  as  the  endothelium  of  the  vessel  remains  intact 
and  foreign  bodies  are  excluded  from  its  lumen  this  does  not  occur. 
Mechanical,  chemical,  or  physical  injuries  to  the  vessel  wall  (particles 
of  wire,  needles,  etc.),  of  pre-existing  clots,  parasitic  organisms,  changes 
in  the  blood  or  blood  supply  entailing  disease  of  the  vessel  wall  are  the 
influences  that  bring  about  thrombosis.  In  pyaemia  the  influence  that 
determines  thrombosis  is  phlebitis.  From  a  suppurative  focus  inflam- 
mation proceeds  to  involve  the  vein,  advancing  from  without  until  the 
endothelia  are  reached ;  the  toxins  produced  by  the  pyogenic  microbes 
induce  inflammation  of  its  coats  and  coagulative  necrosis  of  its  endo- 
thelia. Upon  the  roughened  endothelia  a  layer  of  hsematoblasts  forms 
the  basis  for  coagulation.  Upon  this  the  leucocytes  accumulate,  fibrin 
is  formed,  and  a  white  thrombus  is  established  and  projects  into  the 
lumen  of  the  vessel,  which  is  presently  obliterated  by  the  formation  of 
a  red  thrombus.  Coagulation  now  extends  in  both  directions  as  far  as, 
and  often  extending  into,  the  nearest  communicating  veins.  This 
thrombus  is  infected  by  pyogenic  organisms,  and  inflammation  extends 
along  the  vascular  wall  in  contact  with  it.  The  thrombosis  extends  in 
a  proximal  direction  until  large  veins  become  involved ;  it  may  even 
reach  the  vena  cava.  Usually,  however,  the  proximal  end  of  the 
thrombus  jjrojects  into  the  lumen  of  a  still  patent  vein,  and  is  w^ashed 
by  its  blood  current.  An  infected  thrombus  has  no  tendency  toward 
organization  :  it  is  loosely  held  by  the  venous  wall,  and  is  more  or  less 
disintegrated  by  the  pus  organisms  and  pus  cells  imbedded  in  it  and 
surrounding  it.  Suppurative  phlebitis  may  be  restricted  to  the  locality 
primarily  affected,  or  the  reproduction  and  growth  of  the  micro-organisms 
may  be  inhibited  by  vigorous  resistance  on  the  part  of  the  leucocytes 
and  tissues,  and  further  development  may  be  prevented ;  but  often 
particles  of  the  original  thrombus  separate  or  are  broken  off  by  the 
blood  current  in  the  communicating  vein,  and  with  their  contained 
micro-organisms  are  carried  along  with  the  blood  toward  the  heart  and 
arterial  circulation.  Sometimes  only  a  few  of  such  thrombotic  particles 
are  thus  detached ;  at  other  times  their   number  is  very  great.     They 


480  PY.EMIA. 

may  be  very  minute  or  so  large  as  to  be  arrested  in  their  passage 
through  the  heart. 

In  the  constantly  enlargiug  bran(!hes  of  the  venous  system  no  obstacle 
to  their  passage  is  offered.  They  pass  through  the  right  chambers  of 
the  heart,  and  are  finally  arrested  in  the  arterial  system  at  a  point  where 
the  diminishing  calibre  of  the  branching  arteries  is  no  longer  capable 
of  transmitting  them.  Obviously,  the  first  obstacle  they  meet  is  in  the 
ramifications  of  the  pulmonary  artery.  The  size  of  the  thrombotic 
fragments  will  determine  the  location  of  the  plug  or  embolus  in  the 
pulmonary  arterial  system,  and  their  number,  the  number  of  pluggings 
or  embolisms.  One  may  be  so  large  as  to  obstruct  the  pulmonary 
artery  at  its  earliest  bifurcations.  On  the  other  hand,  fragments  may 
be  small  enough  to  pass  through  the  pulmonary  capillaries,  enter  the 
arterial  current,  and  become  arrested  at  some  remote  point  in  the  arterial 
system.  Arterial  embolism,  however,  may  also  occur  by  the  escape, 
through  the  pulmonary  circulation,  of  pus  organisms  and  leucocytes  im- 
pregnated with  pus  organisms,  which  may  become  implanted  in  the 
vascular  wall  and  excite  thrombo-arteritis  and  suppurative  inflammation. 

When  a  portion  of  a  thrombus  plugs  a  branch  of  the  pulmonary  artery 
the  circulation  is  at  once  arrested  as  far  as  the  nearest  communicating 
branch.  If  too  small  to  obstruct  the  lumen  of  the  vessel  completely, 
obstruction  is  presently  rendered  complete  by  a  secondary  thrombosis 
excited  by  the  embolism  and  blood  stasis.  Collateral  circulation  is  not 
established  in  the  lungs  on  account  of  the  terminal  character  of  the 
arteries  of  the  pulmonary  system.  The  thombosis,  therefore,  extends  as 
far  as  the  capillary  distribution  of  the  plugged  artery,  and  a  wedge-shaped 
area  is  established  in  which  the  circulation  is  brought  to  a  stand.  A 
scanty  supply  of  blood  wells  into  this  area  from  the  surrounding  capil- 
laries, and  a  hemorrhagic  infarct  is  formed,  with  its  apex  at  the  point  of 
the  embolism  and  its  base  distal  to  it.  It  is  at  first  pale,  but  soon 
becomes  red  from  hemorrhagic  infiltration.  The  pyogenic  organisms 
entangled  in  the  embolism — or,  more  correctly,  their  septic  products — 
now  excite  a  new  set  of  changes.  They  are  reproduced,  and  induce  an 
inflammation  of  the  arterial  coats  spreading  from  within  outward — an 
infective  arteritis. 

The  tissues  surrounding  the  vessel  are  next  invaded  by  suppurative 
inflammation,  and  an  embolic  or  metastatic  abscess  is  established,  in- 
volving the  infarct  and  spreading  beyond  it,  leucocytes  becoming  pus 
corpuscles  and  the  lung  tissue  necrotic.  Such  an  abscess  Mill,  ordinarily, 
correspond  to  each  embolism.  If  any  portion  of  the  secondary  thom- 
bosis project  into  a  vein  through  which  the  blood  still  courses,  fragments 
of  it  may  become  detached,  in  turn,  and  carried  to  remote  localities, 
where  they  will  be  arrested  and  determine  new  metastatic  abscesses. 
Such  localities  are,  preferably,  the  spleen,  kidneys,  and  liver,  but  any 
part  of  the  body  may  be  involved.  These  abscesses  may  thus  be  widely 
distributed.  In  acute  pyaemia  there  are  many  abscesses  of  small  size ; 
in  chronic  pysemia  the  infarcts  are  few,  but  large.  When  infective 
thrombo-phlebitis  occurs  in  the  portal  system  the  embolisms  will  occur  in 
the  ramifications  of  the  portal  vein  in  the  liver,  where  the  resulting 
abscesses  may  attain  the  size  of  an  orange  or  larger.  Thrombo-phlebitis 
may  arise  at  points  not    in  continuity  with    the  primary  suppurative 


ETIOLOGY.  481 

focus  bv  iinplaiitatiou  of  pus  ()ri;aiiisiiis  iVom  the  hlood  upon  tin-  iiitinia 
of  the  vessels.  Kudophlcbitis,  thus  established,  cuusinj^  eoagidativ^e 
necrosis  of  tiie  endotliella,  excites  parietal  tlirond)osis,  which  narrows  the 
himen  of  the  vein,  and  may  end  by  completely  obstruct! njji;  it.  From 
the  thrombus  formeil  in  this  manner  infected  end)()li  may  be  detached. 
Pvicmia  in  certain  cases  of  pro<»;ressive  sej)ticjemia  may  sometimes  l)e 
accounted  for  this  way,  as  also  the  se(|Ui'lar  femoral  ])hlebitis  of  ty])hoid 
fever  and  other  conditions.  The  [)rimary  focus  may  be  very  obscure 
and  readily  escape  detection,  or  it  may  consist  in  what  is  ordinarily  con- 
sidered a  j)erfectly  innocuous  centre.  The  following  case  affords  an 
example  : 

A  man,  forty-five  years  old,  had  a  limited  but  very  inti'actalde 
eczema  of  the  left  leg.  On  January  IGth  pain  in  the  left  calf  ap[»eared 
and  became  so  severe  that  he  went  to  bed.  Pressure  was  very  painful, 
but  nothing  could  be  feh  upon  palpation.  On  Jannary  17th  he  re- 
mained in  bed  with  intense  pain  in  the  leg  and  thigh.  There  was  a  Avell 
marked  phlebitis  extending  from  the  tibial  side  of  the  leg  just  above 
the  limit  of  eruption  and  extending  to  the  middle  third  of  the  thigh. 
The  vein  was  hard  and  corded,  and  its  course  was  marked  by  a  line  of 
redness  along  the  skin.  Considerable  oedema  of  the  leg  and  foot  de- 
veloped. Fever  appeared  withont  chill,  but  never  exceeded  100.5°  F. 
January  21st  he  was  seized  with  a  sharp  respiratory  pain  in  the  left  side, 
and  a  friction  sound  could  be  heard  over  the  painful  area.  There  was 
frequent  dry  cough.  By  January  25th  a  crepitant  rale  could  be  heard 
over  the  dorsal  and  lateral  base.  This  was  followed  by  prune-juice 
expectoration.  On  the  28th  there  was  tubular  breathing.  The  femoral 
vein  was  occluded  and  cord-like  as  high  as  Poupart's  ligament,  and  the 
entire  extremity  greatly  swollen.  No  new  centres  of  inflammation  de- 
veloped and  the  patient  slowly  improved. 

Pyaemia  rarely  arises  through  infection  by  way  of  the  lymphatics,  but 
that  it  may  thus  occur  can  be  proven  by  the  occasional  presence  of  ac- 
cumulation of  pus  in  deeply  seated  glandular  structures  and  in  the 
thoracic  duct  in  the  bodies  of  those  who  have  died  of  pyaemia.  More 
commonly  the  lymphatic  glands  offer  barriers  of  protection  against 
pyaemia.  Pyaemia,  especially  the  more  chronic  forms,  may  exist  when 
one  cannot  possibly  recognize  a  primary  suppurative  focus.  Those  w^ell 
known  varieties  of  which  ulcerative  endocarditis  and  acute  infective  osteo- 
myelitis are  striking  symptoms,  may  be  cited  as  examples.  In  such  cases 
the  pyogenic  micro-organisms  will  have  gained  admission  to  the  })lood  1)v 
some  unrecognized  external  or  internal  suppurative  lesion,  and,  not  find- 
ing conditions  favoring  their  development  elsewhere,  ultimately  settle 
upon  places  of  enfeebled  resistance  in  damaged  cardiac  valves  or  in  the 
endothelium  of  veins  of  the  osseous  system  (usually  near  an  epiphyseal 
line),  where  they  rapidly  develop  a  phlebitis  and  osteomyelitis,  and  at 
times,  though  fortunately  rarely,  a  septic  intoxication  that  may  have 
destroyed  life  before  suppuration  could  have  had  time  to  occur.  As  has 
been  noted  already,  pyogenic  organisms  may  enter  the  circulation 
without  producing  morbid  results.  Conditions  for  their  growth  do  not 
obtain,  and  they  are  destroyed,  probably  by  leucocytes.  At  times  they 
find  a  loeus  minoris  }-esidentke,  and  excite  suppurative  inflammation  in 
other  localities  than  those  just  mentioned.     Thus  the  pleural,  pericar- 

VOL.  I.— HI 


482  PYEMIA. 

dial,  and  peritoneal  cavities  and  various  joints  are  frequently  invaded. 
In  these  localities  infarcts  cannot  be  demonstrated.  The  infection 
probably  occurs  through  implantation  of  pus  organisms  or  infected 
leucocytes  in  the  capillaries  of  the  parts.  Often  purulent  inflammation 
of  these  parts  is  the  only  evidence  of  pysemic  infection.  Some  tissues 
are  quite  insusceptible  of  secondary  pysemic  inflammation.  Metastatic 
abscess  of  the  brain,  of  the  testicles,  etc.  is  very  rarely  observed.  Some- 
times the  so-called  "  spontaneous  pysemia "  develops  in  persons  who 
have  received  a  slight  injury  or  have  been  exposed  to  various  depressing 
•influences,  as  chilling  or  wetting.  These  influences  suffice  to  lower  the 
normal  level  of  resistance  and  offer  the  opportunity  to  pyogenic  organ- 
isms, already  present  in  the  circulation,  to  find  a  favorable  nidus  for 
their  development.  An  inflamed  joint,  an  osteomyelitis,  or  an  endo- 
carditis thus  arising  serves  as  the  starting  point  of  general  pysemic  in- 
fection, with  metastatic  abscess  and  the  usual  train  of  symptoms. 

From  w^hat  has  preceded  it  is  evident  that  the  distinction  between 
infective  septicsemia  and  pyaemia  is  purely  arbitrary  :  the  differences  are 
of  degree  and  not  of  kind.  They  both  depend  upon  the  presence  of  the 
same  pyogenic  micro-organisms  in  the  circulation.  Pyaemia  is  a  septic 
infection  plus  thrombosis  and  metastatic  abscess — a  septico-pysemia. 
The  course  of  pyaemia,  similarly  to  that  of  septic  infection,  varies  with 
the  virulence  of  the  bacteria  and  the  susceptibilities  of  the  infected 
individual.  The  more  acute  the  pyaemia,  the  more  numerous  will  be 
the  metastatic  inflammations  and  suppurations.  In  chronic  pyaemia  the 
secondary  inflammations  are  usually  less  numerous  in  proportion  to  its 
longer  duration.  Etiologically,  then,  infective  septicaemia  and  pyaemia 
are  identical. 

Pathological  Anatomy. — It  is  not  always  easy  to  trace  the  route  by 
Avhich  the  pus  organisms  have  gained  the  circulation.  A  primary  sup- 
purative focus  will  nearly  always  be  found — a  wound,  an  abscess,  an 
osteomyelitis,  a  uterine  phlebitis,  an  internal  ulceration,  a  middle  ear 
inflammation,  or  other  lesion  will  exist.  If  an  open  wound,  it  will  have 
lost  its  healthy  characteristics,  will  present  a  dry,  dull  appearance,  and 
be  bathed  in  a  thin  or  fetid  pus.  Generally  the  veins  in  relation 
with  the  infecting  focus  will  be  inflamed  and  filled  with  coagula.  The 
inflamed  vein,  however,  may  be  so  minute  as  to  escape  naked-eye  in- 
spection. The  coats  of  the  thrombosed  vein  will  be  thickened,  and  will 
have  a  yellow  or  greenish  yellow  appearance.  Small  hemorrhagic  spots 
will  be  present  in  great  numbers,  and  microscopic  examination  will 
reveal  a  copious  infiltration  of  all  the  coats  with  pus  corpuscles  and 
micro-organisms,  staphylococci  or  streptococci.  The  thrombus  will  be 
•softened,  not  firm,  reddish  brown  or  yellow,  and  puriform,  and  will  con- 
sist of  granular  matter,  disintegrating  red  and  white  blood  corpuscles, 
pus  cells,  and  micrococci,  scattered  and  in  colonies.  Purulent  trans- 
formation of  the  leucocytes  will  have  rendered  the  thrombus  much  less 
adherent  to  the  vascular  wall  than  would  be  the  case  in  benign  throm- 
bus. The  disintegration  of  the  clot  accounts  for  the  ease  with  which 
fragments  may  have  been  detached  from  it,  and  also  for  the  smaller  size 
of  the  emboli  characteristic  of  pyaemia.  At  times  the  phlebitis  will 
have  developed  into  a  periphlebitic  abscess.  The  softened  clot  will 
extend,  sometimes,  for  a  considerable  distance  along  the  venous  connec- 


PATHOLOaiCAL  AXATOMY.  483 

tions.  In  the  portal  circulation  the  ori<i;inal  focus  may  have  been  an 
iippenclicitis,  an  intestinal  ulceration,  and  in  the  newly  born  infant  an 
uinl>ilical  vein  inflaniination. 

The  embolisms  will  usually  hv  found  in  the  hmgs  at  bifurcations  of 
the  pulmouarv  artery,  and  are  oenerally  centres  of  infarction.  As  they 
involve  the  smaller  arteries  for  the  most  part,  they  are  peripheral,  wedge- 
shaped,  and  are  not  always  sharply  defined.  Infarction  is  less  apt  to 
follow  than  in  simple  embolism.  In  multiple  infective  embolism  infarc- 
tion will  be  present  at  some  centres,  absent  at  others.  Pulmonaiy 
metastatic  abscesses  are  not  often  larger  than  a  cherry,  are  usually  situ- 
ated in  the  pulmonary  periphery,  and  involve  the  plcune,  whence  a 
purulent  pleurisy  may  have  originated.  They  are  at  first  grayish  in 
color,  firm  and  surrounded  by  an  intense  hypertemia  ;  later,  they  form 
purulent  foci.  They  become  infiltrated  with  inflammatory  products,  the 
inflammation  having  extended  from  the  intima  of  the  obstructed  artery 
until  the  whole  area  of  the  infarction  has  become  implicated.  The  in- 
filtration occurs  by  migration  from  the  surrounding  hypersemic  zone 
which  bounds  the  abscess.  This  abscess  contains  a  central  necrotic  mass 
and  abounds  in  micrococci.  The  embolic  abscesses  of  other  parts  are 
usually  smaller  than  those  of  the  lungs.  They  differ  in  shape  and  ap- 
pearance. In  the  spleen  they  are  small  and  often  surrounded  by  a  zone 
of  inflamed  tissue.  They  swarm  with  micrococci,  and  are  of  a  dirty 
yellowish  red  color.  Embolic  abscesses  of  the  liver,  which,  as  involving 
ramifications  of  the  hepatic  artery,  are  most  often  a  result  of  endocar- 
ditis ulcerosa,  are  small,  yellow,  wedge-shaped,  and  usually  close  to  the 
capsule.  Arising  in  the  portal  system,  they  are  of  larger  size  and  few  in 
number.  The  abscess  is  always  separated  from  the  surrounding  hepatic 
structure  bv  a  zone  of  enlarged  yellow  lobules.  Colonies  of  micrococci 
are  present  in  the  interlobular  vessel  and  fill  the  capillaries  for  a  long 
distance  (Orth).  Very  few  corpuscles  are  seen,  the  infarct  being  largely 
made  up  of  liver  cells.  In  the  kidneys  the  abscesses  are  rarely  larger 
than  mustard  seed,  and  are  generally  situated  in  the  cortex,  arranged  in 
small  groups,  rarely  in  the  pyramids — in  the  middle  and  outer  portions. 
They  are  of  a  pale  yellow  color,  and  do  not  undergo  softening,  as  their 
contents  are  not  purulent,  but  rather  masses  of  fatty  degeneration. 
Micrococci  will  be  found  in  them  always. 

In  pysemic  arthritis  the  inflammation  begins  in  the  synovial  mem- 
brane, and  the  pus  is  often  ichorous.  The  membrane  is  swollen,  red- 
dened, and  covered  with  pus.  In  the  pleural,  peritoneal,  and  pericardial 
ca\'ities  the  inflammation  speedily  causes  the  accumulation  of  pus. 
Embolic  abscesses  of  other  structures  may  also  be  encountered,  as  in  the 
skin,  subcutaneous  tissue,  and  the  lymphatic  glands,  the  parotid  gland, 
etc.  When  metastatic  abscess  has  occurred  without  embolism  the  sup- 
purative inflammation  will  have  originated  in  foci  in  the  capillaries, 
where  micrococci  have  invaded  the  epithelium  damaged  by  the  toxic 
substances  in  the  blood,  whence  the  inflammation  has  spread  outwardly. 
Widespread  coagulative  necrosis  will  be  found  in  pyoemia.  The  spleen 
is  enlarged  and  softened,  the  heart  flabby,  and  the  mucosa  of  the  intes- 
tines swollen  and  softened  and  the  submucosa  the  site  of  numerous 
capillary  hemorrhages.  Purpuric  spots  will  be  observed  upon  the  skin 
quite  often,  especially  after  ulcerative  endocarditis.      The  brain  and 


484  PYJEMIA. 

spinal  cord  and  their  membranes  are  rarely  the  seats  of  inflammatory 
changes.  Suppurative  meningitis,  embolic  abscess,  and  hemorrhagic 
effusions  are  rarely  found.  In  ulcerative  endocarditis  of  septic  type 
micrococci  pervade  the  vegetations  on  the  valves  or  heart  wall.  When 
the  right  side  of  the  heart  is  implicated,  the  small  detached  fragments 
may  have  caused  embolism  and  metastatic  abscess  in  the  lungs ;  but 
from  the  left  heart  the  embolisms  involve  the  systemic  circulation. 
Ulcerative  endocarditis  is  often  found  without  discoverable  primary 
infective  centre.  As  in  infective  osteomyelitis,  the  micro-organisms 
have  found  a  habitat  in  the  endothelia  damaged  and  destroyed  by  coag- 
ulative  necrosis.  The  secondary  abscesses  exist  sometimes  in  great 
numbers ;  at  other  times  only  one  or  two  may  be  found ;  again,  ulcer- 
ative endocarditis  may  exist  without  embolism.  The  left  heart  is  usually 
implicated  in  ulcerative  endocarditis,  though  the  right  side  is  more  often 
affected  than  in  simple  endocarditis.  The  endocardium  as  well  as  the 
valves  may  be  affected.  Vegetations,  sometimes  luxuriant,  and  ulcera- 
tions are  the  characteristic  features.  The  vegetations  are  grayish  yellow, 
very  friable,  and  of  varied  conformation.  They  consist  of  fibrin  and 
granular  debris,  cellular  elements,  blood  cells,  and  micrococci.  The 
ulcerations  are  irregular,  may  involve  the  myocardium,  and  even  pene- 
trate to  the  pericardium,  or  the  cardiac  septum  may  be  perforated 
(Bramwell).  Small  abscesses  are  found  at  the  bases  of  the  vegetations. 
in  many  cases.  The  organisms  present  are  usually  streptococci  and 
staphylococci. 

The  intestines  are  not  so  frequently  the  seat  of  lesions  in  pyaemia  as^ 
in  septicsemia.  Submucous  metastatic  abscesses  are  occasionally  present,, 
especially  in  the  large  intestine.  These  may  open  through  the  mucosa 
and  form  ulcers.  Metastatic  abscesses  are  often  found  in  the  muscular 
tissue,  even  in  the  walls  of  the  heart,  in  the  subcutaneous  cellular  tissue^ 
the  skin,  and  in  the  medullary  cavities  of  bones. 

Symptoms. — Following  delivery  or  a  wound  or  surgical  opera- 
tion, pygemia  cannot  develop  until  suppuration  has  taken  place.  This 
is  commonly  some  time  during  the  second  week  after  external  sup- 
purative lesions,  but  after  delivery  during  the  latter  part  of  the  first 
week.  Impending  pyeemic  infection  is  usually  indicated  by  alteration 
in  the  appearance  and  behavior  of  the  wound.  The  granulations  will 
become  pale,  inactive,  and  unhealthy.  The  pus  will  lose  its  creamy 
character,  and  become  thin  and  ichorous  and  scanty.  The  surrounding^ 
tissues  will  grow  infiltrated  and  oedematous  and  somewhat  livid.  The 
lochia  of  the  puerperal  woman  will  become  scanty  and  fetid  or  suj)- 
pressed,  the  external  genitalia  hot  and  dry,  and  intrapelvic  pain  and 
tenderness  develop.  The  patient  will  suffer  from  general  discomfort 
and  anorexia.  There  will  be  slight  headache,  elevation  of  tem^Dcrature, 
and  thirst.  The  tongue  will  have  a  thin,  moist  coating.  The  general 
symptoms  will  be  ushered  in  by  a  chill  more  or  less  severe,  and  lasting^ 
from  a  few  minutes  to  an  hour  or  more.  It  may  be  limited  to  a  chilly 
or  "  creepy  "  sensation,  Thermometric  observation  will  already  show 
several  degrees  of  elevation.  In  the  great  majority  of  cases  the  chill 
will  occur  in  the  daytime.  The  initial  chill  does  not  mark  the  occur- 
rence of  suppuration.  It  is  probably  due  to  septic  absorption  or  to  the 
circulatory  changes  consequent  upon  the  entrance  of  infective  material 


SYMPTOMS. 


485 


into  the  l)l<t(Kl  curivnt.  JjUtcr,  the  chills  may  indicate  the  formaticjii  of 
pus.  The  temperature  may  rapidly  rise  to  105°  F.  or  more.  More 
commonly  it  is  not  so  hicrji— 102°,  103°,  or  104°  F.  The  maximum  is 
often  reached  within  a  few  hours.  After  some  hours,  usually  not  until 
the  next  day,  the  tcmpeniture  falls  nearly  or  (piite  to  the  normal,  and  a 
copious  sweatini;:  follows.  With  or  without  chills  the  fever  assvnnes  an 
intermittent  or  remittent  type,  and  is  frequently  confounded  with  mala- 
rial fever.  The  distinct  periodicity  of  the  malarial  ])aroxysnis  is  absent, 
however,  and  both  chill  and  fever  will  vary  in  intensity  ;  more  than  one 
<'hill  may  occur  during  the  twenty-four  hours  (Fig.  41).     After  the  first 


F 

IG. 

41. 

TIME  M 

E  M  E 

M 

E 

M 

E 

MiE 

M  E 

ME 

ME 

M  E 

M,E 

m!e 

m{e 

TEMP. 

1 

1 

1 

F. 

1 

1 

1  ■ 

I 

I 

^ 

1 

I 

1 

1 

. 

\ 

1 

'      i 

1 

1 

.  «  f 

i 

1 

1 

1 

1 

1 

n 

1 

I 

; 

1 

i 

1    ' 

1 

1 

; 

' 

in^ 

\    J 

\ 

1/  _ 

[ 

; 

JT 

1 

1 

1 

1 

1 

1 

, 

i 

, 

1 

. «« 

j 

j 

I    1 

1 

1 

1 

1 

! 

1    \ 

J 

o 

1\ 

101 

1 

1 

1     1 

\ 

■ 

\ 

^ 

Ai 

/  1 

1 

R 

/ 

s 

A 

/ 

o 

\     \ 

j  /  \ 

/ 

/\ 

/ 

\    1 

/ 

\f 

/  ' 

i           '    II 

/ 

Y 

f 

0 

1                II 

1     \ 

/ 

^j 

1     !     IJ 

/ 

I 

1 

c 

i  \\ 

\      1 

\  j 

\      j 

y 

I      , 

1 

\_    1 

1 

\ 

1 

' 

\ 

9b  +- 

j 

; 

\| 

Y 

1 

1 

j 

I 

i 

1 

1 

■      i 

1 

\ 

1 

Ql'- 

1 

1 

1 

. 

1 

1 

Temperature  record  of  pysemia  (Tillmanns). 

day  a  chill  may  not  mark  the  exacerbation.  A  very  remarkable  feature 
of  the  fever  is  its  inequality  :  within  a  few  hours  the  thermometer  will 
mark  changes  of  several  degrees,  though,  as  a  rule,  the  morning  tem- 
perature will  be  lower  than  that  of  the  evening.  The  remissions  are 
always  marked  by  copious  and  persistent  sweats  ;  sweatino^,  however, 
may  be  present  almost  continuously,  and  the  bedclothes  and  bedding 
saturated  with  moisture.  During  the  brief  remission  of  symptoms  the 
temperature  may  even  fall  one  or  two  degrees  below  the  normal.  In 
more  protracted  cases  a  normal  or  subnormal  temperature  is  sometimes 
maintained  for  a  day  or  two,  and  excites  illusive  hopes  of  a  j^ermanent 
betterment,  which,  however,  will  be  interrupted  presentlv  bv  a  recurring 
chill  with  rapid  elevation  of  temperature.  Even  in  favorable  cases 
permanent  defervescence  never  occurs  abruptly ;  it  is  reached  graduallv 
after  repeated  interruptions  and  exacerbations.  The  atypical  character 
of  the  chills,  the  hot  stage,  and  the  sw^eatings  place  pyaemia  in  notable 
contrast  with  non-septic  diseases. 


486  PYEMIA. 

The  pulse  will  vary  with  the  temperature.  In  mild  cases  there  may 
be  but  little  increase  of  frequency.  It  may  not  exceed  80  or  90,  but 
will  be  soft  and  compressible.  In  severer  cases  it  becomes  very  fre- 
quent, and,  as  the  fatal  issue  approaches,  more  frequent,  feeble,  and 
compressible.  An  important  feature  of  the  pulse,  and  one  characteristic 
of  pysemia,  is  that  in  the  remissions  of  temperature  a  corresponding^ 
diminution  in  its  frequency  will  not  be  observed.  It  will  remain  rapid 
even  though  the  thermometer  may  indicate  no  febrile  heat.  In  favor- 
able cases  the  pulse  returns  to  the  normal  very  slowly.  Microscopic 
examination  of  the  blood  will  reveal,  in  addition  to  the  presence  of 
bacteria,  some  leucocytosis  and  increase  of  blood  plaques,  with  diminu- 
tion in  the  number  of  red  blood  corpuscles.  The  micro-organisms  will 
be  found  in  the  plasma  as  well  as  in  the  white  corpuscles. 

During  the  earlier  period  the  tongue  remains  moist  and  thinly  coated. 
As  the  disease  advances  the  coating  becomes  thicker  and  yellower,  and 
when  a  milk  diet  has  been  pursued  it  may  assume  a  dense  cottony 
appearance.  Still  later  the  tongue  may  be  dry  and  cracked,  and  when 
a  typhoid  state  develops  it  may  be  brown,  hard,  dry,  and  cracked.  Not 
unfrequently  it  is  dry,  red,  and  as  if  varnished.  The  teeth  and  gums 
may  be  covered  with  sordes,  and  the  lips  dry,  fissured,  and  partly  covered 
with  brownish  crusts.  The  breath  has  often  a  peculiar  sweetish  odor, 
which  has  been  compared  to  that  of  hay.  Nausea  and  vomiting  are 
not  always  observed,  but  anorexia  may  remain  complete,  though  liquid 
nourishment  and  medicines  will  be  swallowed  without  complaint. 
Thirst  is  intense.  Early  diarrhoea  is  not  so  common  a  symj^tom  as  it  is 
in  septicaemia ;  later  it  is  often  established.  Pus  and  blood  in  the  stools 
indicate  the  existence  of  pysemic  intestinal  lesions.  Fetor  of  the  stools 
sometimes  is  intense.  The  skin,  which  often  glistens  from  the  admix- 
ture of  sweat  and  sebum,  may  be  cold  and  clammy  in  the  extremities. 
When  sweating  has  been  copious  the  flanks  and  abdomen  are  often 
covered  with  sudamina.  The  surface  early  acquires  a  dusky,  sallow 
tint.  This  may  be  hepatogenous  in  part  from  catarrhal  obstruction  of 
the  bile  passages,  but  later  it  is  principally  due  to  disintegration  of  red 
blood  corpuscles  and  liberation  of  pigment  under  the  infective  influence. 
Jaundice  may  become  intense.  Erythematous  eruptions  are  sometimes 
observed.  They  are  usually  encountered  in  the  vicinity  of  the  primary 
suppurative  focus,  but  may  occur  as  a  diffuse  scarlatiniform  rash,  or 
may  closely  simulate  erysipelas,  constituting  an  infective  dermatitis. 
Scattered  papular  and  pustular  (sometimes  ecthymatous)  eruptions  often 
appear.  Herpes  facialis  is  a  very  common  concomitant.  In  a  more 
advanced  stage  a  very  distressing  general  hypersesthesia  may  arise,  so 
that  the  patient  complains  bitterly  of  movement  or  pressure.  This 
hypersesthesia  is  both  cutaneous  and  deep,  and  does  not  depend  entirely 
upon  metastatic  inflammation,  which  is  often  absent  from  the  regions 
implicated.  The  urine  is  scanty,  acid,  high  colored,  and  of  high  specific 
gravity.  At  the  onset  it  is  rarely  albuminous,  though  albumin  may  be 
present  as  an  expression  of  the  febrile  condition.  Later  it  may  become 
albuminous  from  involvement  of  the  kidneys  in  metastatic  inflamma- 
tion. The  splenic  area  is  constantly  enlarged ;  that  of  the  liver  much 
less  frequently.  Widespread  joint  inflammations  often  occur  quite  early 
in  the  disease,  and  not  infrequently  occasion  such  close  simulation  of 


SYMPTOMS.  487 

articular  rluMiinatisin  as  to  load  t<»  erroneous  diagnosis.  Largo  and  small 
joints  may  1)0  attacked  ;  ]irol)al)ly  those  most  i'ro({uently  involved  are  the 
shoulder-joint  and  that  of  the  knee  and  the  sterno-elavicular  articula- 
tion. The  patient  first  complains  of  pain  in  the  affected  locality. 
More  or  loss  rapidly  swelling  will  develo[),  and  fluctuation  may  l)e 
detected.  The  circumscribed  superficial  redness  of  acute  articular 
rhenmatism  will  rarely  be  simulated.  Upon  incision  of  such  a  Joint 
pus  or  sero-pus  will  be  liberated. 

The  intelligence  is  rarely  affected  at  first,  and  often  remains  unim- 
paired almost  to  the  end.  However,  the  patient  is  strangely  inditferent 
to  his  peril,  and  may  be  surprised,  annoyed,  or,  possibly,  amused  at  the 
anxiety  of  his  attendants. 

In  acute  cases  the  disease  runs  its  course  within  a  few  days  to  a  fatal 
termination,  and  the  patient  may  pass  into  a  typhoid  state  and  coma 
before  local  evidences  of  metastasis  may  have  developed.  But  the 
duration  of  an  attack  is  indefinite,  and  chronic  pyaemia  may  last  for 
weeks  and  mouths,  to  terminate  in  death,  or,  rarely,  in  recovery. 
Early  thrombo-phlebitis  may  sometimes  be  detected  in  the  vicinity  of 
the  infective  focus  through  a  painful,  tender,  hardened,  cord-like  vein. 
The  occluded  and  inflamed  larger  veins  may  often  be  followed  to  the 
points  where  they  disappear  in  the  trunk,  and  can  be  marked  out  by 
the  eye  by  the  red  line  of  cutaneous  hypersemia  superimposed  upon 
them.  It  is  quite  possible  for  the  infective  process  to  go  no  farther  than 
this  thrombo-phlebitis,  and  the  patient  finally  recover,  his  blood  and 
tissue  cells  successfully  contending  with  and  destroying  the  pus  organ- 
isms and  neutralizing  their  toxins  by  their  own  products.  In  such 
cases  recovery  will  be  slow  and  interrupted.  The  most  important  phle- 
bitis of  this  character  is  phlegmasia  alba  dolens.  It  is  most  frequently 
observed  after  childbirth,  but  occurs  under  a  number  of  conditions — 
after  surgical  operations  upon  the  pelvic  viscera,  during  the  decline  of 
typhoid  fever,  or  after  convalescence  from  this  disorder  has  been  estab- 
lished ;  in  the  course  of  tuberculosis,  erysipelas,  gonorrhceal  rheuma- 
tism ;  after  parenchymatous  tonsillitis ;  during  various  infectious  dis- 
orders ;  and,  finally,  as  a  result  of  purely  septic  infection.  In  all 
cases  it  is  probably  due  to  secondary  infection  by  pyogenic  bacteria. 
Except  in  cases  of  general  septic  infection  and  pyaemia  its  course  is 
usually  favorable.  The  symptoms  of  this  phlebitis  generally  begin  with 
pain,  especially  in  the  calf  and  in  the  groin.  This  is  quickly  followed  by 
oedema  of  the  limb,  beginning  in  the  foot  and  gradually  ascending.  In 
the  great  majority  of  cases  the  left  lower  limb  is  affected.  The  oedema- 
tons  limb  is  pale  and  shining,  and  sometimes  shows  the  blue  tracings  of 
veins  that  have  been  dilated  in  the  establishment  of  collateral  circula- 
tion. If  the  phlebitis  has  been  primary,  the  detachment  of  a  portion 
of  its  infected  thrombus  may  serve  as  the  starting  point  of  pyaemia. 
These  phlegmasise  often  subside  quickly,  but  quite  frequently,  and  es- 
pecially after  typhoid  fever,  oedema  is  very  persistent  and  may  lead  to 
permanent  enlargement  of  the  limb  with  varicosity  of  the  veins. 

The  occurrence  of  embolism  will  not  be  marked  by  symptoms, 
unless,  as  is  very  rarely  the  case,  the  attached  fragment  of  thrombus  is 
so  large  as  to  plug  a  large  branch  of  the  pulmonary  artery  ;  in  which 
case,  sudden  dyspnoea,  and  possibly  death,  may  occur.     While  embolism 


488  PYEMIA. 

by  an  infected  thrombus  usually  proceeds  to  suppurative  inflammation, 
this  will  not  be  of  necessity.  Occasionally  a  thrombo-phlebitis  will  be 
followed  by  indubitable  evidence  of  metastatic  deposit  in  the  lung,  with 
pneumonic  inflammation  and  even  pleuritis,  without  the  process  advan- 
cing to  suppuration.  A  limited  area  of  pulmonary  consolidation,  marked 
by  characteristic  signs  and  even  pleuritic  friction  sounds,  with  resulting 
effusion,  Avill  slowly  undergo  resolution  and  the  patient  recover  perfectly. 
This  will  not  happen,  however,  when  the  metastases  are  multiple. 

The  occurrence  of  metastatic  abscess  is  marked  by  an  aggravation 
of  the  symptoms  and  by  recurrent  chills  and  sweating.  If  the  infarcts 
are  small  and  scattered  throughout  the  pulmonary  area,  their  usual 
locality,  their  presence  may  not  be  revealed  by  physical  signs.  They 
may  be  inferred  by  an  increase  in  the  respiratory  rate  and  by  the  appear- 
ance of  the  sputa.  At  first  the  sputum  may  resemble  currant  jelly,  a 
result  of  hemorrhagic  infarction.  Later  it  may  become  offensive  and 
purulent,  and  contain  particles  of  lung  tissue  and  elastic  fibres.  Only 
when  the  abscesses  are  large  or  when  several  coalesce  can  they  be 
detected  by  physical  examination.  Cough  will  attract  attention  to  the 
chest,  and  pain  in  the  side  will  indicate  the  presence  of  pleurisy.  The 
number  of  these  abscesses  may  be  enormous.  Empyema  may  occur, 
and  perforation  of  the  visceral  pleura  may  cause  pneumo-pyothorax. 
Metastatic  abscess  of  parts  supplied  by  the  systemic  arterial  circulation 
will  be  revealed  rarely  by  physical  signs.  Intense  pain  in  the  splenic 
region  may  indicate  the  presence  of  splenic  abscess,  and  the  appearance 
of  albuminuria  may,  but  does  not  necessarily,  announce  the  involvement 
of  the  kidneys  in  similar  changes.  On  the  other  hand,  renal  embolic 
abscess  may  exist  without  albuminuria.  Embolic  abscess  of  the  liver 
will  hardly  be  detected,  but  may  be  inferred  from  slight  enlargement 
and  tenderness  of  that  organ.  If  the  infective  focus  involve  the  portal 
circulation,  the  abscesses  that  aflect  the  liver,  with  or  without  pyle- 
phlebitis, may  be  large  and  protracted  in  their  course,  causing  jaundice, 
hepatic  enlargement,  sometimes  palpable  fluctuating  tumors,  and  a 
typhoid  state.  Embolism  of  the  intestinal  canal  will  rarely  present 
symptoms  excepting  diarrhoea.  If  a  large  artery  have  been  obstructed, 
there  may  occur  nausea,  vomiting,  pain,  and  tympanites  (Osier).  Embolic 
abscess  of  the  brain  is  rare  in  pyaemia,  though  more  common  when  it  is 
associated  with  ulcerative  endocarditis.  The  symptoms  are  obscure  and 
depend  upon  localization.  In  the  general  disorder  they  are  apt  to  escape 
observation  unless  accompanied  by  paralysis.  In  some  cases  of  pysemia, 
especially  that  occurring  as  a  complication  or  sequel  of  typhoid  fever, 
suppurative  inflammation  of  the  parotid  gland  occurs.  In  the  most 
acute  cases  death  often  anticipates  the  formation  of  pus  in  this  gland. 

The  presence  of  metastatic  abscess  is  inferred  from  the  persistence 
of  symptoms,  the  recurring  chills  with  varying  temperature,  and  the 
exhausting  sweating,  when  it  is  not  manifested  by  local  signs.  In  its 
further  course  pysemia  is  characterized  by  a  continuation  and,  if  acute, 
by  rapid  intensification,  of  all  the  symptoms.  The  range  of  tempera- 
ture will  be  great,  varying  sometimes  from  five  to  six  degrees  during 
the  day,  rising  and  falling  several  times,  sometimes  with  intermissions, 
during  which  the  temperature  may  be  subnormal,  with  free  sweating  and 
perhaps  symptoms  of  collapse.     In  the  more  acute  cases,  while  cliills 


SYMPTOMS.  489 

may  orciir  .sext'ial  times  diiriiii;-  the  twonty-foiir  hours,  tlic  temperature 
niroly  reaches  tlie  normal,  but  in  tlie  exacerbations  it  may  attain  104°, 
105°  F.,  or  more.  The  pulse  varies  with  the  temperature,  becoming  grad- 
ually more  frequent  and  feeble  as  the  fatal  issue  approaches.  In  acute 
cases  death  generally  occurs  within  a  week  or  ten  days.  When  meta- 
static abscesses  arc  few  the  course  of  the  disease  may  be  very  ])rotracted. 
In  such  cases  the  symptoms  are  uniformly  milder;  the  dailv  range  of 
temperature  is  not  so  great.  Very  often  a  distinct  intermission  will  be 
<5bserved,  during  which  the  temperature  may  remain  normal  or  subnor- 
mal for  hours  at  a  time.  Chills  may  or  may  not  recur  daily,  and  in  the 
remission  of  fever  the  copiousness  of  the  sweats  mav  be  less. 

In  puerperal  pyaMuia,  in  wliich  infective  phlebitis  usuallv  l>egins  in 
the  veins  at  the  placental  site  by  bacterial  invasion  of  the  thrombi,  the 
disorder  may  develop  very  insidiously  from  a  slight  endo-  or  para- 
metritis, usually  during  the  first  week  of  childbed.  The  svmptoras 
begin  w4th  a  chill,  which  may  be  protracted  and  severe.  Apart  from 
the  symptoms  of  intrapelvic  inflammation,  the  course  of  the  established 
disease  is  that  of  ordinary  pyjemia.  Peritonitis  is  generallv  absent. 
Death  usually  occurs  during  the  second  or  third  week,  but  recovervmay 
follow  after  more  or  less  prolonged  illness  in  cases  where  metastasis  has 
been  slight  and  has  not  involved  the  more  important  organs  (Lusk). 

Many  of  the  milder  forms  of  pyaemia,  such  as  occur  in  typhoid  fever, 
scarlet  fever,  etc.,  pursue  very  protracted  courses.  The  occurrence  of 
<"hills  after  the  third  week  of  typhoid  fever  more  often  than  not  signal- 
izes the  engrafting  of  septicaemia  or  pysemic  processes  upon  the  original 
disease  :  and,  although  pure  cultures  of  the  typhoid  bacillus  have  been 
obtained  from  suppurative  foci  in  this  disease  (evidence  that  this  bacillus 
is  also  a  pus  organism),  commonly  typhoid  and  post-typhoid  parotiditis, 
femoral  phlebitis,  pylephlebitis,  etc.  are  of  distinctly  pya?mic  origin. 
Similarly,  the  suppurative  joint  inflammations,  etc.  after  scarlet  fever 
are  evidences  of  secondary  pyaemic  infection.  The  milder  pvaemic  in- 
fections that  arise  in  this  manner  usually  pursue  a  favorable  course,  but, 
as  a  rule,  even  in  chronic  pyaemia  the  course  is  unfavorable.  The 
patient  finally  becomes  exhausted  by  the  toxicity  of  the  disease  and 
the  fever.  He  grows  profoundly  prostrated,  emaciated,  and  anaemic ; 
bedsores,  furuncles,  and  subcutaneous  abscesses  mav  develop  before 
death. 

Osteomyelrtis,  which  is  generally  an  affection  of  childhood,  or,  occur- 
ring later  in  life,  a  recurrence  from  childhood  and  due  to  encapsulation 
of  pyogenic  organisms  after  the  original  attack,  or,  as  is  more  probable, 
a  reinfection  in  a  locus  mi  nor  is  resistentice  from  the  blood  current,  may 
exhibit  only  pain  and  the  symptoms  of  acute  septic  infection  and  k 
rapidly  fatal  course.  But  it  may  also  constitute  one  oif  the  phenomena 
of  ordinary  pyaemia,  and,  on  the  other  hand,  rarely  it  may  serve  as  the 
centre  for  general  pvaemic  infection.  Cases  in  which  infection  of  several 
centres  of  the  osseous  system  by  pyogenic  bacteria  occurs  are  not  so 
very  uncommon.  They  are  not,  strictly  speaking,  truly  pyaemic,  and 
follow  a  much  more  favorable  course. 

The  more  protracted  cases  of  pyaemia  are  often  very  obscure.  It  is 
here  that  errors  in- diagnosis  are  most  often  made,  especially  when  the 
primary  focus  has  escaped  observation.     Chronic  forms  of  pyaemia  mav 


490  PYEMIA. 

originate  in  pyelo-nephritis,  intestinal  ulcerations,  and  various  suppura- 
tive centres  in  internal  parts  of  the  body,  and  present  symptoms  closely 
resembling  those  of  tyj^hoid  fever,  tuberculosis,  etc. 

The  most  interesting  form  of  chronic  pyaemia,  however,  is  malignant 
or  ulcerative  endocarditis.  This  may  occur  as  a  frank  secondary  symp- 
tom of  pysemia,  or  it  may  be  the  primary  lesion  and  infective  focus. 
Though  it  may  proceed  to  a  fatal  termination  within  a  few  days  as  part 
of  an  already  disseminated  pygemia,  or  even  as  a  primary  affection,  its 
course  is  often  prolonged  for  many  weeks  and  even  months.  When 
secondary,  following  a  wound,  a  surgical  operation,  or  suppurative  puer- 
peral lesion,  no  modification  of  the  ordinary  course  of  pyaemia  may  be 
observed.  Should  the  life  of  the  patient  be  prolonged,  however,  embol- 
isms from  the  endocardial  surface,  sometimes  in  countless  numbers,  may 
be  swept  into  the  circulation,  and  small  metastatic  abscesses  evoked  in 
the  various  organs  and  parts  of  the  body. 

Its  presence  will  usually,  but  not  always,  be  recognized  by  the  devel- 
opment of  an  endocardial  murmur.  In  the  great  majority  of  cases  the 
left  side  of  the  heart  is  implicated.  In  209  cases  referred  to  by  Osier 
in  his  Gulstonian  Lectures,  the  left  valves  were  affected  in  171  cases, 
the  right  valves  in  34.  In  9  cases  the  right  heart  alone  was  involved. 
Pysemic  endocarditis  usually  arises  in  hearts  that  have  already  been  dam- 
aged and  aflPord  a  favorable  nidus  for  the  growth  of  pus  organisms.  It 
rarely  begins  as  a  primary  endocarditis.  The  symptoms  are  often 
extremely  vague  and  misleading.  They  may  begin  abruptly  or  insidi- 
ously, with  chills,  pyrexia,  sweats,  all  of  irregular  and  atypical  charac- 
ter, and  pass  gradually  into  a  typhoid  state.  As  a  rule,  subjective 
cardiac  symptoms  are  slight ;  they  may  be  altogether  absent.  Palpi- 
tation, prsecordial  distress,  and  pain  are  occasionally  present  (Bramwell). 
Sometimes  the  symptoms  are  pronounced,  and  at  once  direct  attention  to 
the  heart.  The  earlier  general  symptoms  have  often  a  close  resemblance 
to  those  of  malarial  fever ;  all  phases  may  be  closely  simulated.  In  the 
absence  of  embolic  symptoms  they  may  be  readily  mistaken  for  typhoid 
fever.  During  the  course  of  the  affection  great  variability  of  the 
cardiac  murmur  will  often  be  observed,  and  affords  a  significant  aid  to- 
diagnosis.  These  cases  may  be  protracted  for  months.  They  may  not 
exhibit  symptoms  of  metastasis  until  near  the  end.  More  acute  case& 
rarely  run  their  course  without  metastasis.  The  absence  of  a  heart  mur- 
mur throughout  is  not  so  very  uncommon.  Then  an  early  diagnosis  i& 
quite  impossible.  Later,  ulcerative  endocarditis  may  be  inferred  by 
exclusion  or  determined  by  evidences  of  arterial  metastatic  inflamma- 
tion. Ulcerative  endocarditis  may  endure  days,  weeks,  or  months,, 
gradually  exhausting  the  patient  with  recurring  rigors,  pyrexia,  and 
sweats,  until  he  passes  into  a  state  of  profound  prostration,  coma,  and 
death. 

The  temperature  by  rapid  changes  may  pass  from  the  normal  to 
105°,  106°,  107°  F.,  or  more.  A  continuous  high  temperature  is  some- 
times maintained.  Nearly  always,  sooner  or  later,  the  symptoms  will 
be  modified  by  those  of  metastatic  inflammations.  Excepting  when  the 
right  heart  is  involved  these  will  develop  in  the  systemic  arterial  circu- 
lation, justifying  the  term  arterial  pyaemia  suggested  by  Wilks.  The 
lungs  are,  naturally,  much  less  frequently  the  seat  of  infarcts  than  in 


DIAGNOSIS.  491 

ordinarv  [)y;einia,  hut  pnciiinoiiia,  |)lciirisy,  and  empyema  are  not 
unooinnion  concomitants.  Deliriuin,  paralysis,  coma  will  indicate 
cerebral  and  meningeal  metastasis.  Local  and  general  symptoms  will 
for  the  most  part  he  those  of  general  pyiemia.  Multiple  cutaneous  and 
suhcutaiu'ous  ahscesses,  and  often,  toward  the  end,  innumerahle  cutane- 
ous JuMuorrhages  forming  purpuric  spots,  will  not  infrc(|ncntly  develop 
heforc  death.  Sometimes  gangrene  of  the  extremities  will  indicate  the 
occlusion  of  large  arteries  by  emboli  from  the  valvular  vegetations. 
Parotiditis  sometimes  forms  a  symptom. 

With  the  establishment  of  some  or  all  of  these  symptoms  the  con- 
dition of  the  patient  becomes  more  grave.  Chills,  varying  pyrexia, 
drenching  sweats,  diarrhtea,  hebetude,  delirium,  coma,  succeed  until  the 
patient  finally  succumbs,  usually  within  four  or  five  weeks.  Practically, 
recovery  never  follows.  All  cases  of  ulcerative  endocarditis  in  which 
pus  organisms  pervade  the  endocardial  vegetations,  and  ulcerations  and 
their  resulting  embolic  inftircts,  may  fairly  be  considered  pysemic, 
whether  origmating  with  rheumatism,  old  endocardial  disease,  or 
otherwise. 

Diagnosis. — Pyajmia  is  very  often  mistaken  for  other  affections  ;  most 
commonly  for  septicaemia,  intermittent  and  remittent  malarial  fever, 
typhoid  fever,  acute  miliary  tuberculosis,  and  acute  rheumatism.  The 
diagnosis  from  septicsemia  may  at  first  be  impossible.  Indeed,  progres- 
sive septicaemia  may  pass  into  pyaemia  by  the  development  of  thrombosis 
and  embolism,  and,  conversely,  more  or  less  septic  intoxication  and 
infection  is  present  during  the  progress  of  pyaemia.  Septic  intoxica- 
tion generally  develops  within  a  few  days  after  a  wound  or  injury  and 
after  the  beginning  of  gangrene,  and  is  dependent  upon  putrefactive  as 
well  as  suppurative  foci.  Pyaemia  is  due  to  suppuration,  and  usually 
does  not  occur  earlier  than  the  second  week  of  the  wound  or  injury  or 
suppurative  lesion.  The  course  of  septic  intoxication  is  briefer,  and  is 
without  local  manifestations.  In  progressive  septicaemia  chills  are  not 
nearly  so  often  observed  as  in  pyaemia.  Pyaemia  runs  a  more  protracted 
course,  but  differentiates  itself  by  the  establishment  of  thrombosis  and 
embolism  and  metastatic  abscesses.  The  fever  of  septic  infection  is 
more  continuous  and  attains  a  higher  degree  within  a  few  hours.  Its 
duration  is  much  briefer,  and  when  it  is  prolonged  a  pyaemic  condition 
is  often  established. 

Microscopic  examination  of  the  blood  affords  a  ready  method  of 
distinguishing  malarial  fever  from  pyaemia.  The  presence  of  the 
Plasmodium  malariae  will  establish  the  diagnosis.  The  distinctly  inter- 
mittent and  remittent  character  of  the  fever  of  pyaemia  is  the  cause  of 
■  many  mistakes.  In  the  more  acute  forms  of  pyaemia  doubt  will  be  dis- 
pelled by  the  course  and  development  of  the  essential  symptoms  of  the 
disease.  The  diagnosis  from  symptoms  alone  is  often  very  difficult  in 
the  more  chronic  forms ;  but,  apart  from  the  microscopic  diagnosis,  the 
irregular  development  of  chills,  fever,  and  sweating,  even  without  the 
secondary  local  manifestations,  will  not  long  justify  hesitation  between 
the  two  affections.  Moreover,  as  Osier  has  well  said,  if  a  supposed 
case  of  malarial  fever  persists  despite  the  full  exhibition  of  quinine 
after  several  days,  other  causes  than  malaria  must  be  sought  for. 
Chronic  cases  may  readily  be  mistaken  for  typhoid  fever.     Resemblance 


492  PYJEMZA. 

may  be  heightened  by  abdominal  symptoms — diarrhoea,  tenderness  in 
the  right  iliac  fossa,  splenic  enlargement — delirium  and  the  typhoid 
state  that  is  so  often  observed,  especially  in  malignant  endocarditis.  It 
is  verv  important  to  remember  that  frequently  after  the  third  week  of 
typhoid  fever  a  true  pyaemia  or  septicaemia  may  be  engrafted  upon  the 
original  disorder.  The  occurrence  of  chills  and  the  intensification  of 
svmptoms  during  the  latter  period  of  typhoid  fever  is  very  often  due  to 
septic  or  pysemic  absorption  from  the  intestinal  ulcerations.  Post- 
typhoid parotiditis,  phlebitis,  etc.  are  usually  pysemic.  Except  in  pro- 
tracted cases  of  pyaemia  the  course  of  the  fever  will  soon  remove  uncer- 
tainty from  the  diagnosis.  In  acute  tuberculosis  pyaemia  is  sometimes 
suspected  at  first.  The  course  of  the  former  aifection,  while  occasionally 
very  rapid,  is  always  more  regular  than  that  of  pyaemia.  The  expec- 
toration, and  often  the  discharges  when  present,  will  reveal  the  bacillus 
of  tuberculosis.  Acute  rheumatism  may  be  confounded  with  pyaemic 
arthritic  inflammation.  Post-scarlatinal  and  gonorrhoeal  purulent  arthri- 
tis are  usually  pyaemic,  the  latter  inflammation  sometimes  due  to  meta- 
stasis of  the  gonocoGcus. 

When  the  primary  suppurative  focus  has  been  apparent  pyaemia  is 
usually  recognized  without  difficulty,  but  when  this  centre  has  escaped 
observation  or  has  been  beyond  its  reach,  much  obscurity  often  exists. 
Originating  in  osteomyelitis,  pyelitis,  pylehepatitis,  or  in  any  of  the 
so  called  spontaneous  manners,  the  keenest  powers  of  observation  will 
be  necessary.  In  malignant  endocarditis  the  diagnosis  from  typhoid 
fever  may,  for  a  time,  be  impossible.  The  purpuric  eruptions  of  the 
endocarditic  pyaemia  have  caused  this  disorder  to  be  mistaken  for  typhus 
fever,  cerebro-spinal  meningitis,  or  malignant  specific  exanthematic 
fever.  Hepatic  intermittent  fever — which,  indeed,  is  probably  a  mild 
septic  or  at  least  fermentation  fever — the  fever  of  rapidly  developing 
cancer,  Hodgkin's  disease,  and  the  fever  of  local  suppurations  of  what- 
ever nature  may  at  times  simulate  pyaemia. 

Peogxosls. — The  prognosis  of  pyaemia  is  unfavorable.  Death  will 
usually  occur  before  the  end  of  the  second  week,  sometimes  during  the 
first.  In  chronic  pyaemia  the  prognosis  is  less  absolutely  bad,  though 
most  cases  end  in  death,  sometimes  after  weeks  and  even  months.  The 
course  of  malignant  endocarditis  and  of  pyaemic  cerebral  suppuration  is 
uniformly  fatal ;  of  the  former  rarely  later  than  three  or  four  months, 
usually  within  as  many  weeks.  Where  the  primary  suppuration  focus 
is  within  the  reach  of  surgical  treatment,  and  the  metastatic  abscesses 
are  few  in  number  and  not  situated  in  vital  parts,  recovery  may  take 
place,  though  slowly.  It  cannot  be  denied  that  a  thrombo-phlebitis 
following  a  primary  suppuration  in  its  turn  may  be  followed  by 
symptoms  of  embolism  in  the  lungs  and  elsewhere,  limited,  however,  to 
one  or  two  foci,  and  yet  recovery  eventually  take  place.  In  such  cases 
it  can  only  be  presumed  that  the  micro-organisms  of  the  thrombus  and 
of  the  embolus  have  been  of  feeble  virulence,  and  have  been  destroyed 
by  the  bactericidal  action  of  the  blood  and  leucocytes.  The  prognosis 
is  much  more  favorable  when  metastatic  abscess  affects  a  part  within 
reach  of  the  surgeon's  knife,  as  in  metastatic  parotiditis. 

Teeatmext. — Prophylaxis. — The  basis  of  modern  surgery  is  in 
the  avoidance  of  influences  that  permit  the  infection  of  wounds  and  the 


TREATMKyT.  49:i 

admission  to  the  circulation  ot"  sc})tic  and  pyoircnic  organisms  and  their 
toxic  products.  The  most  certain  t^uarantee  of  protection  to  the  individ- 
ual is  the  maintenance  of  a  rigid  asepsis  in  uninfected  lesions  and  the 
antiseptic  treatment  of  these  when  conditions  of  sepsis  or  supj)uration 
prevail.  The  prevention  of  suj)purati()n  in  a  wotmd  furnishes  absolute 
protection  aj2:ainst  pyjemia  (Senn).  The  details  of  necessary  treatment 
to  this  end  are  strictly  surgical,  and  need  not  be  considered  here.  Aseptic 
and  antisejitic  treatment  in  internal  medicine  has  a  much  more  restricted 
field,  and  is  limited  to  a  more  or  less  ineffectual  clisinfection  of  the 
alimentarv  canal.  Some  measure  of  success  may  be  expected  in  se])tic 
and  suppurative  lesions  of  the  mouth,  nares,  and  fauces,  as  in  diphthe- 
ritic and  scarlatinal  inflammations,  but  it  is  doubtful  if  antiseptics  can 
be  administered  in  sufficient  and  safe  quantities  to  effectually  disinfect 
the  intestinal  canal.  To  the  mouth,  throat,  and  nares  applications  of 
hvdrogen  dioxide,  corrosive  sublimate,  carbolic  acid,  sulphurous  acid, 
and  other  bactericidal  agents  are  universally  employed,  but  no  substance 
should  ever  be  applied  to  these  parts  in  such  strength  as  to  exercise  a 
caustic  action  or  in  such  a  manner  as  to  disturb  mechanically  the  rela- 
tion of  the  parts,  lest  absorbing  surfaces  be  laid  bare  and  the  entry  of 
micro-organisms  and  their  products  to  the  circulation  facilitated.  Nu- 
merous plans  for  preventing  general  infection  through  ulcerating  sur- 
faces in  the  intestinal  canal,  as  from  dysentery,  typhoid  fever,  etc., 
have  been  proposed.  It  has  been  asserted  that  effective  antiseptic 
treatment  of  this  canal  may  be  secured  through  salol,  naphthalin, 
beta-naphthol,  calomel,  and  other  drugs.  That  some  such  influence  may 
be  brought  to  bear  may  be  inferred  from  the  positive  deodorization  of 
the  stools  that  may  be  secured  by  these  means,  but  there  is  little  evi- 
dence of  satisfactory  antiseptic  results.  Salol  in  doses  of  from  60  to 
80  grains  daily,  naphthalin  in  daily  doses  of  from  1  to  2  drachms,  beta- 
naphthol  in  40-grain  doses  daily,  have  all  been  extolled  for  this  purpose. 
Lately  calomel  has  been  recommended  as  an  intestinal  antiseptic,  pos- 
siblv  through  its  conversion  into  corrosive  sublimate.  It  can  hardlv  be 
hoped,  however,  that  an  efficient  antiseptic  effect  can  be  afforded  by 
such  measures. 

The  Treatment  of  Pycenua. — The  first  objective  point  is  the  treat- 
ment of  the  primary  suppurative  focus  and  the  destruction  of  its  power 
for  further  evil.  Pus  should  be  set  free,  tension  relieved,  and  drainage 
secured,  if  practicable,  and  thorough  disinfection  established.  Early 
operative  interference  is  indicated  in  acute  osteomyelitis.  Disinfection 
of  the  uterine  cavity  should  be  attempted  in  puerperal  pyaemia.  Ex- 
cision of  thrombotic  veins  has  been  recommended  by  Klebs.  To 
prevent  detachment  of  infected  thrombi  absolute  rest  and  the  avoid- 
ance of  disturbing  manipulation  should  be  insisted  upon.  Purely 
antipyretic  drugs  should  never  be  given.  The  questionable  advan- 
tage of  the  reduction  of  temperature  is  more  than  counterbalanced 
by  the  decided  depression  following  their  use.  Agents  that  maintain 
the  \'ital  power  should  be  administered.  Quinine  and  iron  seem  to 
serve  this  purpose  best.  At  the  outset  c^uinine  should  be  given  in 
full  doses,  30  to  40  grains  during  the  day,  in  divided  doses.  This 
dose  may  be  repeated  for  one  or  two  days,  but  after  this  not  much 
advantage  is  to  be  obtained  from  such  amounts,  and  the  daily  dose  may 


494  PYEMIA. 

be  reduced  to  10  or  12  grains.  Large  doses  of  iron  seem  to  be  very 
serviceable  occasionally.  From  15  to  30  minims  of  the  tincture  of  the 
chloride,  well  diluted  with  water,  may  be  given  every  fourth  hour. 
This  preparation  of  iron  seems  to  possess  advantages  over  the  others. 
Salicylic  acid,  salol,  sodium  benzoate,  and  many  other  remedies  have 
been  urged,  but  their  value  is  doubtful.  Alcoholic  stimulants  will  be 
indicated  nearly  always,  and  when  the  heart  begins  to  fail  strychnine  is 
of  undoubted  value.  As  there  is  no  specific  treatment  of  pyaemia,  the 
most  important  indication  is  the  support  of  the  powers  of  life  by  sys- 
tematic nourishment  and  stimulation.  This  holds  especially  in  chronic 
pyaemia.  The  food  should  be  the  most  assimilable  possible.  As  the 
main  reliance  nothing  is  so  good  as  milk.  From  three  pints  to  a  half- 
gallon  during  the  day  will  be  sufficient.  Strong  beef  extracts,  pepto- 
noids,  and  peptonized  foods  will  prove  useful  adjuvants,  thus  supporting 
the  patient  until  the  infection  has  become  exhausted.  Whenever 
secondary  infective  inflammations  are  accessible  they  should  be  actively 
treated  surgically.  Unfortunately,  in  the  cases  usually  coming  under 
the  care  of  the  medical  practitioner  the  infective  centres  are  beyond 
reach  in  the  internal  parts  of  the  body.  The  successful  treatment  of 
pyaemia  is  almost  exclusively  surgical.  In  the  rare  cases  of  recovery 
the  result  is  usually  due  to  the  feebleness  of  the  infection,  and  the  merit 
of  the  physician  depends  upon  his  ability  to  supply  to  the  sufferer  support 
in  the  form  of  nourishment  and  stimulation  that  will  strengthen  him  in 
his  struggle  against  the  morbific  influences. 


SEPTICAEMIA. 

By  I.  E.  ATKINSON,  M.  D. 


Definition. — Sopticfcmia  (ar^-zixo::,  putrid,  and  ahm,  blood)  is  an 
acute  febrile  affection  depending  \\\)0\\  the  presence  in  the  blocjd  and 
tissues  of  organic  chemical  substances,  resembling  alkaloids,  which  are 
formed  bv  minute  organisms  or  bacteria  which  are  also  the  causes  of 
suppuration  or  putrefaction.  These  micro-organisms  develop  in  foci  in 
or  upon  the  body,  and  excite  in  them  suppurative  or  putrefactive  pro- 
cesses and  form  poisonous  chemical  products.  From  causes  that  are  not 
well  understood  these  poisonous  chemical  substances,  alone  or  along 
Avith  the  micro-organisms  that  produce  them,  gain  admission  to  the 
circulation  through  lymphatics  and  bloodvessels,  and  produce  morbid 
effects  which  are  known  as  septic  intoxication.  Often  this  septic  intoxi- 
cation is  intensified  and  perpetuated  by  the  continued  activity  and  repro- 
duction of  the  accompanying  micro-organisms  within  the  body,  whereby 
the  supply  of  poisonous  chemical  products  absorbed  from  the  original 
focus  is  supplemented.  The  condition  induced  in  this  manner  is  known 
as  septic  infection  or  progressive  septic  infection.  In  pure  septic  intoxica- 
tion no  lesions  beyond  the  original  soiu'ces  of  contamination  are  pro- 
duced ;  but  in  progressive  septic  infection  minute  areas  of  inflammation 
and  coagulation  necrosis  in  the  vascular  system  will  be  excited  ;  l^ut  the 
disorder  is  characterized  by  the  absence  of  gross  suppurative  or  necrotic 
lesions.  AYhen,  however,  death  does  not  speedily  terminate  the  infective 
processes,  secondary  centres  of  suppuration  and  necrosis  sometimes 
develop.  Septicaemia  is  then  said  to  have  become  complicated  with 
pvsemia,  and  the  result  has  been  called  septico-pycemia.  With  these 
processes  must  be  considered  one  in  which  symptoms  are  produced 
indistinguishable  from  those  of  ordinary  septiccTemia,  though  milder 
and  more  transitory,  which  seem  to  depend  upon  toxic  products  of 
fermentations,  possibly  not  bacterial  in  origin — the  fermentative  fever  of 
Bergmann.  Symptoraatically,  no  sharp  line  of  demarkation  separates 
the  mildest  forms  of  surgical  or  traumatic  fever  or  the  irritative  fever 
following  absorption  of  poisonous  products  of  putrid  food  substances 
and  the  most  pronounced  forms  of  septicaemia. 

The  stress  of  septicaemia  is  thrown  chiefly  upon  the  vascular  and 
nervous  systems  and  the  blood,  but  the*  range  of  its  activity  is  by  no 
means  understood,  and  probably  includes  most  parts  of  the  body. 

Etiologt. — Although  the  secondary  results  of  wounds  and  injuries 
and  suppurative  and  putrefactive  processes  generally  upon  the  system 
at  large  have  attracted  the  attention  of  writers  ever  since  Hippocrates, 
and  in  many  instances  have  excited  shrewd  guesses  as  to  their  parasitic 
origin,  a  scientific  basis  for  their  elucidation  did  not  exist  until  Van 

495 


496  SEPTICEMIA. 

Leeuwenhoek  in  1675  by  means  of  a  simple  microscope  discovered  and 
described  minute  organisms  which  we  now  know  to  have  been  bacteria. 
The  wide  diifusion  of  such  organisms  at  once,  and  naturally,  suggested 
the  dependence  of  many  morbid  conditions  upon  them.  Such  concep- 
tions, however,  were  based  solely  upon  speculation,  and  presently  fell 
into  disfavor,  and  were  soon  almost  forgotten.  Active  interest  in 
minute  organisms  as  possible  causative  influences  of  disease  was  not 
again  awakened  until  the  present  century  had  well  advanced.  Mean- 
while, however,  much  work  had  been  done  in  the  study  of  putrefactive 
and  suppurative  processes  and  their  relation  to  secondary  inflammatory 
and  degenerative  changes,  but  the  results  were  of  pathological  and  not 
of  pathogenic  interest.  Among  the  eminent  men  engaged  in  this  research 
may  be  mentioned  John  Hunter,  Abernethy,  Cruveilhier,  Magendie, 
Haller,  and  Virchow.  With  the  second  half  of  the  century  renewed 
and  scientific  interest  in  minute  organisms  as  pathogenic  influences 
received  a  stimulus  from  Davaine's  discovery  in  1850  of  the  anthrax 
bacillus  in  the  bodies  of  animals  afl'ected  with  splenic  fever,  and  the 
investigations  in  1857  of  Pasteur  demonstrating  the  agency  of  bacteria 
in  fermentative  processes.  In  1866,  Rindfleisch  described  the  presence 
of  micro-organisms  in  local  inflammatory  deposits  in  the  body.  Von 
Recklinghausen,  Waldeyer,  Birch-Hirsehfeld,  Hueter,  and  others  fol- 
lowed immediately  with  important  observations  revealing  the  presence 
of  bacteria  in  pysemic  conditions.  In  1870,  Klebs  described  as  micro- 
sporon  septicum  the  bacterium  which  he  had  detected  in  the  blood  and 
tissues  after  wound  infection,  and  diflerentiated  septicaemia  and  pyaemia. 
The  pathogenic  influence  of  bacteria  was  now  universally  recognized^ 
and  Koch's  observations  in  1870  established  a  scientific  basis  for  bac- 
teriology in  relation  to  pathological  processes. 

Koch's  experiments  with  septicaemia  of  mice  showed  that  the  animal 
surely  died  in  from  eight  to  sixty  hours  (depending  upon  the  virulence 
of  the  injected  fluid)  after  subcutaneous  inoculation  with  putrefying 
fluids.  The  result  depended  upon  the  stage  of  putrefaction.  Blood 
that  had  been  putrefying  five  hours  in  five-drop  doses  killed  in  eight 
hours  without  producing  macroscopic  pathological  changes  and  without 
the  development  of  bacteria  in  the  blood  or  tissues ;  while  blood  taken 
from  the  auricle  had  no  eifect  if  introduced  under  the  skin  of  another 
healthy  mouse.  Smaller  doses,  one  to  two  drops,  of  the  putrid  fluid 
caused  death  in  from  forty  to  sixty  hours.  He  found  that  by  injecting 
the  blood  of  the  mouse  thus  destroyed  he  could  propagate  the  virus 
indefinitely  and  in  undiminished  virulence,  even  in  doses  as  small  as  one 
tenth  of  a  drop.  Different  varieties  of  bacteria  were  found  in  the  blood 
of  mice  made  ill  by  the  injection,  but  when  death  resulted  small  bacilli 
alone  could  be  found.  Gross  lesions  were  never  found,  but  in  capillary 
bloodvessels  alterations  were  produced  resulting  in  extensive  blood 
extravasations  (Senn's  Principles  of  Surgery).  Koch  also  succeeded  in 
causing  septicaemia  in  rabbits  by  injecting  into  their  tissues  putrid 
infusion  of  meat,  whereby  changes  similar  to  those  induced  in  septi- 
caemia of  mice  were  brought  about.  The  organism  found  was  an  oval 
micrococcus  which  invaded,  and  sometimes  completely  obstructed,  capil- 
lary vessels.  Cultures  of  this  coccus  introduced  into  another  rabbit 
evoked  similar  symptoms. 


ETIOLOGY.  497 

A  variety  of  other  niiero-orgtiuism.s  have  been  proven  eapal)h'  ol' 
causinii'  septicioiiiia  in  animals  ;  for  example,  laicrococcu.s  /(incco/dtu.s, 
oriiiiiially  cleseribed  by  .Sternberg,  and  often  present  in  the  months  of 
healthy  persons,  but  also  found  in  croupous  pneumonia,  cerebro-spinal 
meninii'itis,  otitis  media,  and  other  diseases,  and  micrococcus  tetragcnnn 
of  (nitVky  from  healthy  saliva  and  the  sputa  of  tuberculous  patients. 

Pasteur  in  1880  first  cultivated  xt rcptococcas  from  the  organs  of 
women  dead  of  puerperal  fever,  and  it  is  now  well  established  that  in 
the  great  majority  of  catjes  of  human  sei)ticiemia  this  pyogenic  micro- 
organism is  the  pathogenic  factor.  But  it  is  also  certain  that  a  number 
of  other  pyogenic  bacteria  may  determine  the  same  results.  First 
among  these  is  sf(ij)!ii//ococcHs  pi/of/eiiei^  aureus.  These  two  bacteria  will 
be  found  to  be  the  causes  of  nearly  all  cases  of  septicaemia.  Occasional 
causes  of  septic;emia  are  stapJnjlococcuti  pyof/eneti  albus,  f/onococcu.s,  mlcro- 
coccufi  l<inceol(du)i,  bacillus  pi/ocyaneus,  and  others.  But  almost  at  once 
it  became  apparent  that  the  fatal  character  of  the  infections  could  not 
depend  upon  the  mere  presence  of  these  organisms  in  the  blood  and 
tissues,  for  they  could  be  detected  usually  in  only  limited  numbers,  and 
often  enough  very  careful  research  failed  to  reveal  them  at  all,  except 
at  original  foci  or  after  death,  in  animals  that  had  uuquestionaljly  been 
affected  with  septicaemia.  It  became  evident,  then,  that  if  the  bacteria 
themselves  failed  to  account  for  the  results,  the  explanation  had  to  be 
sought  in  some  poisonous  substance  concurrent  with  them,  and  ]>robal)ly 
produced  by  them.  The  conception  of  the  action  of  poisonous  chemical 
substances  elaborated  by  bacteria  upon  the  animal  body  received  its  im- 
petus from  the  discoveries  of  Pasteur  regarding  putrefaction  and  fer- 
mentation. Research  has  shown  that  charactetistic  symptoms  of  sepsis 
may  be  evoked  in  animals  by  the  injection  of  putrid  fluid  from  which 
living  organisms  have  been  carefully  excluded  by  sterilization,  as  well 
as  of  sterilized  cultures  of  pyogenic  organisms.  Indeed,  definite  chem- 
ical substances  which  have  been  called  ptomaines,  toxic  alkaloids, 
toxins,  have  been  obtained  from  the  putrid  liquids,  and  have  been 
proven  to  be  capable  of  exerting  poisonous  influences  over  animals  sub- 
jected to  their  action.  Brieger  and  others  have  isolated  a  number  of 
such  products.  Clinical  observation  appeared  to  justifv  the  conclusion 
that  similar  toxic  effects  are  frequently  produced  in  man,  and  that  a  dis- 
tinct form  of  septicaemia  exists  which  is  an  intoxication  produced  bv 
the  absorption  of  the  chemical  products  of  putrefaction  and  suppuration, 
and  in  Avhich  no  infective  invasion  of  the  blood  itself  bv  putrefactive 
and  pyogenic  organisms  occurs.  Such  septic  intoxication  is  widely  held 
to  depend  upon  putrefactive  processes  alone,  in  which  bacteria  are  not 
to  be  found  in  the  blood,  or,  if  so,  are  only  accidentally  present  and 
are  innocuous.  They  are  saprophytic  bacteria,  and  can  only  grow  in 
necrotic  and  putrefying  foci  exposed  to  the  air.  The  intoxication, 
being  caused  by  toxins  (ptomaines)  formed  in  these  foci  and  absorbed 
into  the  blood,  results  in  death  or  recovery  just  as  the  dose  has  been 
great  or  small.  If  this  be  small  and  the  supply  restricted  by  the  re- 
moval or  destruction  of  the  putrefactive  centres,  recovery  will  pmbablv 
follow  ;  but  if  it  be  large  and  the  supply  continuous,  the  patient  will 
probably  die.  This  form  of  septicaemia  is  more  especially  encountered 
in  puerperal  fever,  where  the  toxic  material  has  been  derived  from  putre- 

VoL.  I.— 32 


498  SEPTICEMIA. 

factive  changes  in  the  cavity  of  the  uterus  following  delivery.  Its  sup- 
posed origin  in  saprophytic  bacteria  suggested  to  Matthews  Duncan  the 
name  sapnemia  {aanpo:;,  putrid,  aiim,  blood),  by  which  it  is  widely 
known.  There  is  some  reason  to  believe,  however,  that  septic  intoxica- 
tion is  not  so  constantly  dependent  upon  the  organism  of  putrefaction 
as  this  term  would  indicate,  as  in  typical  "saprsemia"  Bumm,  Von 
Franque,  and  others  rarely  failed  to  find  in  the  toxic  centres  pyogenic 
bacteria.^  It  is  also  significant  that  proteus  vulgaris,  a  widely  distrib- 
uted micro-organism  of  putrefaction,  according  to  Flexner,  "may  be 
unassociated  with  other  bacteria  in  abscesses  and  in  peritonitis,  and  it 
may  cause  general  infection  by  invading  the  blood  and  internal  organs."  ^ 
When  pyogenic  bacteria  are  the  cause  of  septic  intoxication,  it  is  by  no 
means  certain  that  the  circulation  remains  free  from  them,  but  for  some 
unexplained  reason  they  are  incapable  of  growth  and  reproduction  in 
the  blood ;  the  suppurative  centres  furnish  the  toxins  upon  which  the 
symptoms  depend. 

Not  only  may  a  septic  intoxication  depend  upon  absorption  of  the 
toxic  chemical  products  of  pathogenic  bacteria,  but  it  is  known  that 
similar  effects,  though  in  much  milder  degree,  may  be  caused  by  ferment 
substances  not  bacterial  in  origin.  Thus  a  febrile  reaction  may  be  ex- 
cited by  introducing  into  the  blood  of  a  living  animal  pepsin,  trypsin, 
pancreatin,  or  a  number  of  indifferent  substances.  The  transitory  fever 
that  often  follows  within  a  few  hours  a  wound,  an  injury,  a  surgical  ope- 
ration, even  when  there  may  be  no  external  lesion,  but  especially  after 
more  or  less  extravasation  of  blood,  the  stomach  ingestion  of  various 
'injurious  food  substances,  as  so  often  occurs  in  children, — all  maybe 
supposed  to  be  due  to  the  absorj)tion  of  various  aseptic  substances  which 
Worm-Muller  believes  to  cause  by  their  action  upon  the  blood  the  gen- 
eration of  fibrin  ferment,  which  excites  febrile  reaction.  This  fever 
Bergmann  denominates  "fermentation  fever  ;"  Volkmann,  aseptic  fever  ; 
it  is  also  known  as  irritative  fever,  resorption  fever,  etc.  While  it  is  quite 
possible,  however,  that  this  "  fermentation  fever "  may  be  due  to  the 
absorption  of  "  products  of  aseptic  tissue  necrosis,"  it  is  by  no  means 
certain  that  it  may  not  ultimately  come  to  be  proven  to  depend  upon  a 
true  septic  intoxication  of  feeble  potency. 

Septicemia  in  by  far  the  greater  number  of  cases  is  a  sepdic  infection. 
By  this  is  understood  a  condition  in  which  pyogenic  bacteria  gain  ad- 
mission to  the  blood  and  tissues,  and  there  pursue  their  pathogenic 
activity.  The  common  source  of  septic  infection  (progressive  septic 
infection)  is  streptococcus  pyogenes.  Staphylococcus  pyogenes  aureus  is 
also  a  frequent  cause,  but  indeed  any  of  the  pyogenic  bacteria  may 
determine  septiceemia.  The  best  type  of  the  disorder  in  the  lower  ani- 
mals is  anthrax,  due  to  bacillus  anthracis,  in  which  the  blood  and  tissues 
frequently  swarm  with  the  micro-organism.  In  septic  infection  the 
symptoms  are  due  to  toxins  produced  both  at  the  original  source  of 
infection  in  the  body  and  by  the  micro-organisms  in  the  blood  and 
tissues.  The  essential  difference  between  a  j)ure  septic  intoxication  and 
septic  infection  consists  in  this,  that  the  one  cannot  be  inoculated  upon 
another  individual,  while  the  other  is  freely  inoculable. 

^  Williams,  American  Journ.  Med.  Sciences,  vol.  cvi.,  1893,  p.  47. 
^  Welch,  A  System  of  Surgery,  Dennis,  vol.  i.  p.  322. 


ETIOLoav.  499 

Jn  man,  in  s('j)tic  infection  tlu'  mnnbcr  of"  micro-organisms  is  always 
limited,  and  often  very  small — iiardly  ever  so  ahnndant  that  the  simple 
meeiianieal  I'tfects  of  tlu'ir  presence  can  be  considei'ed  as  a  factor  in  the 
morbid  resnlts.  "  We  find  them  far  more  frequently  in  the  blood  at 
autopsies,  even  very  fresh  ones,  than  we  are  able  to  do  durin<r  life. 
The  pyogenic  cocci,  like  most  })atho_t>'enic  bacteria,  only  exceptionally 
are  al)le  to  multiply  in  the  circulating-  blood  of  hmnan  l)ein<;s.  The 
greater  frequency  of  their  presence  in  demonstrid)le  number  at  autopsy 
may  be  due  in  part  to  their  multiplication  after  death,  but  this  cannot 
be  the  sole  explanation,  as  the  cocci  are  found  in  autopsies  made  very 
early  after  death,  more  frequently  than  they  are  found  during  life. 
The  explanation  is  jn'obably  that  during  the  last  hours  of  life  they 
often  find  suitable  conditions  for  their  multiplication  in  the  blood." 
They  "  grow  outside  of  the  circulating  blood,  and  often  do  not  make 
their  appearance  in  any  considerable  number  in  the  circulation  until 
shortly  before  death  and  after  the  manifestation  of  grave  constitutional 
symptoms."  ^ 

Exactly  what  determines  the  admission  or  exclusion  of  the  organ- 
isms, or  the  mildness  or  severity  of  their  eifects  after  they  gain  access 
to  the  circulation,  is  not  understood :  a  mere  scratch  with  infected 
material  from  a  suppurating  or  erysipelatous  centre  or  a  dissection 
wound  may  be  followed  rapidly  by  fatal  results  after  but  little  local 
reaction.  On  the  other  hand,  the  condition  of  the  infected  tissues  un- 
doubtedly has  great  influence  over  the  result,  and  if  they  permit  the 
passage  of  only  a  few  microbes,  these  may  be  destroyed  without  disas- 
trous consequences  by  their  inherent  germicidal  properties.  The  devel- 
opment of  pathogenic  organisms  within  the  body  is  undoubtedly  facili- 
tated if  their  poisonous  chemical  products  are  absorbed  at  the  same  time 
with  them.  The  septic  intoxication  that  ensues  impairs  the  power  of 
resistance  of  the  blood,  bloodvessels,  and  tissues,  and  favorable  oppor- 
tunities are  afforded  for  the  development  and  reproduction  of  micro- 
organisms at  distant  points.  "  If  a  large  quantity  of  pus  microbes  is 
introduced  into  the  peritoneal  cavity  or  directly  into  the  circulation, 
death  results  from  sepsis  before  a  sufficient  length  of  time  has  elapsed 
for  the  pus  microbes  to  produce  the  histological  changes  which  are 
necessary  for  the  production  of  pus  "  (Senn).  But  in  septic  infection 
the  intoxication  is  intensified  and  perpetuated  by  the  microbes  which 
have  gained  access  to  the  circulation  and  find  conditions  favorable  to 
their  growth  and  reproduction.  Thus  the  patient  is  not  only  poisoned 
by  toxins  formed  at  centres  of  infection,  but  also  by  those  formed 
within  the  body. 

Different  conditions  vary  the  activity  of  pathogenic  organisms.  Ex- 
perimentally, these  variations  have  been  shown  to  be  brought  about  by 
many  modifying  influences  ;  clinically,  widely  different  morbid  results 
are  observed  to  be  produced  by  a  single  species  of  bacterium  in  propor- 
tion to  its  virulence — at  one  time  intense  septic  infection,  at  another 
localized  inflammation.  Under  inoculation  pathogenic  micro-organisms 
prove  more  virulent  when  derived  from  centres  of  infective  inflamma- 
tion. AVelch  points  out  the  modifying  influence  of  mixed  infections 
upon  pathological  results — an  influence  that  probably  depends  upon  the 

^  Welch,  Dennises  System  of  Surgery. 


600  SEPTICEMIA. 

effects  of  the  chemical  products  of  one  bacterium  upon  the  vitality  of 
another,  and  which  may  be  exerted  in  diminishing  or  intensifying  the 
morbid  processes.  "  A  bacterium  of  attenuated  virulence  may  become 
augmented  in  virulence  by  inoculation  in  combination  with  another 
species  which  need  not  necessarily  be  itself  pathogenic,  or  sometimes 
simply  in  combination  with  the  chemical  products  of  another  species. 
These  mixed  infections  very  often  occur  in  mau,'^  He  also  notes  the 
frequency  of  secondary  infections  with  pyogenic  bacteria,  especially 
streptococeus  pyogenes,  in  various  specific  infectious  diseases,  such  as 
typhoid  fever,  tuberculosis,  diphtheria,  scarlet  fever,  smallpox,  and 
other  affections,  these  increasing  the  conditions  favorable  to  the  de- 
velopment of  the  purely  septic  micro-organisms. 

^  At  present  it  is  not  possible  to  offer  a  scientific  justification  of  the 
clinical  definitions  of  the  different  forms  of  septicemia.  Sharp  limita- 
tions do  not  exist,  and  it  is  probable  that  purely  saprophytic  septicaemia 
occurs  but  rarely  ;  but  for  practical  purposes  it' has  been  found  conveni- 
ent and  advantageous  to  assign  to  septicaemia  three  types.     These  are — 

(1)  A  febrile  reaction  due  to  the  presence  in  the  blood  of  toxic  sub- 
stances absorbed  from  putrefactive  or  suppurative  foci,  where  they  are 
produced  by  the  vital  activity  of  bacteria,  which,  however,  remain  re- 
stricted to  the  sites  of  their  original  production,  and  do  not  gain  access 
to  the  blood,  or,  reaching  this  fluid  in  limited  numbers,  are  incapable 
of  growth  and  reproduction  there  (septic  intoxication). 

(2)  A  febrile  reaction  due  to  the  presence  in  the  blood  and  tissues  of 
toxic  substances,  together  with  the  bacteria  which  produce  them  and 
which  are  jDyogenic.  These  are  derived  from  original  foci  upon  the 
body,  and  after  their  entrance  into  the  circulation  continue  to  grow  and 
to  be  reproduced,  and  to  generate  their  toxins  (septic  infection  ;  pro- 
gressive septic  infection). 

To  these  may  be  conveniently  added — 

(3)  A  febrile  reaction  due  to  foreign  aseptic  substances  in  the  blood, 
which  determine  in  it  the  presence  of  fibrin  ferment,  which  is  the  excit- 
ing cause  of  the  fever.  This  is  mild  in  its  course  and  transitory  (fer- 
mentation fever). 

The  sources  of  septic  intoxication  and  septic  infection  are  suppura- 
tive and  putrefactive  centres  of  all  kinds  upon  the  surface  of  tl>e  body  or 
the  mucous  membranes,  as  well  as  lesions  and  abrasion  of  any  kind 
whereby  an  absorbing  surface  is  exposed  to  the  influence  of  the  patho- 
genic organisms.  It  is  doubtful  that  micro-organisms  can  gain  the  cir- 
culation through  the  unruptured  epidermis,  but  it  is  possible  that  the 
mucous  membrane  does  not  offer  an  impassable  barrier  to  them.  It  is, 
of  course,  impossible  to  say  what  channels  for  their  admission  may  not 
be  afforded  by  the  mucous  tract,  and  many  eases  of  so  called  "  sponta- 
neous septicaemia  "  originate  in  the  infection  of  some  undiscovered  lesion. 
The  occasional  development  of  obscure  septicaemic  disorders  Avithout 
previous  recognized  injury  or  lesion  appears  to  justify  the  claim  that  in- 
fection may  occur  througli  an  intact  membrane.  Most  bacteriologists  at 
present,  however,  deny  the  occurrence  of  this  spontaneous  or  crypto- 
genetic  septicaemia. 

Pathological,  Anatomy. — It  is  doubtful  if  any  lesions  of  the  tissues 
are  produced  by  fermentation  fever.  Its  course  is  always  favorable,  and  the 


VATHOLUUICAL    AS  ATOMY.  501 

alterations  it  causes,  if  any,  are  transitory  and  have  not  been  recognized. 
The  morbid  changes  rcsultinii-  from  septic  intoxication  are  never  such  as 
can  be  seen  by  tiic  naked  eye.  I  liey  are  microscopic  and  never  exten- 
sive. The  coagulability  of  the  blood  is  certainly  diminished,  and  putre- 
faction sets  in  earlier  than  is  usually  the  case.  Rigor  mortis  is  also 
established  earlv.  The  blood  will  be  free  of  micro-org-anisms  and  of 
dark  color.  In  fatal  septic  intoxication  the  course  is  so  acute  that  re- 
cognizable changes  in  the  bloodvessels  and  tissues  will  not  have  had 
time  to  appear.  Even  in  septic  infection  (progressive)  there  is  a  notable 
absence  of  gross  lesions  unless  the  course  of  the  disease  have  been  pro- 
tracted and  septo-pvfemia  have  develo])ed.  After  death  from  progressive 
septic  infection  rigor  mortis  occurs  early. 

The  l)lood  is  dark  and  coagulates  feebly  or  not  at  all.  In  it  the 
micro-organisms  of  pus  will  be  found  often,  sometimes  in  considerable 
numbers ;  groups  of  micrococci  may  crowd  tissues  and  capillaries. 
Only  slight  changes  may  be  noted  at  the  primary  centres  of  infection, 
though  lymphatic  vessels  leading  from  them  may  be  found  in  a  state  of 
inflammation.  Thrombosis  and  embolism  are  rarely  present.  There 
may  be  some  cloudy  swelling  of  internal  organs  from  superficial  coagu- 
lation necrosis.  There  will  be  widespread  evidence  of  septic  inflamma- 
tion of  capillary  vessels.  A  coagulation  necrosis  of  these  vessels  caused 
by  the  toxins  in  the  blood  favors  implantation  of  septic  organisms,  and 
their  development  and  an  extensive  metastatic  inflammation.  Should 
the  course  of  the  septiciemia  have  been  protracted,  these  foci  of  inflam- 
mati<in  will  have  proceeded  to  suppuration  and  true  metastatic  abscess. 
Minute  areas  of  hemorrhagic  exudation  from  these  foci  of  vascular 
inflammation  are  often  midtitudinously  scattered  throughout  the  body, 
and  will  often  be  found  in  the  serous  and  mucous  membranes  and  the 
skin.  The  spleen  will  be  softened,  darkened  in  color,  and  at  times  con- 
siderably enlarged.  Effusions  into  the  serous  cavities  are  not  infrequent. 
Putrefaction  will  be  most  intense  in  the  vicinity  of  the  original  infection 
focus  and  in  those  parts  most  abundantly  supplied  with  blood.  The 
cadaver  often  exhales  a  peculiar  putrefaction  odor.  Hypersemia  of  the 
meninges  of  the  spinal  cord  and  brain,  but  no  grosser  lesions,  will  be 
found.  The  lungs  will  be  congested  and  oedematous,  the  liver  fatty, 
and  of  a  dirty  yellowish  gray  color,  the  hepatic  venous  system  engorged. 
The  kidneys  are  always  congested,  their  epithelia  granular  and  swollen. 
There  is  sometimes  exudation  lietween  the  glomeruli  and  capsules. 
There  may  be  capillary  extravasations  into  and  between  the  tubules. 
AVidespread  catarrh  of  mucous  surfaces  will  be  observed  ;  the  bronchial, 
intestinal,  renal,  urinary,  and  uterine  mucous  membranes  will  usually 
present  inflammatory  changes  and  often  limited  areas  of  hemorrhage. 
The  ovaries  and  uterus  are  often  congested,  and  the  muscular  system 
darkened  in  color.  The  endocardium  and  intima  of  vessels  will  be 
stained  by  the  haemoglobin  set  free  by  the  disintegration  of  the  red  blood 
corpuscles.  Capillary  extravasations  are  especially  marked  in  the 
mucous  and  submucous  coats  of  the  intestines.  In  pure  progressive 
septic  infection  pus  may  be  found  in  the  infection  centre,  and  inciden- 
tally in  other  parts,  but  never  as  a  result,  of  the  essential  disorder. 
In  many  instances  after  protracted  septicaemia  metastatic  abscess  and 
pyaemic  inflammations  will  be  found,  but  these  do  not  follow  of  neces- 


502 


SEPTICEMIA. 


sity,  and  when  present  may  be  accepted  as  evidences  of  concurrent 
pysemia. 

Symptoms. — Septicaemia  and  pyaemia  constitute  complications  of 
medical  no  less  than  of  surgical  disorders.  Indeed,  when  their  origin 
is  obscure  they  usually  fall  to  the  care  of  the  physician  rather  than  the 
surgeon.  They  are  observed  with  great  frequency  as  results  of  gan- 
grenous and  suppurative  inflammations  in  typhoid  and  scarlet  fevers, 
diphtheria,  smallpox,  tuberculosis,  and  other  specific  diseases.  Even 
the  analogous  febrile  state  caused  by  the  absorption  of  chemical  sub- 
stances formed  by  fermentations  not  bacterial  in  origin,  fermentation 
fever,  closely  concerns  the  physician,  for  not  only  does  it  follow  injuries, 
wounds,  and  surgical  operations,  but  it  may  be  excited  by  purely  medical 
disorders.  The  transitory  febrile  reaction  so  commonly  observed  in 
childhood  accompanying  or  following  a  severe  indigestion  presents 
precisely  similar  features,  and  may  be  attributed  probably  to  poisonous 
products  of  abnormal  fermentations  in  the  stomach  and  bowels.  Simi- 
larly, it  is  not  improbable  that  the  fevers  following  many  hemorrhages, 
cerebral,  pulmonary,  etc.,  are  due  to  absorption  of  ferment  substances 
developed  in  the  effused  blood.  This  "  fermentation  fever,"  then,  may 
well  find  a  place  in  a  work  on  internal  medicine. 

(1)  Fermentation  Fever. — Within  a  few,  usually  within  twenty-four, 
hours  after  an  injury,  with  or  without  external  lesion,  often  after  sub- 
cutaneous blood  extravasation,  after  a  surgical  operation  even  so  simple 
as  the  passage  of  a  catheter,  or  after  the  ingestion  of  unwholesome  food, 
the  patient  will  develop  fever  with  or  Avithout  preceding  chill.  The  tem- 
perature rises  rapidly  two,  three,  four,  possibly  six  degrees  (Fahrenheit). 
The  pulse  becomes  full  and  frequent,  the  heart  action  violent.  There 
are  often  flushing  of  the  face,  injection  of  the  eyes,  and  throbbing  head- 
ache. The  tongue  acquires  a  slight  whitish  coating,  but  remains  moist. 
More  or  less  complete  anorexia  is  present,  and  sometimes  nausea  and 
vomiting  ensue.     The  secretions  are  all  diminished,  the  urine  becoming 

scanty  and  high  colored,  but  remaining  free 
of  albumin.  The  skin  may  be  hot  and  dry. 
No  especial  influence  is  exerted  upon  the 
bowels,  though  constipation  is  often  present. 
After  rapidly  attaining  its  maximum  the 
fever  gradually  subsides,  and  never  lasts 
lousier  than  two  or  three  davs  ;  it  often 
ceases  within  twenty-four  hours.  (See 
Fig.  42.)  This  fever  corresponds  closely 
to  that  which  may  be  induced  experi- 
mentally by  injecting  pepsin  into  the  cir- 
culation. In  surgical  practice  it  is  said  to 
be  especially  liable  to  occur  if  the  super- 
ficial tissues  of  a  wound  have  become 
necrosed  as  a  result  of  antiseptic  applica- 
Temperature  record  of  fermentation  tions,  or  if  in  a  closed  wound  extravasated 

blood  is  retained  under  high  pressure. 
Headache  and  aching  pains  in  the  back  and  limbs  are  very  common, 
but,  as  a  rule,  all  the  symptoms  are  mild,  and  frequently  the  ther- 
mometer alone  will  reveal  the  existence  of  fever.     During  the  attack 


Fig. 

42 

TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

Wl 

E 

THMP. 

A 

102 

'\ 

'\ 

V 

' 

,   / 

V 

lof 

1 

100 

\ 

\ 

j 

I 

\ 

J 

\ 

99 

/ 

1 

1 

/ 

^ 

98 







_ 

1 

SY3fPT0MS.  503 

there  may  be,  rarely,  inikl  deliriiuu.  Examination  of  the  blood  ^vill 
reveal  nothing  abnormal.  The  symptoms  may  subside  as  rai)idly  as 
they  arise.     No  alter  efteets  are  ever  noted. 

(2)  Septic  Iiifo.rinifion. — In  septie  intoxication  the  symptoms  are 
supposed  to  be  due  to  the  al)sorption  of  toxins  })rodueed  at  suppura- 
tive or  putrefactive  centres  in  the  body  by  pyogenic  or  saprophytic 
micro-organisms  which  do  not  gain  access  to  the  circulation,  or,  at  least, 
are  incapable  of  growth  and  reproduction  in  it.  To  this  form  of  septi- 
caemia l)elongs  the  sapnemia  of  Matthews  Duncan,  though,  as  has  been 
shown,  it  is  very  doul^tful  if  -a])r<)phytic  organisms  alone  are  competent 
to  exert  such  an  important  intiuence  in  septic  intoxication  as  has  been 
claimed  for  them. 

Septic  intoxication  usually  demand.-  for  its  existence  a  centre  of 
necrosis  in  the  body,  and  the  establishment  of  putrefaction  in  this. 
Thus  it  frequently  <lepends  npon  the  decomposition  of  a  retained 
placenta,  of  a  blood-clot,  or  any  area  of  dead  tissue  exposed  to  the 
action  of  the  atmosphere.  The  primary  seat  of  infection  will  present 
evidences  of  gangrene.  The  surface  of  the  slough  will  be  dry  and 
brownish,  or  will  have  scattered  grayish,  membrane-like  patches.  Usu- 
ally a  fetid  odor  will  be  exhaled.  This  may  become  intense  and  pervade 
the  apartment.  Many  so  called  septic  intoxications  originating  in  purely 
suppurative  centres  are  really  septic  infections,  and  indeed,  in  many 
"septic  intoxications"  from  putrefactive  centres  pyogenic  micro-organ- 
isms may  be  demonstrated.  The  symptoms  of  septic  intoxication  will 
rarely  develop  within  twenty-four  hours.  They  may  appear  later  as 
long  as  any  gangrenous  tissue  is  in  relation  with  an  absorbing  surface. 
Usually  without  an  initial  chill  there  is  a  rapid  rise  of  temperature, 
which  may  attain  104^  F.  within  a  few  hours.  At  other  times  the  rise 
is  moderate,  or,  again,  very  slight ;  the  temperature  may  even  fall  below 
the  normal,  and  this  sometimes  in  the  worst  cases.  The  irregular  tem- 
perature curves  of  pyaemia  do  not  occur.  The  stress  of  the  disorder  is 
thrown  upon  the  nervous  system,  but  the  respiratory  and  circulatory 
organs  and  the  alimentary  canal  are  often  profoundly  aifected.  The  ner- 
vous symptoms  principally  consist  in  headache,  prostration,  and.  later,  a 
tendency  toward  narcosis  and  often  delirium.  The  prostration  shows 
itself  in  great  muscular  weakness  and  cardiac  debility.  The  patient 
becomes  indifferent  to  his  surroundings  and  disposed  to  sleep.  A  low 
muttering  delirium  may  appear,  and  in  l)ad  cases  turn  into  coma.  How- 
ever, the  mind  often  retains  its  clearness,  even  in  fatal  cases,  almost  to 
the  end.  The  tongue  is  at  first  coated  with  yellowish  white  fur,  but 
may  become  dry  and  brown.  Anorexia  is  present ;  vomiting  is  not 
uncommon,  and  is  sometimes  uncontrollable.  The  bowels  may  be 
either  constipated  or  relaxed.  Copious  diarrhoea  may  be  present,  and 
the  stools  may  contain  mucus  and  blood.  The  respirations  become 
quick  and  shallow,  but  cough  and  intrathoracic  pain  are  generally 
absent.  Dyspnoea  may  occur  from  hypostatic  engorgement.  Jaundice 
is  not  so  frequent  as  in  septic  infection  and  pyaemia,  but  the  skin  often 
has  a  yellowish  tinge,  which  may  be  due  to  bile  pigment  or  more  proba- 
bly to  blood  pigment  from  disintegration  of  red  blood  corpuscles.  Under 
the  microscope  the  red  corpuscles  will  arrange  themselves  in  clumps. 
The  urine  Avill  be  scanty,  high  colored,  and  acid,  rarely  albuminous. 


504 


SEPTICJEMIA. 


Fig. 

43 

TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

TEMP. 

F. 

104 

^ 

/ 

/ 

103 

102 

1 

101 

\ 

I 

\ 

1 

1 

\ 

100 

1 

' 

1/ 

99 

, 

1 

A 

\ 

V 

\ 

/ 

\ 

t 

1 

1  *> 

»  / 

1 

1 

• 

1 

Temperature  record  of  septic  intoxi 
cation. 


Septic  intoxication  usually  develops  from  centres  of  considerable  size, 
and  should  the  dose  of  toxins  not  be  repeated  the  symptoms  attain  their 

acme  almost  at  once,  within  a  day  or  two 
if  the  amount  absorbed  have  been  insuf- 
ficient to  destroy  life,  or  terminating  in 
death  within  the  same  brief  period  should 
an  overwhelming  quantity  have  been  re- 
ceived into  the  circulation.  The  disease 
may  run  a  more  protracted  course,  if  the 
centre  of  absorption  persist,  from  the  re- 
peated admission  of  the  toxin  into  the 
blood.  In  this  event  there  will  be  no 
repetition  of  the  chill,  but  recrudescence 
of  the  other  symptoms  may  be  expected, 
varying  in  intensity  with  the  extent  of 
the  intoxication,  generally  tending  toward 
a  fatal  termination. 

The  course  of  septic  intoxication  is 
usually  from  two  to  four  or  five  days.  (See 
Fig.  43.)  It  rarely  persists  beyond  the 
week,  except  in  certain  cases  when  the 
supply  of  toxin  is  limited  and  its  source 
inaccessible,  as  in  some  examples  of  pul- 
monary gangrene,  etc.  Progress  toward  recovery  is  marked  by  a 
gradual  subsidence  of  all  the  symptoms  and  the  return  of  healthy 
action  in  the  periphery  of  the  putrefactive  focus.  A  fatal  termination 
is  preceded  by  intensification  of  all  symptoms.  The  essential  failure 
is  in  the  nervous  system.  The  prostration  becomes  extreme,  the  heart 
action  feeble  and  rapid,  and  the  arterial  tension  gradually  fails.  The 
respiration  grows  more  shallow  and  hurried.  The  intelligence  becomes 
more  blunted  ;  delirium  supervenes  and  passes  into  coma.  The  eyes  are 
sunken,  the  skin  bathed  in  sweat.  Death  occurs  from  failure  of  the 
heart. 

(3)  Se'ptic  Infection  (Progressive  Septic  Infection). — AVhile  in  septic 
intoxication  the  intensity  depends  largely  upon  the  extent  of  the  toxin- 
producing  centres,  this  is  not  the  case  with  septic  infection.  Here  the 
micro-organisms  are  always  pyogenic,  more  or  less  freely  reproduced 
within  the  body,  and  continue  to  contaminate  it  with  their  freshly  pro- 
duced toxins.  Thus  we  very  commonly  see  intense  infection  follow  a 
very  insignificant  lesion,  such  as  a  dissection  wound  or  the  prick  of  an 
infected  needle  or  scalpel.  That  general  infection  may  occur  it  is  not 
at  all  essential  that  the  point  of  original  infection  be  in  a  state  of  sujjpu- 
ration  or  putrefaction.  It  is  impossible  to  ascertain  what  routes  for  the 
admission  of  bacteria  may  be  offered  by  the  parts  of  the  mucous  tract 
inaccessible  to  the  eye.  Internal  sepsis  is  by  no  means  rare.  Thus, 
septicffimia  may  originate  from  intestinal  ulceration,  from  pulmonary 
cavities  and  suppurative  centres,  from  empyema,  from  purulent  peri- 
carditis and  peritonitis,  from  otitis  media,  from  osteomyelitis,  from 
pyelitis  and  pyelo-nephritis,  and,  in  short,  from  any  internal  part  of 
the  body  involved  in  suppurative  inflammation.  An  intense  and  rapidly 
fatal  sepsis  follows  septic  peritonitis  and  acute  multiple  osteomyelitis. 


.';iyMrTOMS. 


505 


while  the  septic  symptoms  from  ])iiriilent  pleurisy  and  pericarditis  will 
be  much  less  severe,  thoui;h  often  more  })r<)traeted.  It  is  reasonably 
certain  that  sei)ticaMnia  may  develop  from  an  urethral  stricture.  While 
the  so  called  spontaneous  septic  iniection  cannot  be  allowed,  the  obscu- 
ritv  of  the  source  of  vsome  septicemias  even  su<2;gests  the  entrance  of 
micro-orijanisms  throuoh  the  intact  mucous  mend)rane. 

It  is  usuallv  impossible  to  account  for  the  origin  of  an  osteomyelitis 
or  of  an  ulcerative  endocarditis  in  the  absence  of  any  demonstral)le 
lesit)n  ;  but  at  present  it  would  be  rash  to  assert  that  septic  bacteria  ean 
reach  the  circulation  except  through  some  lesion  of  continuity.  The 
unruptured  pulmonary  mucous  membrane,  for  example,  is  almost  cer- 
tainly impervious  to  them,  though  intoxications  from  sewer  gas  by  this 
route  may  readily  take  place.  Without  doubt,  pyogenic  organisms  in 
limited  numbers  may  enter  the  circulation,  and,  not  finding  conditions 
favorable  to  their  development,  perish,  or  at  least  remain  quiescent  so 
long  as  the  blood  and  tissues  maintain  their  normal  powers  of  resist- 
ance. On  the  other  hand,  especial  virulence  may  destroy  life  so  speedily 
that  time  will  not  have  been  allowed  for  the  production  of  anatomical 
changes  ;  but  in  other  and  more  protracted  instances  the  organisms  may 
onlv  find  favorable  opportunities  for  growth  in  special  structures,  such 
as  the  bones,  the  endocardium,  etc.  Again,  the  toxins  absorbed  from  pri- 
marv  centres  of  suppuration  may  so  empoison  the  blood  and  the  intima 
of  bloodvessels  that  the  powers  of  resistance  of  these  is  diminished  to 
the  degree  that  they  come  to  aiford  the  conditions  for  bacterial  devel- 
opment. It  is  thus  that  in  ordinary  cases  of  septic  infection  colonies 
of  micro-organisms  will  be  found  in  scattered  foci  of  the  capillary 
system,  and  when  life  has  been  sufficiently  prolonged  the   results  of 

Fig.  44. 


103 


102 


M 

E 

M 

E 

■ME 

m;  e 

M 

E 

M 

E 

M 

E 

IV1,E 

M 

E 

A 

> 

) 

/\ 

f 

A 

,/ 

' 

A- 

— 

— 

f 

\, 

V 

' 

V 

J 

1 

/ 

/ 

, 

/ 

/ 

f 

1 

1  f 

1 

/ 

f 

1 

/ 

/ 

i\ 

i\ 

/{ 

A 

/ ! 

v 

\i  ! 

[ 

j 

1 

1 

' 

1 

Temperature  record  of  septic  infection. 


their   activity  may  even   be    thrombosis    and    embolism    and   pysemic 
abscess. 

The  symptoms  of  septic  infection   rarely  begin  wathin  tw^enty-four 


506  SEPTICEMIA. 

hours,  usually  only  after  three  or  four  days.  There  may  be  an  initial 
chill ;  more  commonly  there  are  only  chilly  or  "  creepy "  sensations. 
Unlike  septic  intoxication,  septic  infection  does  not  reach  its  maximum 
intensity  immediately  after  the  onset.  (See  Fig;  44.)  The  fever  gathers 
force  as  the  micro-organisms  develop  and  produce  their  toxin.  The 
course  of  the  established  disease  is  that  of  a  septic  intoxication.  In  some 
cases,  even  in  those  pursuing  a  rapidly  fatal  course,  there  may  be  but  little 
elevation  of  temperature.  Generally,  however,  the  fever  rapidly  attains 
a  height  of  102°-104°  F.  The  latter  temperature  is  not  often  exceeded, 
even  in  fatal  cases.  Slight  morning  remissions  are  often  observed. 
The  pulse  is  notably  of  low  tension,  and  may  be  very  frequent,  120-140 
or  more  to  the  minute.  Microscopic  examination  of  the  blood  rarely 
reveals  the  presence  of  bacteria,  but  will  show  sometimes  marked  leu- 
cocytosis  with  decided  diminution  in  the  number  of  red  corpuscles. 
The  nervous  symptoms  quickly  appear,  and  the  patient  develops  a 
remarkable  indifference  to  his  surroundings  and  his  danger.  Little  or 
no  agitation  or  jactitation  will  be  exhibited.  There  is  rather  a  profound 
depression  of  muscular  activity.  The  mental  indifference  is  often  ac- 
companied by  persistent  somnolence  and  succeeded  by  low  muttering 
delirium.  The  tongue,  at  first  moist  and  coated,  as  the  disease  advances 
becomes  reddened  at  the  tip  and  border,  but  often  dry  and  brown, 
almost  black,  at  the  centre.  There  are  great  thirst  and  complete  loss 
of  appetite.  JSTausea  and  vomiting  are  frequent,  as  is  diarrhoea.  Later 
the  stools  may  become  bloody,  and  sometimes  pronounced  entero-colitis 
results.  The  skin  assumes  an  earthy  color.  This  often  passes  into  a 
slight  icteroid  hue,  which  is  attributable  rather  to  liberation  of  blood 
pigment  than  to  hepatogenous  changes.  Toward  the  conclusion  of  fatal 
cases  it  may  be  bathed  in  sweat.  Sweating  is  frequent  in  all  cases  ;  it 
may  be  intermittent.  Various  cutaneous  eruptions  are  often  observed. 
These  are  usually  erythematous.  They  may  be  distinctly  scarlatinoid 
in  character.  Most  cases  of  so  called  surgical  scarlatina  are  really  septic. 
This  eruption  often  begins  in  the  vicinity  of  the  original  focus  of  infec- 
tion, but  may  show  itself  upon  any  part  of  the  surface.  It  rarely  shows 
the  diffuse  characters  of  true  scarlet  fever.  The  erythema  may  also  be 
distinctly  erysipeloid,  but  differs  from  erysipelas  in  being  painless. 
Usually  the  erythema  is  in  scattered  patches.  Vesicular  and  pustular 
eruptions  are  also  occasionally  observed.  In  fatal  cases  petechise,  some- 
times in  large  numbers,  and  ecchymotic  extravasations  of  blood,  appear 
ujDon  the  skin. 

The  urine  is  scanty,  of  high  specific  gravity,  loaded  with  urates,  but 
usually  free  from  albumin.  The  primary  seat  of  infection  becomes  dry 
and  inactive,  and  in  severe  cases  very  foul.  In  puerperal  septicaemia 
the  lochia  become  offensive  in  odor,  and  are  diminished  or  even  sup- 
pressed. (In  favorable  cases  the  primary  lesion  gradually  acquires  a 
healthy  appearance  or  a  re-establishment  of  the  lochia  takes  place.)  The 
secretion  of  milk  diminishes  or  is  suppressed.  During  the  course  of  the 
disease  fresh  absorption  of  infective  material  may  be  marked  by  recur- 
ring chills,  but  these  are  never  so  pronounced  or  frequent  as  in  pyaemia, 
nor  are  the  variations  of  temperature  so  decided  as  in  this  disease.  In 
milder  and  favorable  cases,  though  the  temperature  may  be  high,  the 
pulse  retains  some  volume,  and  its  frequency  may  not  exceed  80  to  90. 


sYMrro.y.s. 


507 


The  Ivinpliatic  system  is  always  iiivolvi'd  in  s('|)tic  infection.  Upon  tlic 
skin  tlu'  i)atli  of  invasion  may  often  he  traeed  hy  a  red  line  e()n'esj)ond- 
ing  to  the  inllamed  lymphatics  leadin<>;  from  the  point  of  infection. 
Tlie  lymphatic  lilands  nearest  to  the  infective  centre  are  often  much 
enlaro-cd  and  very  tender.  A  general  adenopathy  may  .sometimes  be 
developed.  The  spleen  is  always  enlarged  and  its  percussion  area 
increased.  8t)metimes  it  may  he  discovered  by  palpation.  Some  cough 
may  be  present.  It  is  generally  dependent  upon  bronchitis.  Pneumo- 
nia is  not  a  common  complication  of  septicsemia.  Occasionally  a  con- 
siderable degree  of  hypostatic  engorgement  of  the  lungs  will  be  encoun- 
tered.    In  favorable  cases  of  septic  infection  improvement  is  first  noted 


Fig. 

45 

TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

IVI 

E 

M 

E 

M 

E 

TEMP. 

F. 

106 

II 

l\ 

A 

105 

/\ 

, 

N 

/ 

V 

/ 

V 

y 

104 

J 

\ 

f\ 

l\ 

\/ 

1 

103 

Y 

\ 

\ 

\ 

I 

1 

li 

102 

v 

■ 

1 

/ 

1 

lOf 

J'*' 

«j 

\ 

/ 

1 

/ 

1 

1 

\ 

100 

v 

A 

v^ 

\ 

1 

1 

99" 

V 

J 

> 

/ 

L     i 

U 

A 

/ 

98 

f\ 

\/ 

\ 

J 

V 

y 

^ 

\j 

97 

1 







1 







V. 





Temperature  record  of  septic  infection. 


in  a  lowering  of  the  temperature  and  increased  tension  and  diminished 
frequency  of  the  pulse.  In  fatal  cases  death  approaches  as  in  septic 
intoxication,  with  increasing  asthenia,  failing  heart,  delirium,  and  coma, 
though  a  fair  degree  of  intelligence  may  be  preserved  until  near  the 
end.  It  may  occur  within  twenty-four  hours  ;  usually  it  is  not  delayed 
beyond  the  week. 

Carbuncular  inflammation  is  often  a  cause  of  even  fatal  septicaemia, 
probably  of  infective  nature,  but  it  is  impossible  to  decide  whether  we 
should  consider  as  septic  infections  or  septic  intoxications  those  milder 
febrile  reactions  that  so  often  accompany  the  development  of  a  furuncle 
or  small  abscess  and  similar  processes.  Usually  the  general  symptoms 
promptly  subside  with  the  amelioration  of  the  suppurative  centres,  but 
occasionally  fatal  septicaemia  and  even  pyaemia  result. 


508  SEPTICEMIA. 

A  most  important  consideration  is  the  septic  infection  that  so  often 
forms  a  factor  in  the  course  of  various  specific  disorders,  such  as  scarlet 
fever  with  severe  angina,  smallpox  in  the  maturation  fever,  typhoid 
fever,  diphtheria,  tuberculosis,  etc.  This  is  nearly  always  a  streptococ- 
cus infection,  occurring  through  the  peculiar  lesions  of  these  diseases, 
and  in  many  cases  constituting  the  essential  cause  of  death.  Important 
as  these  secondary  infections  must  be,  it  is  most  difficult  for  the  physi- 
cian to  determine  the  extent  to  which  they  are  responsible  for  the 
results,  as  distinguished  from  those  of  the  primary  infections.  It  is 
reasonably  certain  that  the  enormous  streptococcus  invasion  of  the 
mature  eruption  of  smallpox  largely  influences  the  outcome  of  this  affec- 
tion. Similarly  in  scarlet  fever  and  diphtheria  the  abundant  presence 
of  streptococci  and  staphylococci  in  the  faucial  membrane  affords  the 
fairest  possible  opportunity  for  the  concurrent  development  of  septicse- 
mia.  In  the  former  affection  especially  the  suppurative  complications 
and  sequels  even  in  remote  parts  of  the  body  conclusively  prove  the 
admission  of  pyogenic  organisms  to  the  circulation.  It  is  well  known 
that  the  hectic  fevers  of  advanced  tuberculosis  are  principally  due  to 
septic  intoxication  following  the  invasion  of  softened  tuberculous  foci 
by  pyogenic  bacteria.  Probably  the  most  interesting  secondary  septi- 
caemias are  those  complicating  and  following  typhoid  fever.  (Though 
the  typhoid  bacillus  is  itself  pyogenic,  and  may  be  found  occasionally 
as  a  pure  culture  in  post-typhoid  pus  formation,  it  is  likely  that  the 
great  majority  of  these  inflammations  are  dependent  upon  the  commoner 
pus  bacteria.  After  the  third  or  fourth  week  of  this  fever  typhoid 
bacilli  are  discovered  only  with  difficulty,  and  the  prevailing  bacteria 
found  in  localized  inflammations  are  streptococci.')  It  is  not  impossible 
that  many  unduly  protracted  cases  of  typhoid  fever,  and  even  of  sup- 
posed relapse,  are  really  septicemic. 

The  most  obscure  septicaemias  are  those  that  have  been  called  cryp- 
togenetic,  from  the  supposed  passage  of  pyogenic  bacteria  through  a 
healthy  or  intact  mucous  membrane.  Such  cases,  in  fact,  probably 
always  originiate  in  some  undiscovered  primary  focus  :  the  root  of  a 
carious  tooth,  the  middle  ear,  a  nasal  sinus,  an  urethral  stricture,  or 
any  minute  lesion  of  the  mucous  tract  (Welch)  may  be  the  starting 
point  These  infections  often  result  in  a  more  chronic  septicaemia,  last- 
ing often  several  weeks,  and  often  enough  running  a  mild  course.  In 
chronic  septiceemia  there  are  often  developed  recognizable  centres  of 
local  inflammation  ;  mild  endocarditis,  pleuritis,  pericarditis  may  arise. 
There  may  be  also  pulmonary  engorgement  and  oedema  and  pronounced 
enteritis.  Apart  from  puerperal  and  ordinary  surgical  septic  infection, 
there  can  be  no  doubt  that  many  septicaemias  of  feeble  intensity  and  of 
favorable  course  are  encountered,  especially  by  the  physician,  and  are 
accountable  for  many  unduly  protracted  and  not  understood  febrile 
processes.  Chronic  septicaemia  of  greater  potency  may  not  only  de- 
velop localized  inflammations,  as  has  been  shown,  but  may  result  in 
pronounced  pyaemia.  The  micro-organisms  of  septic  infection  and  of 
pyaemia  are  the  same. 

Diagnosis. — Fermentation  fever  ends  at  a  time  when  septic  intoxi- 
cation and  septic  infection  begin  :  within  a  few  hours  after  its  exciting 

1  Dunin,  Archivfiir  klin.  Med.,  Bd.  39,  S.  369. 


injcxosis.  509 

cause  it  bogint^,  and  within  a  day  or  two  it  terminates.  Its  uniformly 
favorable  course  will  serve  to  ilistin<i;uish  it.  It  is  inii)()ssil)le  to  draw  a 
sharp  distinction  between  septic  intoxication  and  sej)tic  infection  ;  it  is 
not  even  certain  that  such  exists.  Septic  intoxication  can  usually  be 
traced  to  a  putrefactive  centre,  a  sloutrli  or  a  deconiposin*;  retained  pla- 
centa or  a  blood  clot,  which  announces  itself  by  a  strouuly  putrefactive 
odor.  It  usually  does  not  a[)i)car  earlier  than  twenty-four  hours  after 
the  establishment  of  putrefaction,  sometimes  not  earlier  than  several 
days.  It  acquires  its  acme  almost  at  once,  and  its  intensity  depends 
upon  the  quantity  of  toxine  absorbed.  Removal  or  destruction  of  the 
putrcfving  tissues  will  l)e  followed  at  once  by  a  subsidence  of  the  symp- 
toms, provided  a  lethal  dost'  of  the  toxin  has  not  been  al)sorbed  already. 
Septic  infection  also  requires  time  for  its  develoi)ment  after  inoculation, 
and  its  symptoms  increase  in  intensity  as  the  bacteria  increase  in  the 
body.  Absence  of  putrefaction  and  the  appearance  of  septictemic  symp- 
toms after  a  slight  or  uot  extensive  injury,  or  the  occurrence  of  suppu- 
ration, would  indicate  septic  infection,  though  it  should  not  be  forgotten 
that  septic  infection  may  also  arise  from  a  putrefactive  focus.  It  may 
be  extremely  difficult  to  distinguish  between  milder  and  more  protracted 
forms  of  septicaemia  from  typhoid  fever ;  indeed,  during  the  latter  part 
of  this  disorder  and  while  the  intestinal  ulcers  are  unhealed  a  septic  in- 
fection often  occurs  and  a  state  of  mixed  infection  is  created.  So  called 
recrudescences  and  relapses  of  typhoid  fever  are  often  examples  of  pure 
septic  infection  in  which  a  typhoid  element  may  no  longer  exist.  Dur- 
ing the  early  stage  of  typhoid  fever  the  diagnosis  may  generally  be  made 
after  a  few  days — by  recognition  of  essential  typhoid  symptoms  on  the 
one  hand,  and  on  the  other  by  the  absence  of  a  primary  infective  focus. 
Internal  sepsis,  however,  very  frequently  oifers  great  difficulties  of  diag- 
nosis, and  only  the  most  careful  observation  and  comparison  of  symptoms 
will  protect  from  error. 

The  microscope  will  reveal  the  presence  of  the  plasmodium  in  the 
blood  in  malarial  fever.  But  in  default  of  these  means  of  dilferentiating 
the  greatest  difficulty  often  exists,  and  the  presence  or  absence  of  chronic 
septic  infection  can  only  be  determined  at  times  by  the  development  of 
local  inflammatory  lesions,  or  even  of  the  evidences  of  local  suppura- 
tions characteristic  of  pysemia.  The  septic  infection  of  multiple  acute 
osteomyelitis  may  be  determined  after  careful  examination  of  the  osseous 
structures.  A  rash  is  sometimes  seen  in  septiceemia  which  may  resemble 
that  of  scarlatina  or  rubella.  This  is  generally  circumscribed,  and  fol- 
lows a  course  quite  unlike  that  of  these  affections.  In  pyelo-nephritis 
and  tubercular  disease  of  the  kidney,  as  of  other  organs,  the  febrile 
reaction  is  probably  the  result  of  a  mild  septic  infection. 

As  a  rule,  however,  the  diagnosis  of  septicaemia  is  not  a  matter  of 
difficulty,  since  in  most  cases  there  is  a  clear  history  of  a  wound  or 
surgical  operation  or  of  an  infective  inflammation  or  of  an  abortion  or 
delivery.  Much  greater  difficulty  will  exist  when  the  source  of  infection 
remains  undiscovered.  In  such  cases  the  symptoms  are  often  sufficiently 
characteristic,  but  frequently  the  diagnosis  can  only  be  made  by  exclu- 
sion. 

Septicsemia  should  always  be  suspected  during  the  course  of  any  dis- 
order the  lesions  of  which  afl'ord  any  opportunity  for  the   growth  and 


510  SEPTICEMIA. 

development  of  septic  micro-organisms,  when  the  symptoms  of  that  dis- 
order depart  from  the  usual  type  and  an  elevated  temperature  continues 
beyond  the  usual  duration. 

Prognosis. — Fermentation  fever  always  pursues  a  mild  and  favor- 
able course.  Septic  intoxication  is  always  dangerous,  but  its  termination 
depends  upon  the  amount  of  toxin  absorbed.  Generally,  the  greater 
the  area  and  intensity  of  the  primary  putrefaction  the  more  surely  will 
the  end  be  fatal.  A  septic  intoxication  may  destroy  life  within  twelve 
hours.  Septic  intoxication  from  progressive  gangrene  is  generally  fatal. 
The  prognosis  is  much  more  favorable  if  the  primary  focus  is  limited  in 
extent,  and  so  situated  that  it  may  be  removed  or  destroyed ;  otherwise 
the  continuous  absorption  of  toxin,  even  from  areas  of  limited  extent, 
may  cause  death.  A  favorable  prognosis  is  justifiable  if,  after  the  orig- 
inal intoxication,  the  source  of  supply  be  destroyed  and  the  graver  symp- 
toms not  manifested.  Increased  frequency  of  the  pulse  with  constantly 
lowering  arterial  tension,  the  occurrence  of  delirium  and  coma,  increas- 
ing depression,  extravasation  of  blood,  are  all  signs  of  approaching 
death.  Progressive  sepsis  or  septic  infection  is  generally  fatal.  The 
prognosis  cannot  be  determined  from  the  condition  or  extent  of  the 
primary  infective  focus.  Rapidly  fatal  septicsemia  may  depend  upon  a 
slight  scratch  or  abrasion,  and  the  result  is  determined  by  the  virulence 
of  the  organisms,  the  numbers  in  which  they  enter  the  circulation,  and 
the  degree  of  resistance  offered  by  the  blood  and  tissues  of  the  individual. 
Other  things  being  equal,  however,  the  introduction  of  large  numbers  of 
infective  micro-organisms  to  the  blood,  which  find  conditions  favorable 
to  their  growth,  renders  recovery  almost  hopeless.  The  presence  of 
more  than  one  infective  centre  greatly  increases  the  gravity  of  the  case. 
Internal  sepsis  is  also  very  fatal,  though  often  very  protracted  in  its 
course.  The  probabilities  of  recovery  will  be  increased  by  destruction 
of  the  activity  of  the  primary  centres  of  infection.  The  occurrence  of 
subcutaneous  hemorrhage  almost  certainly  presages  approaching  disso- 
lution. Delirium,  coma,  increasing  debility  of  the  cardiac  and  general 
muscular  systems,  are  most  unfavorable  signs.  A  favorable  prognosis 
may  usually  be  made  in  the  milder  sepsis  that  accompanies  the  course 
of  boils,  carbuncles,  small  abscesses,  and  that  occurs  as  a  sequel  to 
typhoid  and  scarlet  fevers.  The  septic  symptoms  that  arise  in  the 
course  of  purulent  inflammation  of  serous  membranes  will  usually 
subside  if  successful  surgical  treatment  corrects  the  suppurative  focus. 

Treatment. — Fermentative  fever  requires  no  treatment :  with  the 
removal  of  its  exciting  cause  it  subsides  spontaneously  and  speedily. 
For  septic  intoxication  and  septic  infection  there  are  no  specific  remedies 
or  methods  of  treatment.  In  septic  intoxication  the  most  important 
therapeutic  indication  is  to  disinfect  the  putrefactive  or  suppurative 
centre  whence  the  toxins  have  been  absorbed.  The  removal  of  gan- 
grenous masses  by  surgical  measures  and  the  arrest  of  progressive  gan- 
grenous processes  by  cauterization  and  other  appropriate  means,  the 
thorough  sterilization  of  centres  of  putrefaction  and  suppuration,  will 
ensure  the  recovery  of  the  patient,  provided  a  fatal  dose  of  toxin  have 
not  been  absorbed  previously.  Surgical  measures  for  the  prevention  of 
coagula  which  may  become  putrid,  and  the  removal  of  these  when 
formed,  the  removal  of  putrefying  portions   of  placenta  or  of  blood 


TREATMENT.  511 

cl(Jt  t'roni  the  uterine  and  vati::inal  cavities,  and  siihsecinent  disinfection 
of  these  bv  irriuation  and  the  use  of  antisej)tic  aii:ents,  are  best  detailed 
in  works  upon  surgery  and  obstetrics.  The  efficient  performance  of 
such  treatment  is  often  followed  by  the  most  gratifying  results.  Even 
within  a  few  hours  the  temperature  falls,  the  pulse  becomes  fuller  and 
slower,  the  nervous  symptoms  disappear,  and  the  patient  enters  at  once 
upon  convalescence. 

In  combating  the  eft'ects  of  the  poison  already  absorbed  all  hope  of 
specific  treatment  should  be  abandoned.  The  sole  object  should  be  to 
support  the  vital  powers  against  the  profound  depression  that  involves 
them.  The  use  of  internal  antipyretics  it  never  justifiable.  The  reduc- 
tion of  febrile  temperature  brought  about  by  them  never  compensates 
for  the  increased  danger  of  further  enfeebling  the  already  depressed 
heart  action.  It  is  not  so  certain  that  quinine  may  not  exert  a  favor- 
able influence,  not  simply  as  an  antipyretic,  but  possibly  through  some 
specific  action  upon  microbes  and  as  checking  tissue  metamorphosis. 
In  reasonable  doses  it  does  not  depress  the  nervous  system  as  do  the 
coal  tar  derivatives.  Daily  doses  of  from  twenty  to  thirty  grains  often 
.seem  to  be  beneficial.  If  the  range  of  temperature  be  high,  positive 
benefit  will  often  follow  cold  water  sponging  or  bathing.  The  reduc- 
tion of  temperature  thus  secured  is  at  the  cost  of  no  depression  of  the 
nervous  svstem ;  indeed,  a  tonic  influence  upon  this  system  may  often 
be  noted  in  the  slower  and  fuller  pulse,  the  cleansing  of  the  tongue,  and 
the  diminution  of  delirium.  Intense  headache  may  be  relieved  by  the 
ice  cap.  To  support  the  failing  heart  is  a  most  important  indication. 
To  this  end  strychnine,  digitalis,  strophanthus,  and  belladonna  are  the 
most  valuable  drugs.  Digitalis  and  strophanthus  too  often  impair 
appetite  and  digestion,  and  even  excite  nausea  and  vomiting ;  moreover, 
their  value  as  heart  tonics  is  greatly  less  in  febrile  than  in  afebrile  con- 
ditions. Strvchnine  is  far  preferable  to  all  other  heart  tonics  and  stim- 
ulants, and  often  affords  remarkable  benefit ;  from  one  twenty-fifth  to 
one  fiftieth  grain  of  the  sulphate  may  be  given  every  fourth  hour,  hypo- 
dermically,  for  days  at  a  time.  Concurrently,  small  doses  of  bella- 
donna (from  one  to  three  minims  of  the  fluid  extract)  or  of  atropine  sul- 
phate (from  one  ninetieth  to  one  hundred  aud  fiftieth  of  a  grain)  may 
be  administered.  Alcoholic  stimulation  is  nearly  always  advantageous. 
In  severe  cases  the  quantity  of  brandy  or  Avhiskey  that  can  be  taken 
with  apparent  advantage  is  sometimes  enormous.  As  much  as  a  quart 
of  whiskey  has  been  given  during  the  twenty  four  hours  to  patients  who 
have  recovered.  Pronounced  flushing  of  the  face  aflbrds  a  guide  for 
limiting  the  supply  of  alcoholic  fluids.  Ordinarily,  from  a  half  ounce 
to  an  ounce  of  brandy  or  whiskey  may  be  given  every  second  hour. 
Evidence  of  the  favorable  action  of  these  agents  will  be  an  improved 
tone  and  diminished  frequency  of  cardiac  pulsations,  a  lowered  tempera- 
ture, and  an  amelioration  of  nervous  symptoms.  From  one  to  five 
grains  of  ammonium  carbonate  may  be  given  alternately  with  the  alco- 
holic stimulant.  The  use  of  opium  is  rarely  called  for  in  septicemia, 
except  when  diarrhoea  or  entero-colitis  becomes  troublesome  ;  then  small 
doses  are  often  useful :  a  fluidrachm  of  the  camphorated  tincture  of 
opium,  -vx-ith  twenty  grains  of  bismuth  subnitrate,  given  every  third  or 
fourth  hour,  will  usually  suffice  to  hold  these  symptoms  in  check. 


512  SEPTICJEMIA. 

When  the  primary  infection  centre  is  in  the  alimentary  canal,  as 
from  typhoid  or  dysenteric  ulceration,  intestinal  antisepsis  should  be 
attempted.  The  best  drugs  for  this  purpose  are  napthaline  and  salol. 
From  sixty  to  eighty  grains  of  either  of  these  would  be  a  daily  dose. 
In  mild  degrees  of  intestinal  sepsis  this  treatment  may  do  good ;  the 
stools  can  certainly  be  deodorized,  but  it  is  unlikely  that  any  remark- 
able antisepsis  can  be  exerted  by  so  small  an  amount  of  disinfectant 
upon  so  great  a  surface. 

The  medical  treatment  of  septic  intoxication  and  septic  infection  is 
the  same.  Equally  in  the  two  forms  the  only  specific  treatment  is  sur- 
gical, whereby  the  foci  of  putrefaction  and  suppuration  are  destroyed 
or  deprived  of  their  power  to  intoxicate  or  infect.  Internal  medication 
depends  upon  supporting  remedies  and  nutrition.  In  chronic  septicae- 
mia the  result  will  largely  depend  upon  the  support  thus  given.  The 
diet  in  all  cases  should  be  simple  and  almost  exclusively  liquid.  If  it 
be  possible  to  limit  the  patient  to  a  milk  diet,  nothing  better  could  be 
wished.  From  three  pints  to  a  half  gallon  of  skimmed  milk  will  be 
ample  for  the  twenty  four  hours.  This  may  be  given  in  quantities  of  a 
half  pint  every  three  hours  or  in  smaller  amounts  at  shorter  intervals, 
as  the  case  may  require.  Strong  beef  or  other  animal  broths  or  soups 
may  alternate  with  the  milk.  Eggs,  boiled  or  poached  or  beaten  up 
with  milk  or  water,  are  often  acceptable,  and  will  be  readily  borne  by 
the  stomach.  It  is  better  to  give  rather  too  little  than  too  much  nour- 
ishment. In  the  latter  case  gastric  distress,  nausea,  and  vomiting  may 
be  excited.  During  convalescence  iron  preparations  with  bitter  tonics 
will  be  indicated. 


SMALLPOX  AND  VARIOLOID. 

By  AVILLIAM  M.  WELCH,  M.  D. 

Smallpox. 

Synonyms. — Latin,  Variola;  French,  Petite-verole ;  German, 
Bliittern  or  Pocken  ;  Italian,  Vajuolo. 

Definition. — Smallpox  is  an  acute  iiifectiou.s  disease,  characterized 
by  an  initial  fever  of  about  three  days'  duration,  succeeded  by  an  erup- 
tion passing  through  the  stages  of  papule,  vesicle,  and  pustule,  ending 
in  incrustation,  and  leaving  pits  or  scars ;  the  fever  either  intermitting 
or  remitting  in  the  papular  and  increasing  in  the  pustular  stage. 

History. — There  is  no  doubt  that  smalljjox  was  known  for  several 
centuries  before  it  was  described.  The  credit  of  having  first  described 
the  disease  is  generally  given  to  Rhazes,  an  Arabian  physician  who  lived 
in  the  early  part  of  the  tenth  century.  This  physician,  however, 
ascribes  to  Galen  and  others  before  his  time  a  knowledge  of  the  disease, 
although  they  failed  to  give  an  intelligent  account  of  it.  According  to 
Gregory,  the  word  variola  appears  in  several  Latin  manuscripts  pre- 
served in  the  British  Museum  and  bearing  date  considerably  prior  to 
the  year  900,  thus  proving  that  the  disease  was  known  before  Rhazes 
called  attention  to  it. 

The  term  "  variola "  is  probably  derived  from  the  Latin  word 
varius  (variegated  or  spotted),  while  the  term  "  pock  "  is  of  Saxon  origin 
and  signifies  a  bag  or  pouch.  To  the  latter  term  was  prefixed  the  Eng- 
lish word  small  or  the  French  word  jjetite  somewhere  about  the  year 
1500,  in  order  to  designate  this  disease  from  syphilis,  ^vhich  was  some- 
times called  the  great-  or  grandpox. 

From  the  East  smallpox  extended  to  other  parts  of  the  world,  fol- 
lowing, doubtless,  the  lines  of  travel  and  commercial  intercourse.  It 
appears  to  have  reached  England  in  the  latter  part  of  the  ninth  century. 
Soon  after  the  discovery  of  America  the  scourge  Avas  introduced  on  this 
continent.  It  first  appeared  in  Mexico  in  1520,  having  been  brought 
there  by  a  negro  slave,  and  thence  it  spread  over  the  whole  of  this  vast 
country,  decimating  in  many  instances  large  settlements  of  Indians. 
Multitudes  of  these  people  were  swept  away  by  the  disease  when  it  first 
appeared  in  Massachusetts  in  1633.  It  reached  Boston  in  1649,  and 
subsequently  prevailed  there  or  in  that  vicinity  in  epidemic  form  every 
few  years. 

In  almost  every  country  on  the  globe  smallpox  long  constituted  one 
of  the  most  dangerous  and  dreaded  diseases  to  which  mankind  was  sub- 
ject. It  was  present  in  one  place  or  another  almost  constantly,  and 
frequently  prevailed  with  great  malignancy  over  vast  tracts  of  territory, 
claiming  as  its  victims  persons  of  all  ages  and  from  every  station  of  life. 

Vol.  I.— 33  513 


514  SMALLPOX  AND    VARIOLOID. 

JSTot  only  the  number  of  deaths,  but  the  marred  visages  of  persons  in 
every  community,  testified  to  the  frequency  of  the  disease.  Indeed,  it 
was  so  prevalent  in  the  Middle  Ages  q,s  to  lead  to  the  common  saying 
that  "  From  smallpox  and  love  but  few  remain  free." 

The  inoculation  period,  or  the  time  when  the  practice  prevailed  of 
inoculating  the  variolous  poison,  constitutes  an  interesting  epoch  in  the 
history  of  smallpox.  This  practice  was  based  upon  the  well  known  fact 
that  the  disease  very  rarely  occurs  more  than  once  in  the  same  indi- 
vidual ;  hence  the  advantage  of  producing  in  this  way  a  possibly  milder 
type  of  the  disease. 

Inoculation  was  undoubtedly  practised  in  China  and  India  at  a  very 
remote  period,  though  in  a  very  crude  manner.  Thence  it  gradually 
extended  to  Asia,  but  it  does  not  appear  to  have  been  used  very  intelli- 
gently or  scientifically  until  it  reached  Constantinople,  about  the  year 
1700.  The  method  was  introduced  into  England  by  Lady  Mary  Wort- 
ley  Montague,  who,  after  satisfying  herself  of  its  advantages,  subjected 
her  two  children — a  son  and  daughter — to  the  new  process.  The  son 
was  sent  to  Constantinople  in  1717  to  be  inoculated,  and,  the  result 
proving  satisfactory,  the  daughter  was  inoculated  in  England  in  1721. 
There  was  at  first  violent  opposition  to  the  method,  both  on  the  part  of 
physicians  and  the  clergy,  yet,  mainly  through  the  influence  and  example 
of  this  woman,  it  was  very  soon  brought  into  widespread  esteem. 

From  England  the  novelty  travelled  rapidly  to  most  other  countries, 
reaching  America  the  same  year  (1721).  It  was  introduced  into  this 
country,  at  the  suggestion  of  the  Rev.  Cotton  Mather,  by  Dr.  Zabdiel 
Boylston  of  Boston,  who  first  inoculated  his  only  son,  about  thirteen 
years  of  age,  and  two  negro  servants.  Before  the  practice  was  gen- 
erally accepted,  however,  it  was  necessary  to  overcome  here,  as  in 
England,  much  violent  opposition. 

The  principal  advantage  claimed  for  inoculation  was  that  smallpox 
thus  produced  was  much  milder  in  type  than  when  the  infection  was 
received  in  the  natural  way.  While  the  death  rate  from  natural  small- 
pox was  one  out  of  every  three  or  four  persons  attacked,  it  was,  at  the 
highest,  from  the  inoculated  disease,  not  greater  than  one  out  of  fifty, 
and  sometimes  as  low  as  one  out  of  two  hundred — the  average  death 
rate  being  somewhere  between  the  two.  The  disadvantage  was  that 
smallpox  jD  rod  need  in  this  manner,  although  milder  in  type,  was  just  as 
contagious  as  when  contracted  naturally;  hence  inoculation  had  the 
effect  of  keeping  the  disease  almost  constantly  in  existence,  and  the 
annual  number  of  deaths  from  the  disease  was  even  greater  than  prior 
to  its  introduction. 

Inoculation  was  practised  for  nearly  a  century,  when  it  was  super- 
seded by  Jenner's  discovery.  Vaccination  was  soon  found  to  possess  all 
the  merits  of  the  former,  without  partaking  of  any  of  its  objectionable 
features,  and  hence  its  greater  claim  for  preferment.  The  introduction 
of  vaccination  may  be  said  to  have  brought  about  a  great  change  in  the 
history  of  variola.  Instead  of  being  the  widespread  and  fatal  disease 
of  former  times,  smallpox  prevails  today  with  frequency  and  intensity 
■only  in  countries  and  communities  where  this  eminently  protective  agent 
is  refused  or  neglected. 

Etiology. — The  spread  of  smallpox  to  nearly  all  countries  of  the 


KTIOLUUY.  ,"3 15 

j;^U)l)i'  shows  that  conditions  of  soil  or  cliniato  exert  no  infl nonce  over 
the  disease.  It  [)revails  wherever  predisposed  indivi(hials  are  exposed 
to  the  infeeti()n.  lint  few  can  boast  of  natui'al  iniiunnity  from  the  dis- 
ease. This  individual  peculiarity  is  occasionally  met  with,  as  may 
be  seen  by  reference  to  the  history  of  the  disease  durinjr  the  pre- 
vaceiuation  period.  Persons  have  been  known  to  ^o  through  life 
constantly  exposed  to  the  infection  Avithout  sutlc>rin<^'  from  any  of  the 
manifestations  of  small])ox.  It  is  said  that  Morgagne,  Boerhaave,  and 
Dienu'rbroek  could  boast  of  this  peculiarity.  Yet  instances  are  recorded 
where  persons  have  resisted  the  infection  when  received  in  the  natural 
way,  but  have  yielded  to  the  disease  late  in  life  by  inoculation.  Gregory 
gives  an  example  of  this  kind  in  the  case  of  a  lady  who  brought 
up  a  large  family  of  cliildren,  many  of  whom  she  nursed  through  small- 
pox Avithout  receiving  the  infecjtion  herself,  but  at  the  age  of  eighty- 
three  she  took  the  disease  by  inociulation.  While  but  few  are  naturally 
insusceptible  to  smallpox,  yet  at  the  present  day,  through  the  agency 
■of  vaccination,  individual  susceptibility  is  greatly  changed,  and  even 
iibsolute  immunity  is  enjoyed  by  the  greater  part  of  the  population. 

Sex. — The  predisposition  to  smallpox  is  certainly  not  influenced  by 
sex.  Under  the  same  conditions  males  and  females  are  equally  suscep- 
tible to  the  disease. 

Race. — As  to  whether  race  exerts  any  influence  there  is  some  differ- 
ence of  opinion.  Most  authors,  however,  agree  that  the  predisposition 
is  more  marked  among  the  dark  skinned  races,  particularly  the  negro 
race.  There  is  no  doubt  that  when  smallpox  prevails  epidemically  in 
this  country  the  proportion  of  deaths  to  the  cases  is  greater  among  the 
negro  than  the  white  race ;  but  this,  I  believe,  is  owing  to  the  fact  that 
there  is  greater  neglect  of  vaccination  by  the  former.  In  my  expe- 
rience the  uuvaccinated  cases  of  each  race  have  perished  in  about  the 
«ame  proportion. 

Age  cannot  be  said  to  influence  the  predisposition  to  the  disease,  as  it 
is  naturally  present  at  all  periods  of  life  from  earliest  infancy  to  ex- 
treme old  age.  If  aged  persons  are  found  less  susceptible  at  all,  it  is 
because  of  the  prophylactic  power  of  vaccination.  While  nursing 
infants  under  six  months  old  commonly  resist  the  infection  of  measles 
and  scarlet  fever,  they  are  quite  sure  to  yield  to  the  infection  of  small- 
pox. Even  the  foetus  in  utero  is  not  exempt  from  the  danger  of  an 
attack  when  a  pregnant  woman  suffers  from  the  disease.  The  variolous 
process  in  such  a  patient  is  exceedingly  liable  to  excite  abortion  or  pre- 
mature delivery,  and  the  foetus  or  child  may  show  evidence  of  the  disease 
in  the  form  of  local  lesions.  Such  evidence  has  been  observed  as  early 
as  the  fourth  month  of  foetal  life,  and  at  various  periods  thereafter  until 
the  completion  of  gestation.  I  can  recall  in  my  experience  at  least  one 
case  in  which  the  child  was  born  at  the  eighth  month  with  the  variolous 
eruption  just  appearing.  The  eruption  was  confluent,  and  death  oc- 
curred during  the  suppurative  stage. 

In  the  majority  of  cases  of  infection  of  the  foetus  it  is  found  that  it 
does  not  pass  through  the  disease  coincidently  with  the  mother,  but  at  a 
somewhat  later  period.  It  would  appear,  therefore,  that  infection  in 
its  case  does  not  occur  until  the  mother  manifests  symptoms  of  the  dis- 
ease, and  that  its  case  is  marked  by  a  distinct  and  separate  incubation 


516  SMALLPOX  AND    VARIOLOID. 

period.  When  we  consider  the  close  relationship  of  the  blood  of  mother 
and  fcetus,  this  seems  remarkable,  bnt  not  more  so  than  the  fact  that 
the  foetus  frequently  escapes  infection  altogether.  Very  often,  indeed,, 
the  pregnant  Avoman  passes  through  an  attack  of  smallpox  without 
abortion  occurring,  and  when  the  child  is  born  at  full  term  it  is  found 
to  have  the  usual  susceptibility  to  variola  or  vaccinia.  I  have  vacci- 
nated a  considerable  number  of  infants  born  under  such  circumstances, 
and  have  seldom  if  ever  failed  to  produce  in  them  the  vaccine  disease. 
Very  exceptionally,  however,  a  child  survives  an  intra-uterine  attack 
of  variola  :  such  a  child  when  born  may  or  may  not  show  scars,  but  is,, 
of  course,  insusceptible  to  vaccinia. 

It  is  well  known  that  a  pregnant  woman  while  personally  immune 
from  smallpox  is  liable  to  miscarry  when  exposed  to  the  infection  of 
the  disease.  In  consequence  of  such  exposure  during  the  latter  stage 
of  pregnancy  healthy  mothers  are  said  to  have  given  birth  to  infants 
affected  with  variola.  While  the  possibility  of  such  an  occurrence  can- 
not be  excluded,  yet  it  seems  to  me  that  the  more  probable  explanation 
in  such  cases  is  that  the  mother  had  suffered  from  variola  sine  exanthe- 
mata— a  form  of  the  disease  most  likely  to  pass  unrecognized.  A  child 
thus  infected  in  utero  and  recovering  from  the  disease  might  be  found 
at  birth  and  ever  afterward  insusceptible  to  variola.  It  is  not  impossi- 
ble that  some  of  those,  like  Diemerbroek  and  others,  who  claimed  for 
themselves  natural  insusceptibility  to  the  disease  may  have  acquired 
immunity  in  this  way. 

Infrequent  instances  are  met  with  of  apparently  healthy  persons 
resisting  the  infection  of  smallpox  at  one  time  and  yielding  to  it  at 
another.  I  will  relate  a  case  in  point:  In  1874  a  colored  man,  aged 
thirty,  came  under  my  care  suffering  from  confluent  variola.  He  stated 
that  vaccination  had  been  performed  at  different  times  during  his  life,, 
but  never  successfully.  In  1871  he  belonged  to  the  crew  of  a  sailing 
vessel  on  which  several  cases  of  smallpox  occurred,  and  his  duties 
required  him  to  come  frequently  in  quite  close  contact  with  those  who 
were  ill,  yet  he  did  not  take  the  disease.  He  was  vaccinated  at  the 
time,  but,  as  before,  without  result.  When  he  fell  ill  with  variola  three 
years  later  he  was  unable  to  account  for  the  source  of  the  infection. 
The  attack  proved  fatal.  Not  only  cases  like  this,  but  those  cited  when 
considering  the  history  of  smallpox  inoculation,  show  that  susceptibility 
to  the  disease  may  occasionally,  from  some  unknown  cause,  be  tempo- 
rarily absent.  Experience  also  shows  that  the  susceptibility  may  at  one 
time  be  diminished,  and  at  another  greatly  increased. 

The  existence  of  acute  and  chronic  diseases  is  said  by  some  to  lessen 
temporarily  the  susceptibility  to  the  infection  of  variola.  Curschmann 
believes  that  it  is  very  slight  among  patients  while  in  the  acute  stage 
of  scarlet  fever,  measles,  or  typhoid  fever.  Several  patients  of  his 
while  suffering  from  the  latter  disease  were  exposed  to  the  contagium  of 
smallpox,  but  infection,  he  thinks,  did  not  occur  in  any  case  until  the 
body  temperature  became  permanently  normal.  He  was  led  to  this 
conclusion  from  the  fact  that  the  interval  bet-ween  the  time  when  the 
temperature  reached  the  normal  point  and  the  beginning  of  the  initial 
stage  of  variola  corresponded  to  the  longest  period  of  incubation  of  the 
disease  that  is  met  with — namely,  fourteen  to  nineteen  days.     There  is 


ETIOLOGY.  517 

no  doubt,  however,  tlmt  variol<nis  intectioii  doe.s  IVeqiiently  occur  dur- 
ing the  existence  of  an  acute  disease,  and  that  the  incubation  period  in 
such  case  is  often  greatly  j)roh)nged  ;  and,  furthermore,  that  smallpox 
lias  been  known  to  coexist  with  almost  every  form  of  chronic  disease — 
M'ith  typhoid  fever  and  the  acute  exanthemata,  especially  -carlet  fever 
and  measles.  I  have  seen  luiprotected  children,  while  siittering  from 
measles  in  its  most  acute  stage,  exposed  not  longer  than  two  minutes  to 
the  infection  of  variola,  sicken  with  the  disease  after  the  usual  incuba- 
tion period.  Also,  I  have  seen,  in  one  instance  at  least,  smallpox  coex- 
ist with  scarlet  fever,  and  quite  frequently  with  syphilis  in  its  various 
stages. 

The  suseej)tibility  to  smallpox  is  removed  by  vaccination,  but  fre- 
quently reappears  to  a  greater  or  less  degree  in  a  variable  period  of  time. 
So  also  one  attack  of  smallpox  does  not  invariably  protect  the  individual 
for  the  remainder  of  life  against  a  future  attack.  It  is  undoubtedly  the 
rule  that  a  person  does  not  suiFer  from  the  disease  more  than  once,  but 
quite  well  authenticated  cases  of  second  attacks  arc  recorded.  Indeed, 
some  writers  allege  that  the  jDredisposition  to  smallpox  in  some  persons 
is  so  strongly  marked  as  to  render  them  susceptible  to  the  infection  more 
than  twice,  even  as  often  as  five  or  six  times.  The  authenticity  of 
reported  cases  of  this  kind,  however,  is  not  to  be  taken  for  granted,  but 
accepted  Avith  extreme  caution,  as  there  are  so  many  sources  of  error. 

As  to  the  frequency  of  secondary  or  recurrent  smallpox,  there  is  some 
difference  of  opinion  on  the  part  of  authors.  Some  of  the  more  prac- 
tical of  those  who  wrote  in  the  early  part  of  the  last  century  hesitated 
very  long  before  believing  that  it  was  possible  for  the  disease  to  recur. 
It  was  estimated  at  that  time  that  among  ten  thousand  cases  of  small- 
pox not  more  than  one  or  two  were  genuine  recurrent  cases.  The  infre- 
quency  of  such  cases  was  also  noticed  during  the  inoculation  period. 
Jenner,  who  closely  studied  both  casual  and  inoculated  variola  for  more 
than  thirty  years,  was  very  positive  in  his  views  as  to  the  permanency 
of  the  protection  which  one  attack  of  the  disease  confers,  and  it  was 
doubtless  his  positive  convictions  on  this  point  that  led  him  to  announce 
his  over-sanguine  belief  in  the  never-failing  efficacy  of  vaccination. 
Gregory,  who  enjoyed  unusual  opportunities  for  studying  variola,  was 
very  incredulous  on  the  subject  of  recurrence  of  the  disease.  Most  of 
the  reported  cases  which  he  was  called  upon  to  examine  he  found  incor- 
rectly reported.  Ecthyma,  pustular  syphilis,  and  particularly  varicella, 
he  states,  were  fruitful  sources  of  error.  But  few  patients  claiming  to 
have  had  smallpox  previously  came  under  his  care  as  physician  to  the 
Smallpox  Hospital  of  London  for  more  than  twenty  years,  and  of  these 
fe^\'  only  a  very  small  fraction  could  stand  the  test  of  rigid  scrutiny. 
In  regard  to  the  historic  case,  frequently  quoted,  of  Louis  XV.,  king 
of  France,  who  is  said  to  have  died  of  smallpox  at  the  age  of  sixty-four, 
after  having  previously  suffered  from  the  disease  when  fourteen  years  of 
age,  Gregory  says  that  he  took  much  pains  to  investigate  this  case, 
inquiring  particularly  into  dates,  the  course  and  duration  of  the  erup- 
tion, and  came  to  the  conclusion  that  His  ^Majesty  did  not  have  small- 
pox in  early  life,  but  that  the  disease  from  which  he  then  suffered  was 
varicella. 

It  is  rare  indeed  that  a  physician  is  able  to  say  that  he  himself  has 


518  SMALLPOX  AND    VARIOLOID. 

seen  two  distinct  attacks  of  smallpox  in  the  same  individual :  the  evi- 
dence relied  upon  to  prove  the  occurrence  of  second  attacks  is  usually 
obtained  from  the  patients  themselves.  To  accept  without  question  their 
statements  on  this  point  would,  I  am  sure,  be  very  misleading.  I  have 
seen  in  the  hosj^ital  a  number  of  patients  who  claimed  to  have  had  small- 
pox previously,  but  only  a  very  few  were  able  to  show  anything  like 
characteristic  pitting ;  and  all  of  those  who  did  show  such  evidence  of 
a  previous  attack  had  the  disease  the  second  time  in  the  mildest  possible 
form — so  mild,  indeed,  as  to  be  scarcely  recognizable,  the  eruption  being 
either  simply  papular  or  barely  vesicular.  I  have  never  seen  an  un- 
modified, or  even  a  severe,  case  of  smallpox  occur  in  a  person  who  was 
deeply  and  characteristically  pitted  from  a  previous  attack.  Xor  has 
any  person  during  the  last  quarter  of  a  century  been  admitted  to  the 
Philadelphia  Municipal  Hospital  twice  suifering  from  the  disease.  In 
view  of  these  facts  it  seems  probable  that  second  attacks  of  smallpox 
are  much  rarer  than  is  generally  supposed. 

The  cause  of  smallpox  doubtless  resides  in  a  specific  micro-organism. 
As  pathogenic  microbes  have  been  found  in  a  number  of  contagious 
diseases,  it  is  evident  that  such  a  microbe  must  exist  in  a  disease  so  typ- 
ically infectious  as  smallpox,  although  it  has  not  yet  been  described. 
The  only  micro-organisms  thus  far  discovered  are  such  as  belong  to  sup- 
purative processes.  For  example,  there  have  been  found  in  the  pustules 
the  streptococcus  pyogenes,  and  in  cultures  from  the  pustules  the  staphylo- 
coccus p>yogenes  aureus  and  staphylococcus  alhus.  The  bacteriological 
study  of  the  disease  is  therefore  incomplete. 

But,  while  we  are  not  yet  positively  informed  as  to  the  bacteriology 
of  smallpox,  there  is  no  doubt  that  the  disease  is  spread  by  means  of  a 
specific  virus  which  is  reproduced  in  every  patient.  That  the  infecting 
principle  is  contained  in  the  pustules  has  been  clearly  proved  by  small- 
pox inoculation.  It  is  also  contained  in  the  exhalations  from  the  body, 
in  the  breath,  and  probably  in  the  various  secretions,  although  this  has 
not  been  demonstrated.  Ziilzer  proved  that  it  is  contained  in  the  blood 
by  successfully  inoculating  a  monkey  with  blood  taken  from  a  smallpox 
patient. 

The  contagium  emitted  by  a  patient  is  most  intense  in  his  immediate 
vicinity,  but  it  may  be  transported  in  an  active  state  for  some  distance 
by  the  atmosphere.  It  is  impossible  to  fix  definitely  the  striking-dis- 
tance of  the  contagium,  since  this  depends  largely  upon  the  number  and 
severity  of  the  cases  collected  together.  If  a  susceptible  person  should 
enter  a  small  apartment  containing  one  or  more  severe  cases  of  small- 
pox, infection  would  almost  certainly  occur,  Avhile  if  the  apartment  be 
large  and  well  ventilated  and  the  cases  few  and  mild,  the  risk  of  infec- 
tion M'Ould  be  greatly  diminished,  or  if  he  should  approach  equally  near 
the  same  cases  in  the  open  air,  the  risk  would  be  still  less. 

Smallpox  is  undoubtedly  infectious  in  all  stages  characterized  by 
symptoms.  It  is  alleged  by  some  that  the  disease  is  even  infectious 
during  the  incubation  period,  but  I  think  there  is  very  little  reason  to 
believe  that  such  is  the  case.  It  is  not  improbable,  however,  that  the 
blood  of  a  person  in  this  stage  of  the  disease  might  convey  the  infec- 
tion if  it  were  introduced  into  the  veins  of  a  susceptible  individual. 
An  interesting  case  is  reported  by  Schaper,  showing  that  the  infection 


ETIOIJKiY.  519 

was  transmitted  during"  this  stage  bv  sicin-grai'ting.  The  small  pieces 
of  skin  used  for  the  purpose  were  taken  from  a  person  who  several 
hours  later  began  to  manifest  symptoms  of  smallpox,  and  the  individual 
upon  whom  this  skin  was  transplanted  was  attacked  by  the  disease  on 
the  sixth  day  after  the   operation.' 

Excepting  the  incubation  period,  the  disease  is  least  infectious  during 
the  initial  stage,  and  most  highly  so  during  the  sup[)urative  and  early 
period  of  the  desiccative  stages.  The  scabs  are  unquestional)ly  infec- 
tious, and  as  long  as  these  remain  on  the  skin  the  patient  should  l)e 
regarded  as  dangerous  to  the  community.  Even  after  death  the  body 
still  retains  the  power  of  transmitting  the  contagium.  This  fact  has 
been  demonstrated  more  than  once  where  public  funerals  have  not  been 
interdicted,  and  where  the  bodies  of  persons  who  have  died  from  small- 
pox have  by  accident  found  their  way  into  dissecting  rooms. 

While  the  contagium  of  smallpox  is  perhaps  more  commonly  con- 
veyed from  person  to  person  through  the  atmosphere,  yet  this  is  not  the 
only  medium  of  infection.  The  infecting  germs  become  attached  to  all 
objects  in  the  immediate  vicinity  of  the  patient  and  cling  to  them  for 
a  variable  length  of  time.  Objects  which  have  a  rough,  shaggy  surface, 
such  as  blankets,  woollen  clothing,  etc.,  not  only  become  more  intensely 
infected,  but  hold  the  infection  much  longer,  than  smooth  objects. 
AVoollen  garments  closely  packed  and  excluded  from  the  air  as  com- 
pletely as  possible  have  been  known  to  retain  the  infection  for  many 
months,  and  even  years.  If,  however,  such  garments  be  freely  exposed 
to  the  atmosphere  and  sunlight,  the  contagium  will  soon  be  destroyed. 
Of  course  it  may  be  destroyed  at  once  by  disinfecting  agents. 

Not  only  objects  in  the  room  of  the  patient,  but  also  healthy  persons 
whose  duties  require  them  to  come  in  contact  with  the  sick,  may  be  the 
means  of  communicating  the  infection.  The  infection  may  adhere  to  the 
hands  and  other  parts  of  the  body  of  the  attendants,  but  the  chief  dan- 
ger is  from  their  clothing.  Great  caution  should  therefore  be  observed 
by  physicians,  nurses,  and  others  in  attendance  upon  smallpox  patients. 

The  manner  in  which  the  contagium  enters  the  system  is  usually  by 
absorption  in  the  respiratory  tract.  When  there  is  susceptibility  to 
smallpox  a  single  inspiration  of  air  containing  the  germs  of  the  disease 
is  quite  sufficient  to  ensure  infection  of  the  individual.  While  it  is 
possible  for  the  contagium  to  be  absorbed  by  the  mucous  membrane  in 
the  upper  part  of  the  air  passage,  there  is  no  doubt  that  absorption 
takes  place  principally  through  the  lungs.  It  is  well  known  that  the 
contagium  never  enters  the  circulation  through  the  skin,  except  by  inoc- 
ulation. The  older  writers  believed  that  it  was  possible  for  the  virus 
to  enter  by  the  mucous  membrane  of  the  alimentary  canal,  especially 
by  the  stomach,  but  the  comparatively  recent  experiments  of  Ziilzer  on 
a  monkey  which  was  forced  to  swallow  smallpox  crusts  were  followed 
by  negative  results. 

Conditions  seem  to  exist  at  times  more  favorable  to  the  spread  of 
smallpox  than  at  others.  For  instance,  at  one  time  the  disease  is  met 
with  in  isolated  cases,  and  shows  but  little  disposition  to  spread,  or  if 
it  spreads  and  assumes  the  proportion  of  an  epidemic,  the  epidemic  is 
small  and  marked  by  unusual  mildness.     At  another  time  the  disease 

'  Carschmann  in  v.  Ziemsaen's  Cydopcedia  of  the  Practice  of  Medicine. 


520  SMALLPOX  AND    VARIOLOID. 

rapidly  spreads  from  a  single  case,  and  speedily  assumes  the  dimensions 
and  fatality  of  an  extensive  and  malignant  epidemic.  This  variation  in 
the  behavior  of  the  disease  at  different  times  has  never  been  satisfac- 
torily explained.  To  say,  as  the  earlier  writers  were  wont  to  do,  that  it 
is  owing  to  some  peculiar  condition  of  the  atmosphere  is  no  solution  of 
the  problem.  Perhaps  Diemerbroek  was  not  far  wrong  when  he  ex- 
pressed the  belief  that  "  this  is  one  of  those  mysteries  which  nature  for 
ever  intends  to  keep  to  herself." 

There  is,  however,  one  cause  well  understood  which  at  the  present 
day  influences  to  a  great  extent  the  recurrence  of  epidemics,  and  that 
is  the  neglect  of  vaccination.  During  the  prevalence  of  smallpox  this 
important  agent  is  freely  employed  and  serves  as  a  powerful  factor  in 
extinguishing  the  epidemic.  But  it  is  well  known  that  in  the  course 
of  a  few  years  the  susceptibility  of  very  many  of  those  previously  pro- 
tected by  vaccination  becomes  gradually  re-established.  If  we  consider 
the  large  numl^er  of  susceptible  persons  belonging  to  this  class,  together 
Avith  the  number  of  those  who  are  apt  to  neglect  vaccination,  we  can 
readily  see  how  there  is  provided  from  time  to  time  a  suitable  soil  into 
which  only  a  few  smallpox  germs  need  be  introduced  to  give  rise  to  an 
epidemic  of  the  disease. 

Pathological  Anatomy. — While  it  is  generally  conceded  that  the 
etiology  of  smallpox  must  be  explained  by  the  germ  theory,  yet  nothing 
is  known  of  the  nature  of  the  specific  micro-organisms  believed  to  be 
present  in  the  disease,  nor  of  their  manner  of  attacking  the  blood  and 
tissues  of  the  body.  The  only  bacteria  described  are  those  belonging 
to  the  cocci  group,  especially  such  as  are  peculiar  to  pus  formation,  but 
they  can  scarcely  be  said  to  bear  a  causative  relation  to  the  pathological 
processes  of  the  disease. 

The  Skin. — The  earliest,  and  indeed  the  chief,  anatomical  changes 
met  with  are  found  in  the  skin.  Usually  on  the  third  day  of  the 
disease  the  characteristic  cutaneous  lesions  begin  in  the  form  of  small 
red  spots.  These  are  produced  by  circumscribed  hypersemia  of  the 
papilla?  and  extend  deeply  into  the  skin.  Papulae  are  thus  formed,  and 
as  they  advance  in  their  development  the  epithelial  cells  above  the  con- 
gested pa|)illse,  through  an  increase  of  protoplasm,  become  enlarged 
and  granular.  This  distinctly  granular  condition  of  the  involved 
epithelia  causes  the  papules  to  assume  at  quite  an  early  stage  a  solid, 
dense  character. 

The  papulae  are  next  converted  into  vesicles  by  an  exudation  of  lymph 
from  the  papillary  layer.  As  the  lymph  increases  the  altered  cells  over 
the  engorged  papillae  are  separated  and  changed,  so  as  to  form  septa  or 
partition  walls,  which  give  to  each  vesicle  a  reticulated  or  many  celled 
cavity.  AVhile  the  contents  of  the  vesicles  at  first  is  principally  lymph, 
together  with  coagulated  fibrin  and  granular  matter,  eventually  pus  cor- 
puscles are  formed,  mainly  by  the  transformation  of  epithelia. 

Quite  early  in  the  vesicular  process  a  depression,  known  as  "  umbili- 
cation,"  is  seen  in  the  centre  of  very  many  of  the  vesicles.  This  is 
believed  to  be  due  either  to  the  hair  follicles  or  the  excretory  ducts  of 
sweat  glands,  as  in  either  case  the  epidermis  dips  downward  and  forms 
a  part  of  their  anatomical  structure.  If,  for  instance,  a  vesicle  forms 
about  a  hair  follicle,  the  centre  of  its  epidermic  covering  will  be  held 


PA  THOLOGICA L   .  1 A . I  T'>M  V.  52 1 

down  bv  the  .sheath  of"  the  tolliele,  while  the  surrouiuHu^  portion  will 
become  more  elevated.  The  (hicts  of  the  .sweat  glands  have  the  .same 
relation  to  the  epidermis  and  may  act  in  the  same  way.  It  shoid«l  be 
stated,  however,  that  some  authors  do  not  aeeept  this  explanation,  but 
believe  that  the  eentre  of"  the  vesicle  is  held  down  i>y  a  resistant  portion 
of  tissue  from  some  other  eau.>ie.  According  to  Curschmann,  Auspitz 
and  Basel)  teach  that  the  j3eripherv  of  the  vesicle  swells  more  rapidly 
and  thus  l)ecomes  more  voluminous  than  its  centre. 

When  the  vesicle  has  advanced  to  the  pustular  stage  and  the  pock  is 
fully  di'V(lo])ed,  the  umbilication  disap])ears.  This  results  from  accumu- 
lation of  tile  |)us  corpuscles,  which,  by  maceration  and  tension,  causes 
the  fibre  of  tissue  holding  down  the  centre  of  the  pustule  to  give  way. 
When  desiccation  commences  it  is  not  unusual  to  find  that  many  of  the 
pustules  begin  to  dry  in  their  centre,  and  thus  assume  again  an  umbil- 
icated  appearance  ;  but  the  umbilication  previously  described  is  some- 
thing very  different,  both  in  its  cause  and  appearance. 

In  unmodified  smallpox,  sometimes  also  in  varioloid,  both  the  papilke 
and  connective  tissue  beneath  the  pustules  become  involved  in  the  iuflam- 
matory  process,  and,  through  the  accumulation  of  pus  corpu.scles  in  the 
papilhe,  the  bloodvessels  are  compressed,  producing  necrosis  of  the  upper 
layers  of  the  true  skin.  The  extent  of  tliis  necrotic  action  determines 
the  size  and  shape  tjf  the  cicatrices  ;  for  wherever  fibrous  connective 
tissue  is  destroyed  its  place  is  supplied  by  cicatricial  growth.  Perma- 
nent scars  may  therefore  be  expected  to  follow  the  eruptive  process. 

The  vesicles  in  hemorrhagic  variola  differ  from  the  ordinary  vesicles 
in  that  they  contain  i)lood  instead  of  lymph  and  pus.  In  the  milder 
oases  of  this  form  of  the  disease  there  may  be  only  a  slight  admixture 
of  blood  with  the  elements  usually  found ;  in  the  severer  cases  not  only 
do  the  vesicles  literally  fill  with  blood,  but  there  is  hemorrhagic  infil- 
tration in  all  the  layers  of  the  cutis  and  even  in  the  subjacent  areolar 
tissue.  This  latter  condition  is  often  very  extensive,  covering  almost 
the  entire  surface  of  the  body.  In  such  cases  death  usually  occurs 
before  there  is  time  for  the  development  of  vesicles.  Wagner's  inves- 
tigation shows  that  the  hemorrhagic  extravasation  is  not  the  result  of 
rupture  of  the  bloodvessels,  but  is  due  to  transudation  of  the  altered 
blood  through  the  relaxed  and  weakened  vascular  walls.  Certainly  no 
anatomical  changes  sufficient  to  account  for  this  condition  have  yet  been 
found  in  the  walls  of  the  vascular  system. 

The  iiiiicous  membranes  are  not  exempt  from  the  eruptive  process.  The 
eruption  on  this  membrane,  however,  rarely  observes  the  same  course  as 
on  the  cutaneous  surface.  Instead  of  running  through  the  distinct 
stages  of  papule,  vesicle,  and  pustule,  it  is  apt  to  assume  the  form  of 
diffuse  purulent  infiltration  of  the  layers  of  the  epithelium,  and  may 
even  become  diphtheritic  in  character.  The  extent  and  intensity  of  the 
involvement  of  the  mucous  membrane  usually  bear  a  very  direct  rela- 
tion to  the  eruption  on  the  skin. 

That  part  of  the  mucous  surface  which  comes  in  immediate  contact 
with  the  air  is  more  apt  to  be  attacked.  Indeed,  the  mucous  lining  of 
the  nose  and  mouth  seldom  escapes.  The  tongue,  posterior  nares,  and 
pharynx  are  often  severely  attacked,  even  to  the  extent  of  interfering  with 
deglutition.     The  eruption  may  occur  in  the  larynx,  trachea,  and  bron- 


522  SMALLPOX  AND    VARIOLOID. 

chial  tubes,  even  below  the  bifurcation,  giving  rise  to  various  grades  of 
catarrhal  inflammation.     Catarrhal  pneumonia  occurs  not  infrequently. 

The  eruption  has  been  found  in  the  upper  part  of  the  oesoj^haguSy 
but  it  is  doubtful  whether  it  ever  extends  to  the  stomach  and  intestines. 
It  has,  however,  been  seen  at  the  lower  end  of  the  rectum  close  to  the 
anus.  The  vulva  and  outer  portion  of  the  vagina  are  often  severely 
attacked,  and  I  think  there  is  good  reason  to  believe  that  the  cavity  of 
the  uterus  is  not  infrequently  involved.  The  eruption  is  found  at  the 
orifice  of  the  urethra,  but  the  urethra  and  urinary  bladder  seem  to  be 
exempt. 

The  Viscera. — There  are  no  pathological  changes  found  in  any  inter- 
nal organ  that  can  be  regarded  as  peculiar  to  smallpox.  The  liver,  kid- 
neys, and  s^Dleen  have  been  found  sw^ollen  and  engorged  with  blood,  and 
occasionally  in  a  state  of  fatty  degeneration.  When  the  latter  condition 
exists  there  is  also  apt  to  be  degeneration  of  the  walls  of  the  heart.  In 
the  severer  forms  of  hemorrhagic  variola,  where  death  occurs  early,  the 
heart,  according  to  Ponfick,  is  contracted,  firm,  and  of  a  brownish  red 
color.  In  this  class  of  cases  the  spleen  also  is  small,  dense,  and  very 
dark.  Besides  these  changes  hemorrhages  are  found  in  the  viscera,  the 
cavities  of  serous  membranes,  the  loose  connective  tissue  of  the  medias- 
tinum, and  in  various  other  parts  of  the  body. 

The  brain  and  spinal  cord  have  been  found  congested  and  oedematous. 
Changes  not  well  defined  sometimes  occur  in  the  nervous  system,  giving 
rise  to  aphasia  and  certain  forms  of  paralysis.  Hemorrhages  into  the 
sheaths  of  nerves  have  been  seen  by  Zlilzer. 

Abscesses  and  purulent  collections  in  various  serous  cavities,  as  the 
result  of  septicsemia,  not  infrequently  occur.  I  have  several  times  seen 
large  collections  of  pus  in  the  pleural  cavity,  and  also  in  the  larger  joints, 
especially  the  elbow  joint. 

The  eyes  are  often  severely  affected.  Conjunctivitis  and  oedema  of 
the  lids  are  common.  The  cornea  is  frequently  attacked  by  ulcerative 
action,  resulting  often  in  perforation  and  protrusion  of  the  iris.  Suppu- 
ration of  the  globe  sometimes  follows. 

Symptoms. — Incubation. — The  period  that  intervenes  between  the 
reception  of  the  variolous  contagium  into  the  system  and  the  earliest 
manifestation  of  symptoms  is  known  as  the  "  period  of  incubation."  The 
duration  of  this  period  generally  does  not  vary  very  greatly.  In  the 
majority  of  cases  in  which  I  have  had  opportunities  of  observing  it  care- 
fully I  have  found  it  to  be  from  ten  to  twelve  days.  It  is  seldom  less  than 
eight  or  more  than  fourteen  days.  The  period  can  only  be  determined 
accurately  when  an  individual  is  exposed  to  the  contagium  but  once  and 
for  a  short  time.  Where  the  exposure  is  frequent  or  extends  over  a 
long  period  it  is  not  easy  to  determine  the  exact  time  when  the  con- 
tagium enters  the  system.  When  the  disease  prevails  epidemically  it  is 
not  impossible  for  an  unknown  exposure  to  precede  the  one  of  which 
the  individual  has  knowledge,  and  in  such  case  the  period  of  incubation 
would  appear  to  be  unusually  short.  These  facts  may  explain  many 
eases  in  which  this  stage  is  believed  to  be  either  unusually  long  or  short. 
When,  however,  infection  takes  place  by  inoculation,  constitutional 
symptoms  usually  manifest  themselves  on  the  latter  part  of  the  seventh 
or  beginning  of  the  eighth  day. 


SYMPTOMS.  ry2^ 

Alter  the  ooutugium  i.s  received  into  the  system  certain  unknown  pro- 
cesses are  doubtless  set  up,  although  rarely  indeed  are  any  symptoms 
observed  during  the  incubation  period.  Some  authors  describe  as  occa- 
sionally present  such  symptoms  as  languor,  gastric  disturbance,  pain  in 
the  head  and  back,  and  a  peculiar  pallor  of  the  face,  but  I  have  never 
met  with  any  of  these  except  toward  the  close  of  this  stage.  Usually 
the  individual  appears  to  enjoy  perfect  healtli  until  the  invasive  symj> 
toms  appear. 

Initial  Sfaf/e. — After  slight  malaise,  of  short  duration,  the  symp- 
toms of  smallpox  appear  suddenly,  and  often  with  considerable  violence. 
The  earliest  symptom  is  usually  a  distinct  chill  or  repeated  rigors ;  high 
fever  follows  immediately,  and  continues  unabated  until  the  peculiar 
cutaneous  lesions  appear.  This  comprises  a  period  of  from  two  to  four 
days,  and  is  designated  the  stage  of  invasion,  or  initial  stage,  of  smallpox. 

The  chill  which  usually  marks  the  beginning  of  the  initial  stage  is 
sometimes  severe,  though  more  frequently  it  assumes  the  character  of 
repeated  rigors.  While,  as  a  rule,  the  latter  are  well  pronounced,  yet 
occasionally  they  are  so  mild  as  scarcely  to  attract  attention.  Synchron- 
ously with  the  chill  or  immediately  folloNAnng  it  fever  appears.  The 
temperature  on  the  first  day  often  rises  to  103°  or  104°  F.,  and  on  the 
second  and  third  llays,  with  perhaps  the  exception  of  slight  morning 
remissions,  it  rises  still  higher,  frequently  reaching  105°,  and  in  some 
cases  even  107°  F.  The  elevation  of  the  temperature  is  usually  sud- 
den ;  in  but  few  diseases  does  it  rise  so  quickly  from  the  normal  to  a 
high  degree.  Even  in  varioloid  the  early  symptoms  are  not  infrequently 
equally  severe,  although  occasionally  they  are  so  mild  as  to  escape  atten- 
tion, so  that  the  first  symptom  noticed  is  the  skin  lesion.  But  the 
eruption  of  unmodified  smallpox  never  appears  without  being  preceded 
by  a  well  marked  invasive  stage. 

While  the  fever  continues  the  skin,  of  course,  is  hot  and  sometimes 
dry,  though  more  frequently  covered  by  a  moderate  perspiration.  The 
pulse  is  full,  tense,  and  rapid ;  its  rapidits*  generally  corresponds  ^A^ith 
the  temperature  curve.  In  adults  it  may  vary  between  100  and  130, 
while  in  children  it  not  infrequently  reaches  160.  The  respirations  are 
almost  always  increased  in  frequency,  especially  when  the  temperature 
is  excessively  high.  Prostration  is  often  extreme,  being  out  of  all  pro- 
portion to  the  length  of  the  illness.  Strong  and  robust  patients  are 
frequently  unable  to  stand  without  support,  and  when  in  the  upright 
position  soon  become  pale,  languid,  and  liable  to  be  attacked  by  vertigo 
or  syncope. 

There  is  also  thirst,  the  lips  and  tongue  are  parched  and  dry,  and  loss 
of  appetite  is  manifest.  Constipation  is  common.  The  tongue  is  usually 
coated  with  a  thick  yellowish  covering,  and  the  breath  is  heavy  and 
offensive.  According  to  some  authors,  the  odor  from  the  body  of  a 
patient  at  this  stage  of  the  disease  is  so  peculiar  and  distinctive  as  to 
make  it  possible  for  the  diagnosis  of  smallpox  to  be  made  by  this  symp- 
tom alone.  I  have  heard  of  many  curious  instances  of  this  kind,  but 
I  must  confess  that  my  olfactories  have  never  acquired  this  degree  of 
acuteness. 

Irritability  of  the  stomach  is  a  very  frequent  symptom  at  this  stage. 
It  is  often  verv  obstinate,  continuinsf  for  two  or  three  davs  or  until  the 


524  SMALLPOX  AND    VARIOLOID. 

eruption  appears,  and  is  apt  to  be  accompanied  by  marked  tenderness  of 
the  epigastrium.  The  irritability  usually  ceases  when  the  eruption  ap- 
pears, but  if  it  continues  longer  the  case  should  be  viewed  with  some 
solicitude.  In  hemorrhagic  smallpox  especially  this  symptom,  together 
with  epigastric  pain,  is  not  infrequently  very  prominent  and  distressing. 
Certain  nervous  symptoms  are  usually  present.  The  most  prominent  is 
headache,  which  is  scarcely  ever  entirely  absent.  Delirium  is  often  seen, 
especially  when  the  temperature  is  high.  It  may  be  mild  in  character, 
the  patient  simply  talking  incoherently,  or  so  violent  that  forcible  re- 
straint is  necessary.  The  latter  form  is  usually  attended  with  great 
restlessness  and  insomnia.  Coma  is  rare,  although  it  may  be  met  with 
in  children.  Convulsions  are  very  common  among  children — more  so, 
perhaps,  in  this  disease  than  in  any  other  of  the  exanthemata.  Pain  in  the 
back  is  a  symptom  so  commonly  observed  that  it  is  believed  to  be  of 
special  diagnostic  value.  It  is  not  so  constant  as  some  other  symptoms, 
yet  it  occurs  in  more  than  half  of  the  cases.  Like  headache,  it  begins 
at  the  onset  of  the  disease  and  continues  until  the  eruption  has  made  its 
appearance.  The  lumbar  and  sacral  regions  are  the  parts  to  which  the 
pain  is  usually  referred,  although  it  may  extend  to  the  dorsal  region. 
As  a  rule,  it  is  more  severe  in  unmodified  smallpox  than  in  varioloid, 
yet  this  rule  is  subject  to  many  exceptions.  In  heAiorrhagic  cases  the 
pain  is  often  excruciating. 

Pain  in  the  back  is  perhaps  more  constantly  seen  among  female  than 
male  patients,  owing  to  the  fact  that  the  menstrual  function  is  very 
liable  to  be  excited  by  the  initial  process  of  smallpox,  causing  the 
menses  to  appear  out  of  their  regular  period.  Pregnant  females  also 
are  exceedingly  liable  to  suffer  from  premature  delivery  or  abortion. 
The  pain  in  the  back,  therefore,  resulting  from  these  causes  tends  to 
give  greater  prominence  to  this  symptom  of  smallpox  in  females. 

The  urine  is  usually  more  or  less  diminished  according  to  the  degree 
of  fever.  The  solid  constituents  are  not  out  of  their  normal  propor- 
tion, except  the  chlorides,  which  are  considerably  diminished.  In 
severe  cases,  especially  those  about  to  assume  the  hemorrhagic  type, 
albuminuria  may  be  present.  A  high  grade  of  fever  might  be  respon- 
sible for  a  small  quantity  of  albumin,  but  if  it  be  present  in  great 
abundance,  a  malignant  type  of  the  disease  should  be  suspected.  Before 
giving  an  unfavorable  prognosis,  however,  care  should  be  taken  to  see  that 
the  albumin  is  not  the  result  of  some  chronic  disease  of  the  kidneys. 

The  sj)leen,  according  to  Curschmann,  whose  attention  has  been 
especially  directed  to  it  in  a  large  number  of  patients,  is  not  rarely 
enlarged.  He  says  he  has  never  been  able  to  detect  any  enlargement 
of  this  organ  in  the  initial  stage  of  varioloid,  but  has  found  this  con- 
dition present,  and  often  to  a  marked  degree,  in  unmodified  smallpox. 
In  many  severe  and  grave  cases,  however,  the  splenic  tumor  was  absent. 
Therefore  no  great  diagnostic  value  can  as  yet  be  attached  to  this 
symptom. 

A  peculiar  prodromal  rash  often  makes  its  appearance  during  this 
stage.  When  it  occurs  it  is  usually  seen  on  the  second  day  of  the 
invasive  fever,  and  continues  not  longer  than  forty-eight  hours  or  until 
the  beginning  of  the  true  eruption.  The  frequency  of  this  rash  appears 
to  vary  in  diiferent  epidemics.     During  the  widespread  and  malignant 


SYMPTOMS.  525 

epicleiuic  of  1871-72  it  was  very  coiuiikmi.  Some  authors  describe  it  as 
])rt'sentiii^  an  erythoinatous  or  scarlatiiiilonii  a|)[)('araiice,  but  according 
to  my  observation  it  more  nearly  resembles  the  rash  of  measles.  So 
close,  indeed,  is  the  reseml)lanee  that  the  first  time  I  met  with  it  I  fell 
into  the  error  of  sup])()sing  the  case  to  be  one  in  which  measles  and 
smallpox  coexisted.  The  name  generally  given  to  the  rash — roaeula 
variolosa — conveys  a  very  good  idea  of  its  appearance. 

This  ])eculiar  exanthem  occurs  quite  as  often  in  varioloid  as  in 
variola.  In  the  absence  of  any  exact  data  1  venture  the  assertion  tiiat 
I  have  met  with  it  more  frequently  in  the  former.  I  am  able  to  recall 
at  this  moment  two  cases  of  variolous  disease  in  which  it  was  tlie  only 
eruption  that  occurred  at  all.  In  one  of  these,  it  is  true,  about  half  a 
dozen  small  papules  appeared  as  the  initial  rash  faded  away,  but  they 
disappeai'ed  in  two  or  three  days  without  becoming  in  the  slightest 
degree  vesicular.  These  belonged  to  the  class  of  cases  commonly  desig- 
nated variola  sine  cnDttlioiiafa,  the  most  benignant  form  of  the  disease 
that  occurs,  as  well  as  the  rarest.  That  such  cases  are  encountered 
occasionally  is  evident  from  the  writings  of  all  authors,  both  ancient 
and  modern.  Perhaps  in  every  epidemic  patients  are  seen  who  give  a 
history  of  exposure  to  the  contagium  of  variola,  and  after  the  usual 
incubation  period  are  suddenly  seized  with  repeated  rigors,  followed  by 
headache,  fever,  irritable  stomach,  prostration,  and  pain  in  the  l)ack  ; 
Avhich  symptoms  continue  three  or  four  days,  and  then  subside  without 
any  cutaneous  manifestations,  except  perhaps  the  rash  just  described. 
It  is  difficult  to  explain  such  cases  on  any  other  supposition  than  that 
the  disease  was  smallpox  without  the  eruption. 

While  the  initial  stage  may  present  the  most  varying  phases,  some 
symptoms  may  be  entirely  absent  and  others  appear  Avith  great  severity, 
yet  there  are  usually  no  indications^,  thus  far,  to  justify  the  certain  ex- 
pectation that  the  case  will  be  mild  or  severe,  modified  or  unmodified ; 
this  can  only  be  clearly  determined  when  the  eruption  has  made  its 
appearance,  which  is  not  until  the  invasive  stage  has  passed.  The  dura- 
tion of  this  stage  is  commonly  forty-eight  to  seventy-t^vo  hours  ;  it  is 
rarely  less,  but  it  may  be  somewhat  prolonged.  There  is,  however,  no 
decided  remission  in  the  fever  until  the  second  or  third,  and  sometimes 
not  until  the  fourth,  day  of  the  eruption. 

Stage  of  Eruption. — By  observing  carefully  the  early  stage  of  the 
disease  it  will  be  found  that  the  true  eruption  makes  its  appearance  with 
remarkable  regularity  on  the  third  day  of  the  illness,  counting  the  day 
on  which  the  initial  chill  or  rigors  occurred  as  the  first.  The  eruption 
almost  always  appears  first  on  the  forehead  and  temples  near  the  edge 
of  the  hair,  and  on  the  wrists.  Not  infrequently  it  may  be  seen  first 
on  the  upper  lip  or  near  the  mouth.  It  rapidly  spreads  to  the  scalp, 
face,  neck,  ears,  forearms,  and  hands,  always  showing  a  decided  prefer- 
ence for  the  cutaneous  surface  habitually  exposed  to  the  atmosphere. 
In  the  course  of  twenty-four  hours,  sometimes  somewhat  earlier,  it 
extends  to  the  body  and  lower  extremities.  ISot  simultaneously  does  it 
appear  on  these  parts,  but  first  on  the  back,  arms,  and  breast,  then  on 
the  legs  and  feet.  Nor  does  the  entire  eruption  make  its  appearance  all 
at  once  on  any  one  part,  but  it  continues  to  multiply  for  two  or  three 
days  before  its  definite  limit  is  reached.     A  careful  study  of  the  eruption 


526  SMALLPOX  AND    VARIOLOID. 

has  shown  that  the  lesions  are  exceedingly  apt  to  locate  themselves 
around  the  hair  follicles  and  orifices  of  the  glands  of  the  skin.  Another 
notable  feature  of  the  lesions  is  that  they  show  a  remarkable  predilection 
for  all  irritated  or  abraded  surfaces,  and  hence  collect  in  dense  clusters 
around  an  ulcer  or  any  localized  inflammation  of  the  skin.  Even  the 
redness  produced  by  a  sinapism  predisposes  that  part  to  an  intensely 
confluent  form  of  the  eruption.  But  while  the  lesions  may  thus  be 
increased  on  certain  areas,  they  do  not  seem  to  be  thereby  diminished 
on  other  parts  of  the  body. 

As  the  outbreak  of  the  eruption  is  gradual,  so  also  is  its  develop- 
ment. It  usually  appears  in  the  form  of  minute  red  points,  some  of 
which  may  be  so  small  as  to  be  scarcely  visible,  and  others  as  large  as 
a  mustard  seed.  These  gradually  increase  in  size  and  number,  becom- 
ing more  and  more  prominent,  so  that  in  twenty  four  hours  they  assume 
the  form  of  elevated  papules,  characteristically  indurated,  and  convey  to 
the  touch  a  sensation  similar  to  what  would  be  expected  if  grains  of 
shot  were  buried  in  the  skin.  The  papules  at  first  are  always  discrete, 
but  they  may  rapidly  increase  in  number  and  become  confluent,  even 
before  the  vesicular  stage  is  reached.  At  first  the  small  red  spots  give 
rise  to  no  subjective  symptoms,  but  as  they  advance  to  the  papular  stage 
there  is  a  slight  pricking  or  painful  sensation,  and  this  increases  as  the 
lesions  become  more  prominent. 

On  the  third  day  of  the  eruption,  or  fifth  day  of  the  disease,  very 
many  of  the  lesions  which  made  their  appearance  first  will  be  found  to 
contain  a  little  clear  serum.  By  the  fourth  or  fifth  day  all  the  lesions 
are  transformed  into  vesicles  with  cloudy  and  milky  contents  (Fig.  46). 
These  continue  to  enlarge,  attaining  their  maximum  size  about  the 
seventh  or  eighth  day.  As  soon  as  the  vesicles  form  there  can  be  seen 
in  very  many  of  them  a  central  depression,  which  deepens  as  they 
enlarge,  giving  them  the  peculiar  umbilicated  appearance  which  has 
been  described  in  a  previous  section.  Umbilication  of  the  vesicles  is  a 
very  important  diagnostic  symptom  in  variola,  since  the  vesicular  erup- 
tion of  no  other  disease  presents  exactly  the  same  appearance. 

A  close  examination  of  the  vesicles  shows  that  their  interior  is  divided 
into  many  partitions  or  cells.  This  is  evident  from  the  fact  that  if  a 
simple  puncture  be  made  into  the  epidermic  covering  of  a  vesicle  only 
a  small  part  of  its  contents  will  escape  through  the  opening,  while  the 
principal  part  remains  undisturbed. 

^^tage  of  Suppuration. — The  contents  of  the  vesicles  gradually  grow 
more  and  more  turbid  by  the  constant  accumulation  of  pus  corpuscles 
until  it  becomes  distinctly  purulent.  This  condition  is  usually  reached 
in  unmodified  smallpox  about  the  sixth  day  of  the  eruption,  and  marks 
the  beginning  of  the  stage  of  suppuration.  The  pustules  now  in  good 
part  become  large  and  globular,  losing  to  a  great  extent  their  umbili- 
cated character.  The  efflorescence  or  areola  which  at  first  surrounded 
them  becomes  broader  and  more  intense,  causing  the  skin  in  their  imme- 
diate vicinity  to  present  an  inflamed  and  tumefied  appearance.  On  parts 
of  the  body  where  the  pustules  are  thickly  set,  particularly  on  the  face 
and  head,  the  redness  and  tumefaction  are  extreme,  often  distorting  the 
features  to  such  an  extent  as  to  make  the  patient  unrecognizable.  The 
eyelids  are  frequently  so  oedematous  that  they  cannot  be  opened,  and 


n 


-0 

r- 
> 
H 
m 


m 
to" 


D 


m 


n 


r- 
> 
H 
m 


sYMrroMs. 


527 


iniiciL-  or  piiritonu  secretions  collect  at  tlieir  margins  ;  the  lips,  nose,  and 
cars  are  greatly  swollen  ;  and  the  scalp  is  often  so  swollen  and  ])ainful 
that  pressnre  from  the  ])illow  is  scarcely  endurable. 


Fig.  46. 


Discrete  variola  ou  the  sixth  day  of  eruption. 

As  the  eruption  on  the  body  and  lower  extremities  is  later  in  making 
its  appearance,  so  also  is  it  later  in  reaching  maturity.  About  the  eighth 
<lay  of  the  eruption  the  pustules  on  the  face  have  usually  reached  their 
greatest  development  and  begin  to  decline.  They  now  turn  yellow,  pre- 
sent a  shrunken  or  shrivelled  appearance,  and  many  of  them  rupture  and 
•collapse.  The  inflammation  and  swelling  also  gradually  subside.  At 
this  time  the  pustules  on  the  trunk  and  legs  are  still  distended  and  glob- 
ular, and  do  not  commence  to  decline  until  several  days  later.  At  this 
stage  of  the  disease  a  peculiar  sickening  odor  emanates  from  the  body 
which  in  severe  cases  is  extremely  offensive. 

The  eruption  on  the  trunk  is  almost  always  much  less  abundant  than 
on  other  parts  of  the  body.  Xot  infrequently  the  hypogastrium  is  quite 
free  from  pustules,  even  when  they  may  be  seen  on  the  face  and  hands 
in  a  confluent  form.  (See  Plates  VI.  and  VII.)  The  pustules  on  the 
trunk  also  seem  to  set  more  superficially  on  the  skin  than  those  on  sur- 
faces habitually  exposed  to  the  atmosphere  ;  hence  they  are  not  accom- 
panied by  the  same  amount  of  painful  tumefaction  nor  as  great  ulcera- 
tive destruction  of  the  cutis.  During  the  period  of  maturation  the 
Angers  and  toes  are  often  excessively  painful.  This  condition  has  been 
not  inaptly  compared  to  a  paronychia  on  each  finger.  The  cause  of  the 
suffering  is  not  difficult  to  explain.  As  the  pustules  develop  into  the 
callous  covering  of  these  parts  they  are  prevented  from  projecting  out- 
ward by  the  hard  and  unyielding  epidermis,  and  hence  considerable 
pressure  is  made  on  the  network  of  nerves  which  lie  between  the  pus- 


528  SMALLPOX  AND    VARIOLOID. 

tules  and  the  bone.  On  the  palms  of  the  hands  and  soles  of  the  feet  the 
pustules  never  project  as  on  other  parts  of  the  cutaneous  surface. 

Simultaneously  with  the  appearance  of  the  eruption  upon  the  external 
surface  of  the  body  certain  portions  of  the  mucous  membrane  also 
become  involved.  If  an  examination  of  the  mouth  and  fauces  be  made 
at  the  very  beginning  of  the  eruptive  stage,  small  yet  distinct  red  spots 
may  be  seen  on  the  roof  of  the  mouth,  buccal  surfaces,  and  the  anterior 
arches  of  the  palate.  Almost  always  is  the  involvement  limited  to  those 
parts  of  the  mucous  membrane  which  are  near  the  external  orifices  of 
the  mucous  tract,  such  as  the  mouth,  nose,  and  pharynx. 

The  extent  of  the  lesions  on  the  mucous  membrane  bears  a  very  direct 
relation  to  the  intensity  of  the  eruption  upon  the  skin.  In  severe  cases, 
as  the  disease  advances  toward  the  stage  of  suppuration,  the  eruptive 
process  extends  from  the  lips  and  mouth  to  the  fauces,  pharynx,  and 
sometimes  to  the  larynx,  frequently  causing  so  much  inflammation, 
swelling,  or  oedema  as  to  make  deglutition  difficult  or  impossible,  or 
causing  hoarseness  or  complete  aphonia,  and  not  infrequently  acute  oedema 
of  the  glottis,  even  to  the  extent  of  seriously  impeding  respiration.  The 
lesions  may  extend  into  the  trachea,  but  rarely  below  the  bifurcation. 
They  often  attack  the  tongue  severely,  and  occasionally  set  up  an  intense 
form  of  glossitis,  causing  the  organ  to  swell  so  enormously  as  to  prevent 
its  retention  wholly  within  the  mouth.  So  peculiar  is  this  condition  of 
the  tongue  that  the  earlier  authors  speak  of  it  as  glossitis  variolosa. 

Much  annoyance  is  often  experienced  from  the  presence  of  the  erup- 
tion in  the  nasal  cavities.  The  mucous  membrane  at  first  is  inflamed 
and  swollen,  and  later  the  nares  are  obstructed  by  the  formation  of 
scabs,  rendering  breathing  through  the  nose  difficult  and  sometimes 
impossible.  The  eruption  may  be  seen  on  the  vulva,  sometimes  in  the 
vagina,  and  occasionally  in  the  lower  part  of  the  rectum  ;  but  on  these 
parts  it  is  not  apt  to  be  very  abundant.  Rarely  is  the  urethra  attacked, 
except  at  the  meatus. 

The  eruption  on  the  mucous  membrane  presents  a  very  diflerent 
appearance  from  that  on  the  skin.  It  does  not  conform  to  the  stages 
of  papule,  vesicle,  and  pustule.  Taking,  for  example,  the  mouth,  the 
lesions  at  first  appear  as  minute  red  spots,  much  deeper  in  color  than 
the  mucous  membrane  itself,  and,  as  the  eruption  on  the  skin  becomes 
vesicular  or  pustular,  they  assume  a  whitish  or  grayish  appearance, 
with  but  little  if  any  elevation  above  the  surface,  rather  than  the  form 
of  distinct  vesicles.  There  is  perhaps  an  effi:)rt  on  the  part  of  nature 
toward  the  formation  of  vesicles,  but  the  thin  and  delicate  epithelium 
which  should  serve  as  their  covering  is  at  once  destroyed  by  the  mace- 
rating influence  of  the  mucous  secretions.  In  severe  cases  the  mucous 
membrane  is  usually  so  denuded  of  its  epithelium,  swollen,  and  painful 
that  mastication  is  impossible,  and  the  patient  is  therefore  forced  to 
subsist  entirely  on  a  liquid  diet. 

As  already  indicated,  the  febrile  symptoms  are  well  marked  during 
the  invasive  stage,  the  temperature  often  jumping  to  106°  F.  or  even 
higher  immediately  after  the  initial  chill.  It  is  commonly  believed 
that  the  temperature  falls  as  soon  as  the  eruption  appears,  but  I  have 
found  that  the  fever  continues  high  until  the  third  or  fourth  day  of  the 
eruption,  when  there  usually  occurs  either  well  marked  remission  or 


SYMJ'TOMS.  529 

complete  apvrexia.  In  very  mild  cases  the  fever  of  course  abates  or 
subsides  earlier.  The  fall  of  temperature  at  this  stage,  even  in  severe 
cases,  is  not  infrequently  very  rapid — so  rapid,  indeed,  as  to  drop  from 
a  high  degree  to  norn)al,  or  even  subnormal,  in  the  course  of  twelve  to 
eighteen  hours.  The  difference  between  the  morning  and  evening  tem- 
j)erature  is  not  great,  although  tiie  latter,  as  a  rule,  is  slightly  higher. 

When  the  temperature  falls  tiu're  is  usually  amelioration  of  all  the 
symptoms.  The  pulse  becomes  almost  normal ;  the  respirations  are 
easier ;  the  pain  in  the  back,  headache,  and  irritability  of  the  stomach 
all  disappear,  except  in  critical  cases ;  the  delirium  ceases,  and  compara- 
tive comfort  ensues,  enabling  the  patient  to  rest  and  enjoy  refreshing 
sleep.  Even  the  appetite  returns,  and  the  transformation  is  so  great 
that  the  patient  is  apt  to  imagine  the  critical  period  of  the  disease  has 
passed.  The  subsidence  of  the  symptoms,  however,  is  never  so  absolute 
in  variola  vera  as  in  varioloid.  In  mild  cases  of  the  latter  all  subjective 
symptoms  often  disappear,  not  to  return  again,  and  convalescence  dates 
from  this  time ;  but  in  the  former  the  chief  danger  is  yet  to  be  encountered. 

At  or  shortly  after  the  commencement  of  the  stage  of  su])puration 
the  temperature  again  begins  to  rise,  and  continues  high  until  the  decline 
of  the  eruption,  or  longer  if  complications  occur.  This  rise  constitutes 
the  secondary  or  suppurative  fever  of  smallpox.  When  the  disease  is 
not  very  severe  the  temperature  may  not  rise  above  102°  or  103°  F., 
but  in  well  marked  confluent  cases  it  frequently  reaches  104°,  rarely 
exceeding  that  point  unless  the  case  be  very  critical,  when  it  may  rise 
to  105°  or  10(3°,  and  I  have  known  it  to  reach  even  107°  F.  The 
variation  between  the  morning  and  evening  temperature  now  is  greater 
than  at  any  previous  stage ;  a  difference  of  2°  F.  is  not  uncommon. 
As  this  is  truly  a  suppurative  fever,  the  rise  of  temperature  bears  a 
very  direct  relation  to  the  cutaneous  involvement.  The  pulse  usually 
runs  parallel  with  the  temperature  curve,  varying  between  100  and  140 
beats  in  a  minute.  With  the  increase  of  fever  other  symptoms  appear. 
The  pain  and  suffering  are  now  much  greater  than  before  ;  heat  and  burn- 
ing sensations  are  complained  of:  there  is  great  restlessness  and  sleep- 
lessness ;  headache  and  delirium  may  return ;  and  the  patient's  life  is 
often  in  great  jeopaixly. 

Disturbance  of  the  cerebral  functions  is  not  seldom  a  very  prominent 
feature  during  the  stage  of  suppuration.  The  high  temperature,  together 
with  the  intense  congestion  and  tumefaction  of  the  face  and  head,  doubt- 
less produce  hyperaemia  of  the  brain,  and  from  this  condition,  Avith  some 
peculiarity  of  temperament,  the  various  forms  of  delirium  arise.  Some- 
times the  delirium  is  mild  ;  the  patient  simply  talks  incoherently  in  a 
low,  muttering  tone  ;  at  other  times  he  may  be  very  restless  and  uneasy, 
constantly  trying  to  get  out  of  bed  and  to  escape.  Then,  again,  the 
delirium  may  assume  such  an  intense  character  that  unless  forcibly 
restrained  the  patient  is  liable  to  seriously  injure  either  himself  or  his 
attendant.  A  strong  tendency  to  self-destruction  is  often  manifested,  and 
warrants  the  utmost  precautions  for  his  safety,  even  the  use  of  the  strait 
jacket  if  the  man  be  large  and  powerful.  It  is  not  difficult  to  see  Ijy  the 
countenance  of  the  patient  that  he  is  moved  by  an  evil  impulse,  for  his 
eyes  are  wild  and  his  expression  fierce.  Hence  the  name  delii-ium  ferox 
was  given  to  this  form  of  cerebral  disturbance  by  the  earlier  authors. 

Vol.  I.— 34 


530  ■  SMALLPOX  AND   VARIOLOID. 

In  an  advanced  period  of  the  stage  of  suppuration,  especially  in 
severe  and  critical  cases,  the  nervous  disturbances  are  not  unlike  those 
familiar  to  surgeons  as  the  result  of  extensive  burns  and  scalds.  Low, 
muttering  delirium,  general  tremors,  subsultus  tendinum,  a  rapid  and 
tremulous  pulse,  a  dark  red,  dry  tongue,  involuntary  evacuations,  labor- 
ious breathing,  and  a  collapsed  expression  of  the  face  are  not  infrequently 
the  precursors  of  a  fatal  termination. 

Stage  of  Desiccation. — The  pustules  having  attained  their  greatest 
development,  maturation  being  completed,  begin  to  dry  and  shrink. 
This  condition  marks  the  beginning  of  the  last  stage  of  the  eruption, 
that  of  desiccation.  As  the  lesions  make  their  appearance  on  the  face 
and  hands  first,  naturally  desiccation  commences  there.  This  stage 
usually  begins  about  the  eleventh  or  twelfth  day  of  the  eruption ;  in 
mild  cases  it  often  begins  earlier,  and  in  very  grave  cases  later.  If  the 
case  is  to  end  in  recovery,  there  is  at  this  time  not  only  improvement  in 
the  local,  but  also  in  the  general,  symptoms.  The  redness  and  tumefac- 
tion of  the  skin  lessen,  the  eyes  open,  and  the  fever  subsides,  either 
gradually  or  rapidly  according  to  the  extent  of  involvement  of  the  skin 
and  mucous  membrane.  In  favorable  cases  the  temperature  each  day 
approaches  more  nearly  the  normal  standard,  and  there  is  also  a  corre- 
sponding lessening  of  the  pulse  rate.  If  there  be  considerable  derma- 
titis, the  temperature  falls  less  rapidly,  or  if  complications  arise,  it  con- 
tinues more  or  less  elevated  according  to  the  nature  of  the  concurrent 
disease.  But  it  must  be  borne  in  mind  that  the  vital  powers  of  the 
system  have  by  this  time  been  severely  taxed,  and  while  the  temperature 
may  be  steadily  decreasing,  the  patient  is  often  in  great  danger  from 
extreme  exhaustion. 

About  the  time  the  pustules  have  attained  their  maximum  size  and 
begin  to  shrink  an  exudation  of  a  sticky,  gluey  nature  appears  on  their 
surface.  This,  at  first,  is  yellowish  in  color,  and,  when  it  has  dried, 
forms  a  rough,  brown  coating  on  the  pustules.  It  is  at  this  period  of 
the  disease  that  the  offensive  odor  previously  mentioned  becomes  most 
marked,  and  in  some  cases  almost  unbearable,  especially  when  the  con- 
tents of  the  pustules  discharge  and  decompose  on  the  skin,  or  soak  into 
the  body  linen  and  bedclothing  and  there  undergo' decomposition. 

The  remaining  contents  of  the  pustules  now  begin  to  dry  and  scabs 
are  gradually  formed.  The  drying  frequently  begins  in  the  centre  of 
the  pustules,  causing  a  depression  or  secondary  umbilication.  Not  only 
does  desiccation  commence  on  the  exposed  portions  of  the  body,  such  as 
the  face  and  hands,  but  the  scabs  which  form  there  are  thicker  and 
more  firmly  adherent  than  on  the  trunk  and  extremities.  On  the  palms 
of  the  hands  and  soles  of  the  feet  the  pustules  dry  earlier  than  on  other 
parts  of  the  extremities,  and  the  scabs  adhere  much  longer.  This  is 
owing  to  the  fact  that  the  pustules  never  acuminate  here,  as  on  other 
parts  of  tbe  body,  but  remain  bound  down  under  pressure  by  the  thick 
and,  in  the  laboring  class,  horny  epidermic  covering,  so  that  the  scabs 
which  form  are  flat  and  imprisoned,  as  it  were,  by  this  covering. 
Patients  are  frequently  obliged  to  make  use  of  artificial  means  in  order 
to  expedite  the  removal  of  these  scabs. 

When  desiccation  commences  an  itching  sensation  often  takes  the 
place  of  pain.     This  sensation  is  sometimes  so  insuiferable  that  it  is  dif- 


VARIETIES   OF  SMALLPOX.  531 

ficiilt  tor  the  patient  to  rclVuiu  t"n)iu  scnitcliiiig-.  Cliildroii  luuy  destnjy 
in  this  way  the  pustules  over  the  entire  face,  leaving  simply  an  abraded, 
bleediuiT  surface.  To  prevent  this  occurrence  it  is  often  necessary  to 
muffle  tiicir  hands.  There  is  perhaps  no  objection  to  destroyinj^  the 
pustules,  provided  the  derm  receives  no  injury  ;  but  constantly  remov- 
ing' tile  scabs  as  fast  as  tiicy  form  l)y  forcible  means  necessarily  inflicts 
additional  injury  on  the  derm,  and  the  resulting  sears  are  thereby  ren- 
dered more  unsightly.  When  fully  formed  and  cicatrization  is  com- 
pleted they  separate  and  fall  with  variable  rapidity  from  different  parts 
of  the  body. 

In  regular  cases  of  r<ir'iola  vera  it  usually  requires,  after  desiccation 
has  commenced,  from  three  to  four  weeks  for  all  the  scabs  to  fall  off. 
This  makes  the  entire  duration  of  the  disease  about  five  or  six  weeks. 
It  is  sometimes  shorter,  and  often  much  longer.  After  the  scabs  have 
fallen  the  skin  presents  a  red,  spotted  appearance  and  is  disfigured  by 
scars.  These  are  always  deeper  on  surfaces  habitually  exposed  to  the 
atmosphere,  as  the  face  and  hands,  than  on  other  portions  of  the  bodv. 
On  some  parts  of  the  face,  particularly  on  the  nose,  the  destruction  of 
the  derm  is  often  so  great  as  to  produce  large  radiated  scars,  very  un- 
sightly in  appearance  and  persisting  for  a  lifetime.  The  scars  at  first 
are  red,  but  after  many  months  become  much  paler  than  the  normal 
skin.  While  the  scabs  are  separating  and  falling,  and  for  a  short  time 
subsequently,  the  greater  part  of  the  hair  also  falls  out,  especially  when 
the  eruption  has  been  very  abundant  on  the  scalp ;  but  it  is  almost 
always  restored  again.  The  nails  may  suffer  in  the  same  w'ay,  but  only 
in  extraordinarily  severe  cases. 

If  serious  complications  do  not  occur,  convalescence  is  usually  rapid, 
in  spite  of  the  more  or  less  numerous  furuncles  which  are  so  exceed- 
ingly common.  The  appetite  returns,  and  is  generally  keen,  sometimes 
even  voracious.  The  digestive  functions  are  active,  and  the  patient 
rapidly  regains  strength  and  flesh  until  restoration  of  health  is 
complete. 

Varieties  of  Smallpox. — Reference  should  be  made  to  other 
forms  and  varieties  of  smallpox  before  its  clinical  history  is  complete. 
The  course  above  described  relates  more  particularly  to  that  form  of 
the  disease  in  which  the  eruption  is  either  discrete  or  semiconfluent. 
According  to  my  experience,  the  vast  majority  of  cases  commonlv  met 
with  belong  to  the  latter  variety ;  that  is  to  say,  the  eruption  is  usuallv 
either  partly  or  wholly  confluent  on  the  face,  the  dorsal  surface  of  the 
hands,  and  the  lower  portion  of  the  forearms,  while  on  the  trunk  and 
extremities  it  is  discrete,  except  that  many  of  the  pustules  on  the  ex- 
tremities may  coalesce.  Variations  from  this  form  may  reach  extreme 
limits,  from  a  few  small  pustules,  scarcely  definite  enough  to  verifv  the 
disease,  to  the  most  extensive  eruption  covering  the  entire  cutaneous 
surface.  Also  types  of  the  disease  presenting  widely  divergent  clinical 
features  still  remain  to  be  considered  :  I  refer  to  the  petechial,  purpuric, 
and  hemorrhagic  forms  of  smallpox. 

Confluent  Variola. — It  can  hardly  be  said  that  there  is  any  symptom 
during  the  initial  stage  of  smallpox  peculiar  to  the  confluent  form  of 
the  disease.  The  symptoms,  however,  are  always  severe  in  this  variety, 
while   in   varioloid  tliev  mav  be  either  severe   or  mild  ;  hence  a  mild 


532  SMALLPOX  AND    VARIOLOID. 

initial  stage  would  warrant  the  exclusion  of  the  confluent  type.  Most 
prominent  among  the  early  symptoms  are  severe  headache,  persistent 
retching  and  vomiting,  wild  delirium  or  stupor  in  children,  violent  pain 
in  the  back,  and  high  fever.  The  temperature  always  rises  rapidly,  and 
frequently  attains  an  extraordinary  height.  Its  maximum  height  is 
rarely  less  than  105°  or  106°  F.,  and  it  has  even  been  known  to  reach 
110°  F.  After  the  eruption  has  fully  appeared  the  temperature  falls 
slowly,  but  rarely  descends  as  low  as  in  milder  cases ;  nor  does  the  re- 
mission of  the  fever  continue  as  long.  During  the  remission  the  tem- 
perature is  usually  not  for  from  101°  to  102°  F.,  and  after  remaining 
at  this  comparatively  low  degree  for  two  or  three  days  the  secondary 
rise  commences.  The  temperature  during  the  stage  of  suppuration  does 
not  usually  rise  as  high  as  in  the  initial  stage,  yet  I  have  known  it  to  go 
considerably  higher.  The  chart  (upon  page  533)  illustrates  the  tempera- 
ture curves  of  a  severe  case  of  confluent  variola  recently  under  my 
observation ;  the  temperature  in  the  suppurative  stage,  however,  was 
somewhat  influenced  by  the  use  of  antipyretics. 

The  eruption  in  confluent  variola  develops  less  rapidly  than  in  modi- 
fied forms  of  the  disease,  but  there  is  a  shorter  interval  between  the 
time  of  its  appearance  on  the  face  and  on  other  portions  of  the  body. 
So  quickly  is  the  eruption  difliised  over  the  whole  body  that  it  has  been 
mistaken,  in  the  papular  stage,  for  measles.  On  account  of  the  exten- 
sive involvement  of  the  skin  redness  and  swelling  begin  early.  Even 
as  early  as  the  second  day  of  the  eruption  the  skin  is  quite  red,  and  often 
it  can  be  determined  at  once  that  the  disease  is  going  to  assume  the  con- 
fluent form.  As  the  eruption  progresses  it  passes  through  the  usual 
stages,  though  somewhat  more  slowly  than  in  milder  cases.  The  papules 
are  thickly  set :  many  of  them  coalesce,  and  when  the  vesicles  develop 
they  run  together  so  completely  as  to  cover  almost  the  whole  cutaneous 
surface.  On  the  face  and  hands  the  septa  within  and  between  the  pus- 
tules often  give  way  and  large  blebs  or  bullte  form.  Usually,  however, 
the  pustules  do  not  acuminate  or  project  from  the  surface,  as  in  the  dis- 
crete variety,  but  remain  flat,  especially  on  the  face,  and  sometimes  pre- 
sent a  milky  or  pasty  appearance.  When  the  eruption  is  fully  devel- 
oped every  feature  of  the  patient  is  so  changed  and  disfigured  as  to 
make  recognition  impossible  even  by  his  nearest  friend  (Plate  VIII.). 

In  this  form  of  the  disease  the  mucous  membrane  of  the  mouth, 
throat,  and  nose  is  always  severely  affected.  The  epithelium  of  these 
parts  frequently  becomes  so  completely  disorganized  by  the  eruptive  pro- 
cess that  it  presents  the  appearance  of  diphtheritic  membrane.  Swell- 
ing of  the  soft  palate  and  tonsils  is  often  so  great  as  to  cause  consider- 
able difficulty  in  deglutition.  It  is  in  the  intensely  confluent  cases  that 
glossitis  variolosa  is  apt  to  occur.  The  parotid  glands  sometimes  be- 
come acutely  inflamed,  perhaps  by  extension  of  the  inflammation  along 
the  ducts  of  Steno.  The  pharynx  and  larynx  are  almost  always 
attacked  with  great  severity,  and  acute  oedema  of  the  glottis,  interfering 
seriously  with  the  respiratory  act,  is  not  an  infrequent  occurrence. 
Death  undoubtedly  results  at  times  from  the  intense  involvement  of 
these  parts. 

When  the  contents  of  the  pustules  begin  to  ooze  and  drying  com- 
mences the  stench  is  often  unbearable.     The  exhaustion  arising  from 


o 


Tl 


2"  D 


D  ^ 

ft 

—  " 

02 

o' 

aq 

w 

o' 

o 

n 


-0 

> 

H 

m 


VAhllF.TIKS   OF  SMALLI'OX, 


533 


o 
> 
-1 

X 

•D 

C 

0) 

is 

0>DO                  OO                  OOO                  Ot 
»,               «,                0„                — ^               KJ^                 lu^                •f'.j               <J}^                 0\„ 

m 

88 

112 

1 1 1 

1 1 1 1 

M 

ll 

s 

40 

120 

1  1 1 

Ml, 

A 

fTl 

s 

40 

WA 

- 

. 

2 

m 

28 

112 

i  3C  ,  102 

1 

> 

~  ■" 

S 

-     24:90     "- 

! 

<, 

m 

24  !  92 

^_ 

1 

1     1 

> 

[ 

S 

20  ,  90 

. 

-*— — 

m 

l« 

-*>2|„. 

♦«=: 

2[ 

~— 

~~^ 

s 

24  j  90 

[ 

1 

m 

34!  104 

CT 

- 

- 

" 

< 

s 

w- 

24    112 

~'^ 

m 

2"    108 

03 

»= 



=•   1 

s 

24    120 

fn 

K.  !112 

^I 

< 

>♦ 

- 

S 

■ 

20  ;iio 

- 

m 

1  10  :  00 

Ci  1 — -i •  'J-. 

1  24  |108| 

^ 

.Mil 

S 

m 

20  [1081 

1 

-^ 

^,>, 

s 

-'    2.!  110-^ 

1 

m 

X 

24    112 

^ 

t 

j 

►== 



S 

24    110 

- 

~^ 

M 

m 

24    112 

- 

, 

, 

1 . 

1 

- 

-c:^ 

2 

~ 

2^    ll'-. 

PH 

NACETIN  GR.TTfS 

kj  2 

AND  . 

P. 

^\ 

_jj 

=i 

■ 

m 

,__, 

24  1 108 

n 

1 

j 

■=r=?lT 

"i  1 1 1 

2 

o 

24    110 

i 

1    1 

1 

T 

r<i 

m 

,_^ 

24    112 

tl 

PH 

;nac 

ETIN  QR.TTSS   lO'A 

M. 

1 

>L- 

^ 

2 

•^ 

28  ,110 

! 

M 

1    {    1    i    I         <    ' 

1    i 

1 

__ 

:  = 

p" 

m 

^  1  24  1  lOS  1  ^ 
*■*  t  24  :  102   ■^ 

PHi 

NAC 

TINGR.—  S5  EV2 

"i 

« 

.>•- 

— 

1 

2 

1 

1 

«<£ 

-J. 

1 

m 

,__, 

20  ,  104 

cn 

1 

111 

! 

i    1 

!j1~*t- 

'  i 

2 

c; 

23  :ii2 

( 

1 

j    1 

1  1  i 

MM 

-^ 

■2M 

m 

*■    ,   2U     102;" 

1 

—r 

1    1"= 

"Vi 

MM 

Ij.lj 

1 

" 

2 

ill    1 

=  4 

1 

\ 

m 

l_^ 

24  i  104 

^ 

1 

t  1 

Ml 

1 1 '  1 

»       ~ 

Ml 

. 

1 

1 

2 

u. 

24  1 108 

1 

1  1 

Mm 

i  ! 

i    1    1 

m 

J__, 

13  !100|t^ 

i 

1    1  1 

1  1 

T 

i 

1 

j 

2 

-  1  20    lOSJ  =" 

1 

1     1  ! 

1   1 

1 

MM 

r= 

■ 

m 

^_^ 

20  I  104 

o 

1 

1 

1 

1   1 

1 

icc;:^ 

^ 

2 

^i 

13  1 100 

1 

\ 

1 

1 

1 

1 

1  1  L 

m 

^  1  20,10o;  = 

1 

n  1 1 

1 

*=rrr 

' 

1  1 

1  1  1 

2 

1  1 

nil 

1 

'-^ 

1  1 

1  1  1 

m 

,_^ 

20  1  90 

is 

1 

1  1 

1 1 

1 M 

-f 

lL_.   1 

^ 

1  1 

2 

^ 

24  : 104 

1 

!  i 

1 1 

1 1 

1 

1  1    1 

^  1 

m 

-   I  20    100 1~ 

1  1 

i  1 

1 

-i-LL 

i  1 

2 

1  1 

i  1  1 

Mil 

~=i-f 

m 

-124j90|^ 

1 

■^ 

1_M^ 

1     1 

2 

[ 

1 

=^ 

fn 

jc  1  2o:oo|;^ 
'^    24  lOo;'*" 

1 

1 1 

»= 

1 

!  1 

1 

2 

1 

1 

1 

1 

1 

==• 

1 

m 

J. 

20     92 

CI 

1 

1 

►=== 

^1  1  i 

1  1  1 

1 

2 

" 

24    104 

j 

1 

I 

1  1  1  1 

jH— = 

-1 

m 

!i 

92 

is 

1 

1 

^= 

^^2::^ 

1  1 

1 

2 

■^ 

'  90 

1 

1 

1 

m 

10 

j  92 

ly 

^CTT 

i 

1 

2 

.. 

lioo 

]> 

1 

m 

,. 

83 

Qo 

i 

<4 

1 

i 

2 

c 

92 

1 

■^ 

=! 

>^ 

1 

1 

1 

m 

^»  !       iiooi=- 

.K 

=r 

■  r 

(  ) 

1 

2 

i=» ' 

1 

1  i 

1 

1 

1 

m 

,. 

S4 

iO 

•< 

— — 

1 

1 

2 

ct 

90 

~ 

■"^p* 

II 

I 

I 

m 

:>•) 

82 

M 

1 

K 

'III 

1  1 

I 

2 

38 

1     i 

U: 

::;!  1 

M   ^ 

m 

84 

i    •= 

;  1  , 

M 

111 

i 

2 

■- 

1  64 

^ 

: 

III 

1 

rn 

162 

zi 

Lr^ 

M  ' 

2 

" 

j88 

> 

m 

;84!*- 

^ 

i  1 

1 

i 

2 

> 

; 

m 

82 

^ 

v^ 

2 

84 

1 

M    ' 

; 1 

m 

534  SMALLPOX  AND    VARIOLOID. 

irritation  and  extensive  suppuration  is,  at  this  time,  extreme,  and  gen- 
erally constitutes  the  chief  source  of  danger.  At  this  stage,  also,  com- 
plications are  liable  to  occur,  such  as  ulcer  of  the  cornea,  purulent  forms 
of  keratitis,  pneumonia,  pleurisy,  empyema,  suppuration  of  the  joints, 
and  gangrene  of  portions  of  the  cutaneous  integument,  especially  of  the 
scrotum.  An  uncontrollable  diarrhoea  frequently  sets  in  and  aids  in 
diminishing  the  vital  forces.  The  mortality  from  confluent  variola  is, 
of  course,  very  great.  If  death  does  not  occur  from  exhaustion,  it  is 
liable  to  result  from  septicsemia,  pyaemia,  or  some  one  of  the  other 
complications  just  named. 

When  this  form  of  the  disease  terminates  in  recovery  it  is  only  after 
a  long  and  tedious  illness  and  a  tardy  convalescence.  During  desicca- 
tion the  inflammation  and  swelling  of  the  skin  and  mucous  membrane 
subside,  and  the  patient  is  able  to  take  nourishment  more  freely.  The 
scabs  form  into  large  coherent  masses,  and  some  of  them  remain  for  a 
long  time  firmly  adherent,  especially  those  on  the  face.  After  they 
have  fallen  ofi*  the  skin  is  very  red  and  spotted,  and  left  permanently 
disfigured  by  unsightly  scars.  During  the  period  of  falling  of  the 
crusts  various  sequelae  are  liable  to  appear,  among  which  furuncles  are 
most  common.  Large  abscesses  also  may  form  on  various  parts  of  the 
cutaneous  surface  ;  the  cellular  tissue  beneath  the  scalp  seems  to  be 
peculiarly  liable  to  this  process. 

Petechial,  Purpuric,  and  Hemorrhagic  Variola. — These  names  are 
applied  to  the  different  phases  presented  by  malignant  or  hemorrhagic 
smallpox.  In  certain  epidemics  a  petechial  eruption  is  frequently  seen 
at  the  close  of  the  initial  stage  of  the  disease  or  about  the  time  the  true 
eruption  appears,  or  should  appear  if  it  is  not  delayed,  and  is  generally 
the  precursor  of  a  train  of  symptoms  indicating  great  malignancy.  This 
eruption  is  often  quickly  followed  by  the  purpuric  or  hemorrhagic  vari- 
ety, and  the  disease  rapidly  runs  its  course  to  a  fatal  termination.  At 
other  times  petechise  and  ecchymoses  appear  between  the  papules  or 
vesicles,  and  as  the  latter  develop  many  of  them  fill  with  a  sanguino- 
purulent fluid,  while  others  fill  with  distinctly  purulent  matter ;  thus  a 
great  diversity  is  sometimes  manifested  in  the  eruption  of  a  single  case. 
While  such  cases  usually  result  fatally,  yet,  if  the  dyscrasia  is  not  too 
great,  they  may  terminate  in  recovery.  There  is  no  doubt  that  in  all 
cases  of  hemorrhagic  variola  the  blood  is  greatly  altered,  and  even  in 
most  cases  so  completely  devitalized  as  to  be  incapable  of  maintaining 
the  vital  functions.  Therefore  recovery  from  this  form  of  the  disease, 
especially  when  well  marked,  is  quite  exceptional. 

The  causes  leading  to  the  hemorrhagic  type  of  smallpox  are,  as 
yet,  unknown.  There  is  no  doubt  that  such  cases  result  from  the  or- 
dinary variolous  infection,  and  that  the  infection  derived  from  them 
may  in  turn  give  to  the  disease  its  typical  aspect.  It  is  knoMai,  how- 
ever, that  this  type  of  the  disease  varies  in  frequency  in  different  epi- 
demics. 

Variola  jpurpurica  is  the  gravest  and  most  malignant  form  of  the 
hemorrhagic  type.  The  initial  stage  in  such  cases  does  not  differ  very 
greatly  from  that  of  ordinary  variola.  There  is  nothing  peculiar  about 
the  rigor,  fever,  and  headache  ;  the  pain  in  the  back,  however,  is  intense 
and  the   prostration   is  generally  excessive.     Toward   the   end  of  the 


VARIKTII'.S   OF  SMALL/'OX.  535 

initial  staj^c  a  dilt'use  cllloivscciicc  npjtcars  on  various  parts  of"  the  trunk 
and  extreniitios,  while  the  face  remains  for  a  time  exempt.  The  rash 
at  first  is  scarlatinoid  in  apjiea ranee,  and  disa])])ears  ])artially  under 
pressure;  later  it  heeonies  more  intense;  peteehije,  vihiees,  and  eeehy- 
moses  ap])ear,  esju'cially  on  the  chest,  the  axilhe,  the  lower  p(»rtion  of 
the  abdomen,  the  groins,  the  legs;  and  the  dark  red  or  purplish  dis- 
coloration now  present  does  not  fade  in  the  least  by  pressure.  Th(>  dis- 
coloration rapidly  extends  to  the  face,  which  also  becomes  swollen  and 
puffy.  The  conjunctivae  are  injected  ;  the  eyes  become  bloodshot  aud 
surrounded  by  dark  rings,  owing  to  hemorrhage  into  the  cellular  tissue 
of  the  lids.  Frc((ucntly  the  hemorrhage  under  the  conjunctiva  cover- 
ing the  sclerotica  is  so  great  as  to  cause  the  conjunctiva  to  project 
beyond  the  lids,  like  a  sac  filled  with  blood,  and  prevent  the  eyes  from 
closing,  while  the  cornea  remains  luiatfccted  and  looks  as  if  it  were 
deeply  sunk  into  the  globe  of  the  eye.  This  condition,  together  Avith 
the  dark  discoloration  of  the  face  and  the  tumefied  features,  g-ives  to  the 
patient  a  peculiarly  hideous  appearance.  A  close  examination  of  the 
body  often  reveals  in  certain  localities,  particularly  the  axillae  and 
groins,  small  and  indistinct  vesicles  thickly  set  and  filled  with  bloody 
serum.  These  vesicles  never  develop  to  any  extent,  but  remain  per- 
fectly flat,  and  are  of  a  blackish  or  leaden  gray  hue.  As  the  disease 
progresses  the  dark  discoloration  of  the  skin  deepens  on  all  parts  of  the 
body,  until  at  last  it  is  sometimes  difficult  to  say,  judging  from  the  color 
alone,  that  the  patient  is  not  a  native  of  Africa.  Hence  this  form  of 
the  disease  has  long  been  known  by  the  name  of  variolce  nigra:.  The 
eruptive  process  does  not  always  afford  unequivocal  evidence  of  small- 
pox, and  the  disease  is  therefore  sometimes  mistaken  for  some  other 
malignant  affection,  such  as  black  measles  and  the  like. 

In  this,  as  in  other  severe  types  of  variola,  the  pharynx  and  upper 
part  of  the  air  passage  usually  suffer.  There  is  apt  to  be  more  or  less 
cough,  with  bloody  sputum.  The  tongue  is  large  and  red,  and  the 
breath  often  horribly  fetid.  Indeed,  the  odor  from  the  body  also  is  ex- 
tremely loathesome.  There  is  persistent  nausea  and  vomiting,  and 
almost  always  severe  pain  or  distress  in  the  precordial  region.  The 
temperature  is  seldom  very  high,  except  in  the  invasive  stage,  but  the 
pulse  is  rapid  and  feeble.  Hemorrhages  are  quite  certain  to  occur 
from  the  nose,  bronchial  mucous  membrane,  kidneys,  rectum,  and 
uterus.  Women  almost  always  suffer  from  metrorrhagia  and,  if  preg- 
nancy exists,  abortion.  According  to  my  experience,  this  type  of  small- 
pox occurs  as  commonly  among  young  and  robust  persons  as  among 
those  infirm  or  debilitated.  Intemperate  persons  and  drunkards,  as  well 
as  lying-in  women,  seem  peculiarly  predisposed  to  this  terrible  form  of 
the  disease. 

One  of  the  most  extraordinary  features  about  this  fatal  malady  is 
that  the  mental  condition  of  the  patient  often  remains  undisturbed  until 
almost  the  last  moment  of  life.  There  may  be  delirium  or  stupor,  but 
usually  the  victim  faces  death  with  his  mind  clear  and  intellect  unim- 
paired. I  remember  on  one  occasion,  as  I  stood  by  the  bedside  of  a 
most  malignant  case  of  purpuric  variola,  not  thinking  that  the  patient 
was  conscious,  of  remarking  to  the  resident  physician  that  there  Avas  no 
ground  for  hope  in  this  case.     At  once  the  patient  sat   up  in  bed  and. 


536  SMALLPOX  AND    VARIOLOID. 

with  surprise,  inquired,  "  Doctor,  do  you  mean  to  say  I  can't  get  well  ?  " 
In  less  than  twenty-four  hours  the  patient  was  a  corpse. 

The  course  of  this  type  of  sruallpox  is  very  rapid.  Death  not  in- 
frequently takes  place  in  consequence  of  the  greatly  altered  state  of  the 
blood  before  any  clear  and  well  pronounced  symptoms  of  the  disease 
appear.  More  commonly  the  eruption  may  be  seen  in  confluent  form  on 
some  parts  of  the  body,  but  it  never  makes  much  progress.  Death 
usually  results  from  the  fourth  to  the  sixth  day.  I  have  never  known  a 
Avell  marked  case  to  recover. 

The  hemorrhagic  type  of  smallpox  may  assume  still  another  form  :  I 
refer  to  the  form  which  Curschmann  designates  variola  hcemorrhagica  pus- 
tidosa.  In  this  variety,  as  soon  as  the  vesicles  appear,  instead  of  filling 
with  serum  they  fill  with  a  sanguinolent  fluid.  In  some  cases  the  vesi- 
cles first  appear,  and  immediately  their  contents  become  mixed  with 
blood  ;  in  still  other  cases  this  change  does  not  occur  until  the  eruption 
has  reached  the  pustular  stage.  This  hemorrhagic  condition  of  the  j^us- 
tules  may  be  limited  to  certain  localities  or  it  may  extend  over  the 
entire  body.  Petechige  and  purpuric  spots,  as  already  described,  may 
be  associated  with  this  form  of  eruption.-  The  hemorrhagic  pustules 
usually  begin  on  the  legs,  although  they  may  appear  first  elsewhere.  An 
early  examination  in  a  case  about  to  assume  this  condition  shows  that 
here  and  there  a  pustule  jDresents  a  blue  centre ;  by  degrees  others  take 
on  the  same  appearance,  and  the  color  gradually  deepens,  until  at  last, 
in  severe  cases,  the  pustules  on  all  parts  of  the  body  become  distinctly 
hemorrhagic.  At  the  same  time,  livid  spots  may  be  seen  on  the  mucous 
membrane  of  the  mouth  and  fauces.  The  gums  are  spongy  and  bleed 
readily.  Hemorrhages  occur  from  the  nose  and  various  internal  organs, 
as  in  purpura  variolosa.  It  is  seldom,  indeed,  that  hsematuria  is  absent 
or  that  metrorrhagia  fails  to  occur  in  females. 

This  form  of  heuiorrhagic  smallpox  is  more  protracted  in  its  course 
than  purpura  variolosa,  but  almost  as  certain  to  end  fatally.  My  own 
experience  leads  me  to  say  that  recovery  from  this  type  of  the  disease 
is  extremely  rare  ;  even  the  so-called  milder  cases,  or  those  in  which  the 
symptoms  are  least  pronounced,  almost  always  terminate  fatally.  I  have 
seen  recovery  in  but  few  cases,  and  only  among  those  in  which  the 
hemorrhagic  condition  of  the  pustules  was  not  only  limited  to  a  com- 
paratively small  number  of  these  lesions,  but  appeared  at  a  relatively 
late  period  of  the  disease,  and  in  which  the  hemorrhage  from  the  nose 
and  internal  organs  was  not  excessive  nor  long  continued.  I  have  never 
known  recovery  to  result  in  a  case  in  which  all  or  nearly  all  of  the  vesi- 
cles assumed  the  hemorrhagic  character  at  an  early  stage,  and  in  which 
there  were  well  marked  epistaxis,  hematuria,  conjunctival  hemori'hage, 
and  bloody  stools,  together  with  the  usual  concomitant  symptoms,  such 
as  a  rapid  and  feeble  pulse  and  the  peculiar  livid,  purplish,  or  indigo 
color  of  the  skin. 

Varioloid. 

Varioloid  is  not  a  disease  which  simply  resembles  variola,  as  the 
name  would  imply,  but  is  truly  smallpox  in  a  modified  form.  This  is 
evident  from  the  fact  that  the  infection  arising  from  this  milder  form  of 


VARIOLOID.  537 

the  (liscMSc  oivcs  rise  to  variola  vera  in  imjirotcctcMl  persons.  Since  the 
introduction  of"  vaccination  varioloid  has  Ix'coine  ninch  more  fVecjnent 
than  in  t'ornier  times.  It  is  well  known  that  the  immunity  conferred  hy 
vaccination,  althoni;h  com[)lete  at  first,  becomes  thron<>;h  lapse  of  time 
more  (»r  less  im]xiire(l  in  the  vast  majority  of  individuals.  The  pro- 
tective intlu(>nce  from  this  measure  frequently  diminishes  very  gradually 
for  a  varial>le  lenuth  of  time,  and  eventually  may  disa])pear  entirely. 
Hence  persons  previously  vaccinated  are  liable  to  suffer  from  various 
grades  of  smallj)ox  according"  to  the  degree  of  j)r()tecti()n  remaining.  In 
every  epidemic  of  the  disease  cases  are  seen  not  only  so  mild  as  to  be 
scarcely  recognizable,  but  also  so  severe  that  when  they  have  finished 
their  entire  course  the  physician  is  in  doubt  as  to  whether  the  attack 
should  be  called  variola  or  varioloid.  It  has  been  my  rule  to  classify 
as  variola  all  unvaeeinated  cases,  all  malignant  cases,  and  all  vacci- 
nated cases  in  which  the  eruption  pursues  its  regular  course  and  is 
atteniled  by  secondary  or  suppurative  fever,  while  I  classify  as  vario- 
loid all  vaccinated  cases  in  which  the  eruption  is  markedly  abridged 
in  its  course,  and  in  which  there  is  but  little  if  any  secondary  rise  of 
temperature.  Of  course  it  is  well  known  that  in  some  unprotected 
persons  there  is  naturally  but  slight  susceptibility  to  the  infection,  and 
that  the  disease  among  this  class  is  mild  and  of  short  duration ;  but 
such  cases  should  be  regarded  simply  as  mild  forms  of  variola  vera. 
Besides  vaccination,  the  only  circumstance  which  determines  the  occur- 
rence of  varioloid  is  a  previous  attack  of  variola. 

Varioloid  cannot  always  be  distinguished  in  the  initial  stage  from 
variola  vera,  since  the  train  of  symptoms  may  be  the  same  in  each  and 
equally  severe.  Occasionally,  however,  in  varioloid  the  eruption  ap- 
pears after  an  exceedingly  mild  initial  stage ;  this  almost  never  occurs 
in  unnKidified  smallpox.  The  length  of  the  initial  stage  is  also  varia- 
ble. While  the  duration  of  this  stage  in  variola  is  quite  uniformly 
three  days,  in  varioloid  it  may  be  as  short  as  twenty-four  to  forty- 
eight  hours,  or  as  long  as  four  or  five  days.  At  the  commencement  of 
the  invasive  stage  the  temperature  at  once  becomes  more  or  less  ele- 
vated :  if  it  should  rise  very  high,  it  usually  drops  suddenly  at  the 
outbreak  of  the  eruption  to  the  normal  degree  or  even  below,  and  does 
not  again  rise  to  any  considerable  extent  unless  complications  occur. 
The  initial  exanthem,  which  has  already  been  described  as  frequently 
appearing  at  this  stage  of  smallpox,  is,  I  believe,  much  oftener  met  with 
in  varioloid  than  in  variola  vera.  Indeed,  this  prodromous  rash,  not 
unlike  measles  in  appearance,  is  so  frequently  followed  by  an  exceedingly 
sparse  variolous  eruption  that  it  might  almost  be  regarded  when  pres- 
ent as  the  forerunner  of  varioloid.  But  if  the  rash  should  be  petechial 
or  purpuric  in  character,  it  is  an  indication  that  the  attack  will  be 
severe. 

There  is  nothing  peculiar  about  the  eruption  of  varioloid  except 
that  it  is  milder  in  its  course  and  of  shorter  duration  than  that  of 
v^ariola.  It  almost  always  appears  on  the  face,  and  rapidly  spreads  to 
other  parts  of  the  body,  although  at  times  it  makes  its  appearance  on  the 
trunk  and  extremities  quite  as  early  as  on  the  face.  The  lesions  do  not 
develop  quite  as  regularly  as  in  unmodified  smallpox,  it  being  not  un- 
usual to  find  some  pustules  larger  and  farther  advanced  than  others. 


538  SMALLPOX  AND   VARIOLOID. 

The  extent  of  the  eruption  and  the  duration  of  its  course  are  also 
variable.  It  may  be  limited  to  a  very  few  lesions  on  the  face  and 
hands,  or  it  may  assume  a  semiconfluent  form  on  these  parts,  and  also 
invade  other  parts  of  the  body  to  a  considerable  extent.  In  the  milder 
forms  the  lesions  do  not  pass  through  all  the  stages,  but  become  abor- 
tive at  an  early  period ;  in  the  severe  forms  the  eruption  passes  through 
the  various  stages  of  papule,  vesicle,  and  pustule,  and  is  quite  as  pro- 
nounced as  in  unmodified  smallpox.  Between  these  two  extremes  the 
eruption  may  assume  every  possible  phase.  It  may  appear  in  the  con- 
fluent or  semiconfluent  form,  as  just  stated,  but,  instead  of  the  inflam- 
matory action  extending  to  the  deeper  layers  of  the  skin,  as  in  variola 
vera,  it  is  limited  to  the  upper  layers ;  hence  the  course  of  the  eruption 
is  shorter,  desiccation  occurs  earlier,  the  scabs  fall  off  more  rapidly,  and 
the  scars  are  not  so  deep.  This  variety  of  smallpox  was  called  by  ear- 
lier authors  "  confluent  superficial."  More  frequently  the  eruption  of 
varioloid  is  less  copious,  but  runs  the  same  mild  course.  The  papules 
very  early  assume  the  vesicular  character  and  reach  the  pustular  stage 
on  the  third  or  fourth  day,  completing  their  development  from  the 
fifth  to  the  seventh  day,  when  desiccation  begins.  The  pustules  dry 
up  quickly,  forming  thin  brownish  crusts,  which  fall  off  much  sooner 
than  in  the  unmodified  form  of  the  disease,  leaving  either  very  super- 
ficial scars  or  slightly  pigmented  spots  which  entirely  disappear  in  the 
course  of  a  few  months. 

When  the  modification  of  the  eruption  is  still  greater,  it  is  not 
unusual  to  find  that  the  lesions  develop  into  large,  solid,  conical  papulae, 
having  at  their  apices  a  vesicular  condition  which  rapidly  desiccates  and 
forms  very  thin  crusts.  After  the  crusts  have  fallen  off  the  lesions 
remain  tuberculated  for  some  time,  especially  on  the  face,  looking  not 
unlike  warty  excrescences  ;  to  this  form  of  the  eruption  the  name  variola 
verrucosa  has  been  given.  Another  somewhat  common  form  of  the  erup- 
tion is  that  known  as  variola  miliaris.  In  this  the  majority  of  the  ves- 
icles are  very  small,  not  larger  than  millet  seeds,  and,  without  progress- 
ing any  farther,  turn  yellow  and  rapidly  disappear.  Not  rarely  a  few 
tolerably  well  developed  pustules  are  found  mixed  with  these  smaller 
lesions.  Still  other  varieties  of  the  varioloid  eruption  have  been  de- 
scribed, and,  according  to  the  fancy  of  the  author,  designated  by  various 
terms,  such  as  variola  siliquosa,  v.  pemphigosa,  v.  globulosa,  v.  crijsfallina, 
etc. ;  but  as  these  varieties  are  of  no  practical  importance,  a  description 
of  them  here  is  deemed  unnecessary. 

The  mucous  membrane  of  the  mouth  and  upper  air  passages  is  usually 
affected,  although  much  less  severely  than  in  unmodified  smallpox. 
Diseases  of  the  eye,  such  as  photophobia  and  corneal  ulcer,  may  occur, 
and  secondary  phlegmonous  processes,  such  as  abscesses  and  furuncles, 
may  follow,  but  these  affections  are  also  less  apt  to  be  severe. 

Complications  and  Sequels  of  Smallpox. — The  skin  is  more 
frequently  the  seat  of  complications  and  sequelae  than  any  other  part  of 
the  body.  Erysipelas  occasionally  appears  w^hen  desiccation  is  com- 
pleted and  the  crusts  begin  to  fall.  It  more  frequently  attacks  the  face, 
but  may  appear  on  almost  any  part  of  the  cutaneous  integument.  I 
have  known  it  to  assume  a  phlegmonous  character  on  the  neck  and  upper 


COM I'lAL'AT loss  AM)  S/U^I'hLyE  OF  SMALLPOX.  539 

portion  of  the  chest,  renderinji:  these  |)ai"ts  as  dense  and  unyieldintr  to 
the  touch  as  if  covered  \vith  a  ])hister-(tf- Paris  dressinjj;.  During-  desic- 
cation <ianiii'ene  of  the  skin,  especially  of  the  scrotum,  may  a])pear.  I 
have  met  with  this  complication  several  times,  and  the  result  has  always 
been  fatal.  By  far  the  most  common  complications  and  sequehe  are 
furuncles  and  abscesses.  But  few  patients  pass  through  an  attack  of 
variola  vera  without  suffering  from  numerous  boils  during  the  latter 
stage  of  the  disease. 

Next  in  frequency  to  the  skin,  the  eye  is  most  liable  to  snffer.  Dur- 
ing the  active  stage  of  smallpox  conjunctivitis  is  common,  and  often 
associated  with  severe  oedema  of  the  lids,  preventing  the  eyes  from 
opening.  In  the  stage  of  desiccation  a  small  vesicle  filled  with  clear 
serum  often  appears  at  the  margin  of  the  cornea.  The  covering  of  this 
vesicle  is  very  thin  and  delicate,  and  almost  always  ruptures  and  dis- 
appears unnoticed,  leaving  a  distinct  ulcer  covered  by  a  little  necrotic 
tissue  of  a  liaht  o-rav  color.  This  condition  is  almost  alwavs  fVdlowed 
by  impaired  vision ;  it  frequently  leads  to  keratitis,  iritis,  perforation, 
and  sometimes  suppuration  of  the  globe,  causing  complete  blindness. 

In  severe  cases  inflammation  and  swelling  of  the  tongue  occur ;  the 
larvnx  also  is  usually  involved  in  the  inflammatory  action,  leading  often 
to  cedema  of  the  glottis.  Perichondritis  laryngea,  sometimes  folh'wed 
bv  necrosis  and  abscess,  has  been  met  with  by  various  observers.  Bron- 
chitis, catarrhal  pneumonia,  and  pleuritis  with  purulent  effusion  are  not 
infrequent  complications.  The  mucous  membrane  of  the  nose  is  usu- 
ally inflamed,  and  sometimes  is  the  seat  of  ulceration. 

The  middle  ear  may  suffer  from  inflammation,  w^hich  may  lead  to 
chronic  suppurative  otitis,  and  even  to  caries  of  the  bones  of  the  ear, 
causing  partial  or  complete  deafness.  The  mastoid  cells  also  may 
become  filled  with  pus,  and  occasionally  suppurative  thrombosis  of  the 
cerebral  sinuses  occurs. 

One  or  more  of  the  joints  may  become  swollen  and  painful.  Some- 
times perichondritis,  and  even  ostitis,  occur,  followed  by  suppuration 
and  destructi(jn  of  the  joint,  and  frequently  by  death.  According  to 
my  observation,  the  elbow  joints  are  most  liable  to  suffer.  Occasionally 
symptoms  of  pyaemia  or  septicaemia  appear  in  the  early  stage  of  desicca- 
tion. Abscesses  in  the  liver  and  lungs  have  been  revealed  by  autopsies. 
The  circulatory  system  rarely  suffers  from  secondary  affections.  Phle- 
bitis, however,  has  been  met  with,  especially  in  the  lower  extremities, 
giving  rise  to  phlegmasia  dolens. 

Smallpox  is  singularly  exempt  from  abdominal  complications. 
Diarrhoea  not  unfrequently  occurs  as  the  result  of  some  derangement 
of  the  digestive  function.  While  this  symptom  is  usually  controllable, 
yet  occasionally  it  is  so  persistent  as  to  precipitate  a  fatal  issue  in  those 
greatly  debilitated  from  the  primary  disease.  The  kidneys  are  not  apt 
to  suffer,  except  in  malignant  cases.  In  such  cases  albuminuria  is  pres- 
ent, and  frequently  also  hsematuria. 

In  the  pregnant  female  abortion  or  premature  delivery  is  very  liable 
to  occur,  and  this  accident  usually  proves  to  be  a  very  serious  complica- 
tion. As  already  shown,  the  parturient  condition  favors  the  develop- 
ment of  the  petechial  or  hemorrhagic  form  of  smallpox. 

Secondary  affections  of  the  nervous  system  are  not  rare  in  smallpox. 


540  SMALLPOX  AND    VARIOLOID. 

Of  course  I  do  not  refer  to  the  delirium  which  is  so  common  in  the 
active  stage  of  severe  cases,  but  to  the  psychical  disturbances  and  various 
forms  of  paralysis  which  sometimes  appear  during  the  decline  of  the 
disease.  Meningitis  is  not  common,  although  it  occasionally  occurs. 
Acute  oedema  of  the  brain  is  perhaps  more  frequent.  I  have  met  with 
a  few  cases  in  which  there  were  peculiar  psychical  disturbances,  followed 
by  aphasia :  this  symptom  would  seem  to  indicate  the  existence  of 
circumscribed  encephalitis.  Certain  portions  of  the  spinal  cord  also 
suffer  at  times  from  inflammatory  action,  giving  rise  to  paralysis  of  the 
extremities  and  bladder.  In  his  study  of  such  cases  Westphal  has 
found  numerous  foci  of  inflammation  in  the  gray  and  white  matter  of 
the  cord.  According  to  my  experience,  it  has  always  been  the  motor 
nerves  which  were  affected,  and,  so  far  as  I  have  been  able  to  follow  the 
cases,  recovery  from  the  paralysis  eventually  resulted. 

Diagnosis. — It  is  only  in  the  initial  or  early  period  of  the  eruptive 
stage  that  variola  vera  is  at  all  liable  to  be  confounded  with  any  other 
affection  :  in  the  more  advanced  stages  this  typical  form  of  the  disease 
is  readily  recognized  by  its  peculiar  manifestations.  But  in  the  modi- 
fied forms  of  the  disease,  especially  when  the  eruption  is  scanty  or 
atypical,  the  diagnosis  becomes  more  difficult.  Great  assistance  may 
often  be  gained  by  inquiring  whether  the  patient  has  ever  been  vacci- 
nated, and,  if  so,  by  examining  the  character  of  the  vaccine  scar.  Like- 
wise, it  is  important  to  know  whether  the  individual  has  previously  suf- 
fered from  smallpox.  The  diagnosis  may  also  be  greatly  aided  if  it  is 
known  that  the  disease  is  present  in  the  community  or  that  there  has 
been  exposure  to  the  contagium. 

As  variola  is  communicable  during  the  initial  stage,  an  early  diag- 
nosis often  becomes  highly  important.  If  in  a  given  case  it  be  found 
that  the  patient  was  seized  with  a  chill  or  had  repeated  rigors,  followed 
by  a  sudden  rise  of  temperature  to  an  unusually  high  degree,  and  that 
there  is  present  epigastric  tenderness,  irritability  of  the  stomach,  and 
severe  pain  in  the  lumbar  region,  variola  should  be  strongly  suspected. 
If,  together  with  these  symptoms,  there  can  be  obtained  a  history  of 
exposure  to  the  variolous  contagium,  the  diagnosis  becomes  compara- 
tively easy.  But  in  many  cases  of  variola,  and  especially  of  varioloid, 
the  initial  symptoms  are  so  indefinite  that  a  diagnosis  is  quite  impossible 
until  the  characteristic  eruption  appears. 

In  making  a  diagnosis  during  the  invasive  stage  of  variola  great 
assistance  may  be  gained  by  excluding  the  various  febrile  affections  more 
commonly  met  with.  For  example,  while  pneumonia  usually  begins 
with  a  chill,  followed  by  high  temperature,  yet  this  disease  can  be 
excluded  by  the  absence  of  physical  signs.  In  the  different  forms  of 
ephemeral  fever  the  temperature  is  usually  much  lower.  In  intermit- 
tent fever  there  might  at  first  be  some  doubt,  but  in  less  than  twenty- 
four  hours  the  doubt  will  be  removed  by  the  sudden  fall  of  tempera- 
ture. The  first  paroxysm  of  relapsing  fever  bears  such  close  resem- 
blance to  the  initial  stage  of  variola  as  to  make  it  difficult  to  differenti- 
ate until  the  eruptive  stage  of  the  latter  disease  is  reached.  In  countries, 
however,  where  relapsing  fever  is  rare,  it  need  not  enter  into  the  ques- 
tion of  diagnosis.  In  typhoid  fever,  to  say  nothing  of  the  enteric 
symptoms,  it  is  easy  to  differentiate  by  the  very  gradual  and  characteris- 


l)lA(;.\(fS/s.  541 

tic  rise  of  tt'inporaturo.  Between  typliiis  lever  and  .sinallpux  in  tluii- 
carlv  staijc's  the  (lia<2:nosis  is  sometimes  very  iliificult.  The  temperature 
in  both  diseases  may  be  equally  iii»2:h  and  the  nervous  symptoms  very 
similar;  but  none  of  these  symptoms  are  in  the  least  abated  by  the 
apjK'aranee  of  the  eruption  in  tyj)hus,  while  in  variola  they  are  all 
i>;reatly  improved,  and  some  ilisa])pear  entirely.  Likewise,  in  searlet 
fever  the  temperature  is  high  at  the  onset,  and  continues  so  after  the 
rash  has  a]>peared.  Not  only  in  this  respect  does  scarlatina  differ  from 
variola,  but  by  the  uniform  ditfusion  of  the  characteristic  rash,  the 
absence  of  papuhe,  and  the  presence  of  angina.  But  between  purpuric 
variola  and  malignant  scarlet  fever  the  diagnosis  is  often  very  difficult, 
as  in  both  affections  the  rash  may  be  diffused  and  intensely  red  or  pur- 
plish, the  fauces  are  usually  inflamed,  and  the  temperature,  even  in 
variola,  does  not  fall  when  the  eruption  appears.  In  such  cases  I  would 
advise  that  the  entire  cutaneous  surface  be  carefully  examined  :  very 
often  small  hemorrhagic  maculo-papules  or  very  flat  and  intensely  })ur- 
ple  vesicles  may  be  found  on  some  parts  of  the  body,  the  presence  of 
which  Avould  be  sufficient  to  exclude  scarlet  fever.  It  should  be  remem- 
bered that  in  this  form  of  variola  the  favorite  seat  of  the  eruption  is  the 
lower  abdominal  region,  together  with  the  inner  surfaces  of  the  thighs 
near  the  external  genitalia.  Next  to  this  locality,  the  hemorrhagic  ex- 
anthem  shows  a  preference  for  the  axillary  regions.  Attention  given  to 
these  points  will  often  aid  very  greatly  in  the  differential  diagnosis  be- 
tween these  malignant  affections. 

When  the  eruption  of  variola  first  appears  it  is  not  infrequently  con- 
founded with  measles.  The  catarrhal  symptoms,  which  are  so  promi- 
nent in  measles  and  so  rarely  absent,  constitute  at  this  stage  one  of  the 
most  striking  points  of  difference  between  these  diseases.  Equally  im- 
portant also  is  the  degree  of  fever.  While  the  temperature  in  the 
initial  stage  of  variola  suddenly  rises  to  104°  to  106°  F.,  in  measles  it 
is  rarelv  hiirher  than  102°  to  104°  F.  In  variola  it  falls  soon  after  the 
eruption  appears,  while  in  measles  it  continues  the  same  or  may  rise 
still  higher.  The  eruption  of  measles  frequently  makes  its  appearance 
quite  as  early  on  the  back  as  on  the  face,  and  the  lesions  are  equally 
numerous  on  both  of  these  localities ;  while  in  variola  the  eruption 
begins  on  the  face  and  extends  gradually  downward.  If  the  eruption 
be  carefully  examined,  it  will  be  found  to  consist  of  innumerable 
maculse,  and  that  the  maculse  of  measles  are  larger  than  the  papulae  of 
variola  ;  that  the  maculse  are  set  in  clusters  or  groups,' while  the  papulae, 
even  in  confluent  cases,  are  at  first  remarkably  discrete  ;  that  the 
maculte  disappear  or  grow  pale  under  pressure,  while  the  color  in  the 
papulte  is  more  persistent ;  that  the  maculae  are  soft  and  velvety  to  the 
touch,  while  the  papulae  are  hard  and  shotlike.  The  latter  condition 
of  the  eruption  in  variola  has  always  been  regarded  as  a  sym])tom  of 
considerable  diagnostic  value — and  justly  so,  too — yet  the  eruption  of 
measles  often  assumes  a  distinctly  papular  character  on  some  parts  of 
the  face,  and  especially  on  the  wrists ;  therefore  care  should  be  taken  to 
examine  the  back  of  the  patient  before  making  a  diagnosis.  But  it 
must  be  admitted  that  the  eruption  of  these  diseases  is  occasionally,  for 
a  very  brief  time,  so  similar  in  appearance  as  to  defy  the  skill  of  excel- 
lent diagnosticians ;  in  such  cases  it  is  advisable  to  defer  the  diagnosis 


542  SMALLPOX  AXL)    VARIOLOID. 

for  twenty-four  hours,  by  which  time  the  eruption  in  either  case  will 
clearly  reveal  its  individuality. 

On  account  of  the  swelling  and  the  vesication  in  facial  erysipelas 
that  disease  has  been  mistaken  for  variola  ;  but  a  careful  physical  ex- 
amination should  be  sufficient  to  avoid  such  an  error.  Glanders,  in  an 
early  stage,  is  said  to  bear  some  resemblance  to  smallpox,  not  only  as  to 
the  "febrile  conditions,  but  also  as  to  the  cutaneous  lesions,  which  con- 
sist of  hard  infiltrations  in  the  skin,  followed  quickly  by  suppuration. 
But  the  lesions  appear  in  successive  crops  and  ulcerate  rapidly ;  more- 
over, the  disease  is  very  rare  and  occurs  only  among  grooms  and 
stablemen. 

Kashes  produced  by  the  ingestion  of  certain  drugs,  as  well  as  various 
skin  diseases  of  a  vesicular  or  pustular  character,  have  been  mistaken 
for  the  eruption  of  smallpox ;  but  a  thorough  knowledge  of  the  course 
and  peculiar  features  of  the  variolous  eruption  is  the  physician's  safe- 
guard against  such  errors.  Vaccination  with  animal  virus  sometimes 
causes  an  ervthematous  or  rubeoloid  rash,  known  as  roseola  vaccinosa,  to 
appear  froni  the  eighth  to  the  twelfth  day  of  the  vaccine  disease.  I 
have  quite  frequently  known  this  rash  to  have  been  mistaken  for  the 
eruption  of  variola,  especially  during  epidemic  visitations  of  the  disease. 
The  distinguishing  features  are  that  it  accompanies  vaccinia,  that  it  is 
not  preceded  bv  a  very  high  temperature,  and  that  it  consists  of  maculse 
rather  than  papulae.  If,  after  considering  these  points,  the  question  of 
diagnosis  cannot  be  clearly  settled,  the  lapse  of  twenty-four  hours  will 
be  sufficient  to  remove  the  uncertainty. 

A  certain  though  comparatively  rare  form  of  secondary  syphilis  is 
occasionally  met  with  in  which  the  eruption  closely  simulates  that  of 
variola.  This  eruption  passes  through  the  stages  of  papule,  vesicle, 
and  pustule.  It  is  preceded  by  elevation  of  temperature,  although 
the  rise  is  not  as  great  as  in  variola.  To  differentiate  between  these 
diseases  it  is  necessary  to  inquire  into  the  history  of  the  case  and  closely 
observe  the  course  of  the  eruption.  Those  who  are  familiar  with  the 
lesions  of  smallpox  will  usually  notice  at  once  in  the  syphilitic  patient 
something  about  the  eruption  which  indicates  that  it  is  not  variolous, 
yet  the  distinction  cannot  always  be  clearly  defined  until  the  case  has 
made  some  progress.  The  pustules  do  not  develop  simultaneously,  as 
in  variola,  but  in  successive  crops,  and  are  more  protracted  in  their 
course. 

There  is,  perhaps,  no  disease  more  often  confounded  with  smallpox 
than  varicella.  Of  course  this  disease  is  very  much  milder  in  every 
particular  than  variola  vera,  and  therefore  liable  to  be  mistaken  only  for 
the  modified  forms  of  the  disease  or  varioloid.  The  differential  diag- 
nosis between  these  diseases  is  postponed  for  consideration  in  the  article 
on  Varicella. 

Peognosis. — Since  the  introduction  of  vaccination  the  presence  or 
absence  of  a  typical  vaccine  scar  on  a  patient  is  an  important  factor  in 
the  question  of  prognosis  in  smallpox.  Formerly,  smallpox  was  not  only 
more  common,  but  uniformly  far  more  fatal,  and  therefore  much  more 
dreaded,  than  at  present.  During  the  last  century  but  few  diseases 
claimed  a  greater  number  of  victims  than  variola,  but  at  the  present  time, 
especially  in  countries  where  vaccination  is  carefully  and  systematically 


PROGXOSIS.  543 

praotisc'il,  the  projxirtion  of  (U-aths  tVoiu  this  inalady  is  not  j^rcatei*  than 
t\t  P^'^'  ^"^''it.  of"  the  entire  mortality,  and  where  rexaeeination  at  the 
proper  aiic  is  also  entoreed  this  proportion  is  even  nuieh  less.  In 
the  prevaeeination  pei'iod  one  tenth  ot"  all  the  children  horn  died  fnmi 
smallpox  ;  now  the  mortality  from  that  disease  amonti'  yonnt;  children 
is  almost  ////  where  vaccination  is  compulsory.  But  after  the  lapse  of 
several  years  the  protection  conferred  by  vaccination  becomes,  in  most 
])ersons,  either  partly  or  wholly  exhausted,  so  that  when  the  variolous 
contaiiium  is  introduced  into  a  community  the  disease  is  seen  in  every 
possible  urade  of  severity,  and  the  death  rate  varies  accordingly. 

Unmoditied  smallpox  is  an  exceedingly  fatal  disease,  the  death  rate 
varying  in  different  epidemics  from  15  to  60  per  cent.  The  epidemic 
which  swept  over  this  and  other  countries  in  the  years  1870  to  1872 
was  everywhere  characterized  bv  unusual  malignancy,  and  the  mortality 
among  the  unvaccinated  cases  was,  in  some  places,  as  high  as  64  per 
cent.  In  the  absence  of  an  epidemic  influence,  however,  the  disease  is 
usually  much  less  fatal.  It  is  believed  by  some  authors  that  the  disease 
is  more  fatal  at  the  beginning  and  during  the  maximum  of  an  epidemic 
than  when  it  is  declining,  but  I  am  not  sure  that  such  is  the  case. 
Certain  seasons  of  the  year  are  also  believed  to  exercise  some  influence 
over  the  mortality  from  the  disease.  It  is  probably  true  that  a  patient 
is  less  able  to  bear  the  depressing  effects  of  confluent  variola  when  the 
weather  is  excessively  warm  than  when  the  temperature  is  cooler. 

In  considering  the  prognosis  in  individual  cases  of  variola  vera  there 
are  various  circumstances  to  be  taken  into  account.  First  of  all,  the 
age  of  the  patient  is  of  great  importance.  It  is  comparatively  rare  for 
an  infant  under  one  year  old  to  survive  an  attack  of  unmodified  small- 
pox. So  also  at  the  other  extreme  of  life  the  death  rate  is  enormous. 
In  children  from  one  to  five  years  of  age  the  disease  is  also  very  fatal, 
but  among  those  from  five  to  fifteen  years  old  the  chances  of  recovery 
are  rather  better  than  in  adult  life. 

Sex  has  but  little  to  do  with  the  question  of  prognosis.  Among 
women  the  mortality  is  somewhat  increased  on  account  of  their  liability 
to  suffer  from  metrorrhagia  or,  when  pregnant,  from  miscarriage  or 
premature  childbirth.  The  occurrence  of  either  of  these  accidents  or 
the  presence  of  the  parturient  state  strongly  predisposes  the  patient  to 
the  hemorrhagic  form  of  the  disease.  Among  men  intemperance  adds 
very  greatly  to  the  danger.  Drunkards  or  constant  drinkers  seem 
peculiarly  prone  to  suffer  from  hemorrhagic  smallpox.  I  have  found 
almost  every  variety  of  the  disease  very  fatal  among  bartenders.  The 
powers  of  resistance  against  the  exhausting  influence  of  variola  are 
often  so  diminished  by  chronic  alcoholism  that  death  results  from  a 
form  of  the  disease  from  which  a  patient  with  a  more  healthy  organism 
would  recover.  ]Mania  a  potu,  of  course,  furnishes  a  very  serious  com- 
plication. Intemperate  persons  are  apt  to  be  badly  nourished,  and  this 
condition  is  always  unfavorable  in  smallpox.  It  need  hardly  be  stated 
that  the  prognosis  should  be  very  guarded  when  variola  occurs  in  a 
convalescent  from  some  acute  exhausting  disease. 

AVith  respect  to  the  danger  in  individual  cases,  it  is  necessary  to  con- 
sider not  only  the  type  of  the  disease,  but  also  the  separate  symptoms. 
During  the  initial  stage  there  is  no  reliable  symptom  to  indicate  the 


544  SMALLPOX  AND    VARIOLOID. 

gravity  of  the  attack.  Not  infrequently  the  mildest  eruption  of  vario- 
loid is  preceded  by  a  very  severe  febrile  stage.  If,  however,  the  initial 
stage  be  very  mild,  it  would  be  safe  to  prognosticate  a  moderate  erup- 
tion. Severe  lumbar  pains  may  be  present  in  both  modified  and  unmodi- 
fied smallpox,  yet  if  they  be  extremely  severe  there  would  be  some 
reason  to  expect  a  hemorrhagic  form  of  the  disease.  Having  met  with 
the  initial  exanthem  [roseola  variolosa)  oftener  in  varioloid  than  in 
unmodified  smallpox,  I  feel  disposed  to  regard  the  presence  of  this 
rash  as  indicating  that  the  true  eruption  will  be  of  the  modified  form ; 
yet  it  must  be  remembered  that  this  peculiar  exanthem  sometimes  pre- 
cedes the  eruption  of  variola  vera. 

In  estimating  the  danger  in  smallpox  there  is  usually  no  better  guide 
than  the  quantity  and  character  of  the  eruption.  As  the  eruption  in 
varioloid  is  sparse  or  superficial  and  runs  a  course  of  short  duration,  this 
form  of  the  disease  rarely  proves  fatal.  Discrete  variola  is  also  attended 
by  no  great  danger,  but  confluence  should  always  be  regarded  with 
apprehension.  If  the  eruption  be  confluent  on  all  parts  of  the  body, 
the  patient's  condition  should  be  looked  upon  as  extremely  perilous.  In 
semiconfluent  cases,  especially  when  the  eruption  on  the  face  is  copious, 
the  question  of  recovery  becomes  problematic.  If  the  pustules  acuminate 
well  and  are  accompanied  with  considerable  swelling,  and  if  those  on 
the  extremities  are  surrounded  with  a  crimson  areola,  and  the  patient 
takes  nourishment  freely,  there  is  good  ground  for  hope.  If,  on  the 
other  hand,  the  pustules  on  the  face  be  flat,  milky  white  in  color,  and 
pasty,  with  almost  an  entire  absence  of  tumefaction,  and  if  those  on 
the  extremities  be  surrounded  with  a  dark  red  or  livid  areola,  no  reason- 
able hope  of  recovery  can  be  entertained.  It  is  also  an  ominous  sign 
for  evil  in  confluent  variola  to  see  here  and  there  a  vesicle  on  the  face 
desiccating  prematurely  or  to  find  some  of  the  vesicles  developing  blue 
centres. 

The  chief  danger  in  confluent  variola  is  from  exhaustion.  When  the 
entire  body  is  covered  with  pustules  the  quantity  of  purulent  fluid  gen- 
erated is  enormous,  and  this  amount  of  pus  formation,  together  with 
the  vast  irritation  and  inflammation  of  the  cutaneous  integument,  very 
seriously  disturbs  the  vital  powers  of  the  patient.  During  the  early 
period  of  maturation  the  patient's  condition  should  be  regarded  as  ex- 
tremely critical  if  the  progress  of  the  eruption  be  suddenly  arrested 
and  the  swelling  of  the  face  and  hands  subside,  leaving  the  skin  in  the 
spaces  between  the  pustules  pale  ;  if  the  pustules  themselves  shrink  or 
collapse ;  if  the  pulse  be  rapid,  dicrotic,  or  feeble ;  if  the  delirium  and 
restlessness  increase  ;  or  if  nourishment  be  refused  or  taken  very  reluc- 
tantly. When  confluent  variola  runs  its  regular  course,  death  seldom 
occurs  before  the  end  of  the  first  week  of  the  eruption  :  the  greatest 
danger  to  life  is  found  to  be  during  the  maturative  stage  or  the  second 
week  of  the  eruption. 

The  condition  of  the  mucous  membrane  of  the  pharynx,  larynx,  and 
trachea  should  be  regarded  as  only  second  in  importance  to  the  skin 
lesions  in  estimating  the  degree  of  danger  in  variola  vera.  If  these 
parts  become  severely  implicated  by  the  variolous  process,  giving  rise  to 
such  symptoms  as  a  diphtheritic  condition  of  the  fauces,  dysphagia,  diffi- 


j'j:()rin/.AX/s.  545 

culty  of  respiration,  or  a'dcina  ol"  the  t;I(»ltis,  the  case  should  l)c  \  icwed 
Avitli  _i;rave  apprcliciisioii.  Kvcn  hoarseness  at  an  early  j)erio(l  ot"  the 
niaturative  stage  should  be  looketl  u})on  with  suspicion. 

Valuable  information  may  often  be  gained  by  observing  the  nervous 
symptoms,  especially  at  an  advanced  period  of  the  disease.  Great  rest- 
lessness, insomnia,  despondency,  constant  moaning,  and  grinding  of  the 
•teeth  in  children  are  unfavorable  sym])toms.  X^iolent  and  j)r()tractcd 
delirium,  convulsions,  or  coma  usually  ])reclude  all  hope  of  I'ccovery. 
If,  on  the  other  hand,  the  state  of  the  nervous  system  be  traucpiil  and 
the  patient  passes  quiet  nights,  has  a  contented  disposition,  and  enter- 
tains a  confident  hope  of  recovery,  the  probability  of  a  favorable 
termination  of  the  disease  is  greatly  increased,  even  though  the  eruption 
be  severely  confluent. 

Even  after  a  patient  has  passed  safely  through  the  perils  of  the 
regular  stages  of  variola,  his  life  may  again  be  placed  in  jeopardy  by 
certain  complications.  Fortunately,  those  which  are  most  frequent — 
furuncles  and  abscesses — rarely  lead  to  a  fatal  issue.  The  occurrence 
of  pneumonia,  pleuritis  with  effusion,  erysipelas,  or  abortion  should  be 
viewed  with  deep  concern.  But  the  most  fatal  of  the  complications 
liable  to  arise  are  suppuration  within  the  joints,  septicaemia,  pyaemia, 
empyema,  and  gangrene  of  the  skin.  When  gangrene  attacks  the 
scrotum  death,  according  to  my  experience,  is  inevitable. 

Recovery  from  the  hemorrhagic  or  malignant  form  of  variola  is 
scarcely  to  be  expected.  Mildly  hemorrhagic  cases  of  varioloid  may 
occasionally  progress  to  a  favorable  termination.  Purpuric  variola 
invariably  ends  fatally,  and  the  fatal  issue  is  rarely  delayed  longer  than 
four  to  five  days  from  the  earliest  symptoms. 

Prophylaxis. — There  is  no  prophylactic  measure  against  smallpox 
of  so  great  importance  as  vaccination.  In  .countries  where  this  agent  is 
carefully  and  systematically  employed  in  infancy  and  repeated  at  the 
age  of  puberty  epidemics  of  smallpox  rarely  if  ever  occur,  and  the 
deaths  from  that  disease  occupy  a  very  low  place  in  the  mortuary  tables. 
In  view  of  the  fact,  therefore,  that  this  very  fatal  and  much  dreaded 
disease  may  be  prevented  or  modified  and  greatly  limited  in  its  spread 
by  vaccination,  it  is  highly  important  to  a  community  that  every 
individual  should  receive  the  benefits  of  this  eminently  protective  agent. 
Gratuitous  vaccination  should  be  provided  for  the  poor,  and  also  for 
those  who,  through  carelessness  or  indifference,  would  otherwise  remain 
unprotected.  Every  nn vaccinated  person  should  be  looked  upon  as  a 
constant  menace  to  the  health  of  a  community,  inasmuch  as  he  is  liable 
to  contract  smallpox  and  disseminate  the  contagium  ;  hence  the  accept- 
ance of  vaccination  should  not  be  subject  merely  to  the  discretion  of 
an  individual  whose  judgment  in  regard  to  the  matter  may  be  warped 
by  ignorance  or  prejudice,  but  should  be  made  obligatory  upon  every 
citizen.  But  in  the  absence  of  any  general  statutory  enactment  very 
much  can  be  done  by  local  authorities  to  enforce  vaccination  by  the 
adoption  of  certain  restrictive  measures.  For  example,  no  unvaccinated 
child  should  be  permitted  to  attend  school,  public  or  private  ;  no  child 
should  be  admitted  into  any  institution  for  the  care  of  children  until 
vaccination  has  been  performed ;  no  unvaccinated  person  should  be 
enlisted  in  the  army  or  navy  or  in  the  State  militia ;  and  no  unvac- 
VoL.  I.— 35 


646  SMALLPOX  AND   VARIOLOID. 

cinated  immigrant  should  be  permitted  to  land  until  vaccination  has 
been  properly  performed. 

If  vaccination  were  generally  practised  in  infancy  and  repeated  as 
circumstances  required,  there  would  be  but  little  need  of  considering 
any  other  means  of  protection  against  smallpox ;  but  as  it  seems  impos- 
sible to  attain  so  desirable  a  result,  it  is  necessary  in  the  event  of  an 
outbreak  of  the  disease  to  have  recourse  to  other  prophylactic  measures. 
When  a  physician  is  called  to  a  case  of  smallpox,  his  first  duty  is,  of 
course,  to  vaccinate  every  member  of  the  household  in  whom  the  opera- 
tion has  not  been  recently  performed ;  next,  he  should,  if  possible, 
isolate  the  case.  As  isolation  can  only  be  accomplished  with  any  degree 
of  certainty  by  removing  the  patient  to  a  special  building  or  hospital,  it 
follows  that  every  city  or  town  of  considerable  size  should,  at  least  in 
the  event  of  an  outbreak  of  smallpox,  at  once  provide  a  well  organized 
hospital,  if  none  already  exists,  for  the  isolation  and  treatment  of  such 
cases.  But  if  the  patient  must  be  treated  at  his  home,  every  possible 
eifort  should  be  made  to  separate  him  from  the  rest  of  the  family  :  only 
those  who  are  required  to  act  as  nurses  should  enter  the  infected  apart- 
ment, and  they  should  be  protected  by  recent  vaccination.  In  selecting 
an  apartment  for  the  patient  preference  should  be  given  to  the  room 
which  is  most  completely  separated  from  all  other  parts  of  the  house. 
It  should  be  well  ventilated,  and,  if  possible,  have  an  oj^en  fireplace. 
All  furniture  which  is  not  actually  necessary  for  the  comfort  of  the 
patients  and  attendants  should  be  removed.  While  in  attendance  upon 
the  sick  the  nurses  should  not  come  in  contact  with  the  other  members 
of  the  family,  and  they  should  use  every  possible  precaution  in  regard 
to  cleanliness,  disinfection  of  clothing,  bedding,  etc.  A  sheet  wrung 
out  in  a  strong  solution  of  carbolic  acid  or,  preferably,  Labarraque's 
liquid,  and  suspended  across  the  doorway,  may  aid  in  preventing  the 
contagium  from  spreading  to  other  parts  of  the  house.  During  the 
illness  of  the  patient  the  privileges  of  the  well  members  of  the  house- 
hold should  be  restricted.  They  should  be  advised  not  to  attend  church 
nor  public  assemblages  of  any  kind.  The  children,  if  there  be  any, 
should  at  once  be  required  to  leave  school,  and  should  not  be  readmitted 
until  the  family  physician  or  some  qualified  sanitary  officer  certifies  that 
the  sickness  has  ended,  that  the  period  of  incubation  has  passed,  and 
that  the  house  has  been  thoroughly  cleansed  and  disinfected. 

Disinfection  is  highly  important  in  preventing  the  dissemination  of 
the  variolous  contagium.  As  the  infecting  principle  clings  to  articles 
which  have  been  used  by  the  patient  or  which  have  been  in  the  same 
apartment,  all  such  articles  as  are  worthless  should  at  once  be  burned. 
All  articles  that  can  be  laundried  should  be  steeped  for  some  time  in 
some  disinfecting  solution,  such  as  2  fluidounces  of  chloride  of  zinc  or 
4  fluidounces  of  strong  carbolic  acid  to  a  gallon  of  w^ater,  and  afterward 
boiled  for  half  an  hour.  For  the  disinfection  of  woollen  goods  nothing 
is  equal  to  superheated  steam.  All  utensils  used  by  the  patient  in  eat- 
ing or  drinking  should  each  time  be  purified  by  boiling  water.  Even 
the  secretions  from  the  patient's  mouth  and  nose  or  the  excretions  from 
his  bowels  should  be  disinfected  by  receiving  them  into  a  strong  solu- 
tion of  chloride  of  lime  or  some  other  equally  powerful  germ-destroying 
agent. 


riiopiiYLAXis.  547 

Till'  atti'iulaiits  ii|)(»n  the  sick  sIkjuIcI  not  bo  more  numerous  than  are 
actually  reciuircd.  Their  elothiiii,^  should  be  made  of  such  material  as 
can  be  readily  boiled  and  laundried.  IJcibre  associatinj^  with  well  per- 
sons they  should  take  an  antiseptic  bath  and  i-hantre  their  entire  cloth- 
ing. The  physician  also  should  exercise  great  care  lest  he  himself  might 
be  the  means  of  spreading  the  infection.  He  should  not  remain  in  the 
sick  chamber  longer  than  is  necessary  to  make  a  careful  examination 
of  the  ])atient  ;  his  ])rescriptions  should  be  written  and  the  instructions 
given  in  another  apartment.  Before  leaving  the  house  he  should  take 
the  precaution  to  wash  his  face  and  hands  :  the  latter  especially  should 
be  washed  in  some  antiseptic  solution.  He  should  then  delay  visiting 
another  patient  until  he  has  spent  some  time  in  the  open  air  or,  what  is 
preferable,  has  changed  his  clothing.  On  entering  the  sick  room  he 
should  not  remove  his  overcoat  nor  even  his  hat ;  the  former  should  be 
kept  buttoned  up  to  the  chin.  It  would,  of  course,  be  safer  to  use  a 
long  rubber  coat  or  linen  duster,  which  should  be  kept  hanging  in  the 
open  air  during  the  intervals  of  his  visits. 

The  isolation  of  the  patient  should  continue  until  all  the  scabs  have 
fallen  off  and  the  skin  has  become  quite  smooth.  Frequent  bathing 
will  aid  in  loosening  the  scabs,  and  the  baths  should  be  of  an  antiseptic 
character.  Finally,  the  patient  should  not  be  permitted  to  associate  with 
the  public  until  his  whole  body  has  been  washed  w'ith  some  disinfecting 
solution,  such  as  a  1  :  2000  solution  of  corrosive  sublimate  or  a  3  per 
cent,  solution  of  Labarraque's  liquid.  The  safest  way  of  using  either 
of  these  solutions  is  simply  to  sponge  the  body,  carefully  wet  the  hair, 
and  then  have  the  patient  take  a  bath  in  plain  water,  with  the  use  of 
soap.  If  he  then  be  provided  with  clean  clothing,  no  one  need  hesitate 
to  associate  with  him,  although  his  skin  may  be  red  and  his  face  deeply 
scarred. 

As  the  body  of  a  patient  who  has  died  from  smallpox  is  still  capable 
of  transmitting  the  contagium,  certain  precautions  in  regard  to  it  are 
necessary.  An  effort  should  be  made  to  disinfect  the  body  by  thor- 
oughly soaking  it  with  some  powerfuL  disinfecting  solution.  There  is, 
perhaps,  nothing  more  reliable  than  chloride  of  lime.  Six  ounces  of 
this  drug  to  a  gallon  of  water  makes  a  very  effective  germicide.  The 
body  should  be  wrapped  in  a  sheet  or  blanket  saturated  with  this  or 
some  equally  powerful  solution  before  it  is  placed  in  the  hermetically 
sealed  casket,  and  the  burial  should  ft»llow  as  speedily  as  possible,  with- 
out, of  course,  a  public  funeral.  From  a  sanitary  point  of  view  crema- 
tion of  the  corpse  would  be  far  preferable,  but,  unfortunately,  this  is  for 
various  reasons  but  seldom  practicable. 

The  sick  chamber  and  every  article  which  it  contains  should  be 
thoroughly  disinfected  after  the  room  has  been  vacated  by  the  patient, 
either  by  his  recovery  or  death.  This  may  be  accomplished  by  burning 
in  the  room  3  pounds  of  sulphur  to  every  1000  cubic  feet  of  air  space, 
the  room  having  first  been  made  as  nearly  air-tight  as  possible.  The 
disinfecting  power  of  the  sulphur  dioxide  will  be  greatly  increased  by 
the  presence  of  moisture.  As  already  indicated,  all  muslin  and  linen 
goods  should  be  subjected  to  the  boiling  temperature  for  half  an  hour, 
and  then  laundried.  AYoollen  clothing,  pillows,  mattresses,  carpets,  and 
all  other  articles  which  cannot  be  laundried  should  be  so  arranged  in  the 


548  SMALLPOX  AND    VARIOLOID. 

room  as  to  be  thoroughly  exposed  to  the  influence  of  the  sulphur  diox- 
ide, or  else  they  should  be  conveyed  to  a  disinfecting  plant  and  exposed 
for  two  hours  to  either  dry  heat  or  superheated  steam  at  a  temperature 
of  230°  F.  After  the  apartment  has  been  disinfected  and  cleansed  it  is 
advisable  that  it  should  remain  unoccupied  for  two  or  three  weeks,  when 
it  can  be  regarded  as  perfectly  safe  for  occupancy. 

Teeatment. — In  considering  the  treatment  of  smallpox  it  should 
be  stated,  first  of  all,  that  there  is  as  yet  no  drug  or  agent  known  that 
is  capable  of  exerting  the  slightest  influence  over  the  course  of  the  dis- 
ease after  symptoms  have  once  become  manifested.  But  as  scientific 
investigations  are  constantly  adding  to  our  knowledge  important  facts 
in  regard  to  the  causes  of  infective  diseases,  it  is  not  improbable  that 
before  long  we  shall  not  only  be  able  to  recognize  the  specific  cause  of 
smallpox,  but  to  antagonize  its  action.  Until  this  new  era  arrives,  how- 
ever, we  must  continue  to  treat  the  patient  rather  than  the  disease,  by 
addressing  our  remedies  to  the  symptoms  as  they  arise  throughout  the 
various  stages  of  the  disease. 

During  the  incubation  period  of  smallpox  there  are  usually  no  symp- 
toms requiring  treatment.  The  only  question  to  be  considered  at  this 
stage  is.  Can  anything  be  done  to  prevent  or  modify  the  approaching 
malady?  Certainly  no  result  can  be  expected  from  the  use  of  drugs. 
What  can  be  expected  from  vaccination  ?  As  the  essential  principles  in 
the  causation  of  variola  and  vaccinia  are  almost  identical,  it  has  been 
alleged  that  vaccination  at  this  period  of  smallpox  will  hasten  the  vari- 
olous process,  instead  of  modifying  it.  This  view  is  extremely  theoret- 
ical, and  is  certainly  not  based  on  experience.  On  the  other  hand,  there 
are  some  who  assert  that  hypodermic  injections  of  vaccine  lymph  have 
produced  good  results.  I  would  advise  that  this  assertion  be  accepted 
cum  grano  sails.  There  are  others,  among  whom  may  be  mentioned 
Curschmann,  who  have  never  been  able  to  see  vaccination  during  the 
incubation  stage  exert  any  prophylactic  influence  whatever  over  the 
disease.  My  own  experience  is  quite  diflferent.  I  have  often  seen 
smallpox  greatly  modified  by  vaccination  after  infection  had  occurred^ 
and  have  not  infrequently  seen  the  disease  prevented  altogether. 

It  is  my  belief  that  when  vaccinia  has  advanced  to  the  stage  of  the 
formation  of  the  areola  around  the  vesicle  it  begins  to  exert  its  prophy- 
lactic power  against  smallpox.  In  perfectly  typical  cases  this  stage  is 
reached  about  the  eighth  clay.  As  the  incubation  period  of  variola  is 
known  to  be  from  ten  to  twelve  days,  it  is  therefore  quite  possible  for 
vaccinia  to  exert  its  protective  influence  in  advance  of  the  time  when  the 
earliest  symptoms  of  smallpox  should  appear,  provided  that  vaccination 
be  not  delayed  too  long  after  the  infection  has  been  received  into  the 
system.  It  may  be  said,  in  a  general  way,  that  the  protection  will  be 
perfect  or  nearly  so  when  the  vaccine  vesicle  reaches  the  areolar  stage  in 
advance  of  any  symptoms,  and  that  in  somewhat  less  advanced  cases  of 
vaccinia  a  modifying  influence  may  be  expected.  As  the  modified  form 
of  vaccinia  which  results  from  revaccination  is  usually  more  rapid  iu  its 
development,  protection  against  the  approaching  disease  in  such  cases 
may  be  expected  with  a  greater  degree  of  certainty  than  in  those  under- 
going true  vaccinia. 

In  endeavoring  to  prevent  or  modify  smallpox  at  this  stage  it  is  of 


TREATMENT.  549 

vital  iinportanco  that  the  vacciiu-  lyiiii)li  ciinjloyed  should  he  fresh  and 
active,  liovine  lymph,  as  supplied  to  us  on  ivory  points,  is  so  often 
attended  by  failure,  and,  when  it  does  succeed,  its  action  is  so  slow,  that 
dependence  t'annot  be  placed  on  it  in  cases  where  vaccinia  has  to  compete 
with  variola.  In  such  cases  I  would  advise  the  use  of  humanized  virus 
when  it  can  be  ])roi'ure(l,  and  es[)ecially  that  which  has  resulted  from  a 
long  series  of  human  transmissions.  Tiiere  is  no  virus  nu)re  reliable  or 
more  certain  to  give  prompt  results  than  that  taken  from  a  typical  ves- 
icle on  the  eighth  day.  In  using  humanized  virus  it  is  important  that 
several  insertions  should  be  made,  as  this  will  not  only  diminish  the 
liability  to  failure,  but,  through  the  development  of  multiple  vesicles, 
will  bring  the  system  more  etfectually  under  the  vaccine  influence. 

During  the  initial  stage  nothing  can  be  done  to  stay  the  progress  of 
variola  nor  even  to  modify  its  course.  The  only  thing  that  can  be  done 
is  to  endeavor  to  make  the  patient  as  comfortable  as  possible  and  to 
ameliorate  special  symptoms  as  they  arise.  The  patient  should  be 
placed  in  a  well  ventilated  bedroom  in  M'hich  the  temperature  is  from 
68°  to  70°  F.  A  light  diet  and  cooling  drinks  are  most  appropriate. 
As  the  fever  is  usually  high,  febrifuge  mixtures,  such  as  liquor  potassii 
citratis  or  liquor  ammonise  acetatis,  containing  a  little  spiritiis  setheris 
nitrosi  or  tinctura  aconiti,  may  be  given  in  suitable  doses  at  frequent 
intervals.     A  good  combination  is  as  follows : 

1^.  Spiritus  letheris  nitrosi, 

Syrupi  limonis,  cici.  fgiv  ; 

Liquoris  ammoniae  acetatis,  f  5v. — M. 

Sig.     Give  one  to  four  fluidrachms,  according   to  age,  every  two 
hours,  in  a  little  ice-water. 

Phenacetin  also  will  often  be  found  very  serviceable  in  doses  of  from 
two  to  three  grains,  every  two  hours,  until  several  doses  have  been  taken 
or  until  there  is  a  reduction  of  the  temperature.  When  there  is  irrita- 
bility of  the  stomach  the  effervescing  citrate  of  potassium  is  preferable 
to  most  other  febrifuge  mixtures.  The  swallowing  of  small  pieces  of 
ice  is  not  only  cooling  in  its  effect,  but  is  very  useful  when  the  stomach 
is  irritable.  AVhen  this  symptom  is  very  distressing,  as  frequently  hap- 
pens, such  remedies  as  lime  water,  aromatic  spirits  of  ammonia,  subni- 
trate  of  bismuth,  a  little  chloroform  water,  and  the  like  may  be  used. 

I  have  found  nothing  more  serviceable  in  moderating  a  high  tempe- 
rature attended  by  a  hot  and  dry  skin  than  frequent  sponging  with  cool 
water.  At  the  same  time,  cold  water,  iced  compresses,  or  the  ice  bag 
may  be  applied  to  the  head.  When  this  condition  is  present  there  need 
be  no  fear  of  suppressing  the  eruption  by  the  use  of  cooling  applications. 

At  this  stage  the  nervous  symptoms  frequently  demand  treatment. 
For  the  relief  of  cephalalgia  and  lumbar  pains,  which  are  often  dis- 
tressing, large  doses  of  some  one  of  the  bromide  salts,  caffeine,  or  phe- 
nacetin in  doses  of  5  or  10  grains,  or,  if  preferred,  some  other  analgesic 
of  the  coal  tar  series,  may  be  employed.  Convulsions,  which  are  so 
common  in  children,  may  be  relieved  by  warm  baths  or  by  giving  in- 
ternally bromide  of  potassium  or  hydrate  of  chloral.  The  latter  drug 
is  especially  serviceable  in  convulsions,  but  care   should  be  taken  to 


550  SMALLPOX  AND   VARIOLOID. 

have  it  well  diluted,  as  otherwise  it  will  aggravate  the  throat  symptoms. 
When  it  cannot  be  swallowed  it  should  be  given  by  the  rectum.  These 
drugs  are  also  very  useful  for  the  relief  of  insomnia  and  restlessness, 
which  so  often  demand  attention.  For  these  symptoms  also  Dover's 
powder,  when  the  stomach  is  not  irritable,  will  often  act  well,  or  hypo- 
dermic injections  of  morphine  and  atropine  may  be  given  with  good  re- 
sults. Care  should  be  taken  not  to  apply  sinapisms  to  any  part  of  the 
body  for  the  relief  of  pain,  as  the  irritation  produced  by  them  is  very 
certain  to  greatly  increase  the  eruption  on  that  particular  surface,  with- 
out diminishing  it  elsewhere. 

After  the  eruption  has  fully  appeared  the  remedies  just  described 
are  no  longer  required,  as  the  fever  now  remits  and  the  nervous  symp- 
toms usually  disappear.  At  this  stage  various  drugs  and  other  agents 
have  been  recommended,  and  some  of  them  from  time  to  time  highly 
vaunted,  as  useful  in  modifying  the  eruption,  but  all  have  proved  un- 
availing. Efforts  have  been  made  to  accomplish  this  desirable  result 
by  the  internal  and  external  use  of  the  various  antiseptic  or  antizymotic 
drugs,  such  as  carbolic  acid,  sulphocarbolate  of  sodium,  salicylic  acid, 
salicylate  of  sodium,  xylol,  and  some  others ;  but,  while  some  writers 
strongly  advocate  their  use,  it  must  be  said  that  none  of  these  drugs 
have  stood  the  test  of  experience.  It  has  frequently  been  asserted 
that  the  exclusion  of  daylight  from  the  bedroom  is  followed  by  good 
results.  The  same  results,  it  is  said,  can  be  produced  by  excluding  the 
ultra-violet  rays,  which  have  strong  chemical  action,  by  means  of  red 
window  panes  or  by  using  red  curtains  tightly  drawn  around  the  bed. 
It  is  claimed  by  a  recent  writer  that  a  patient  thus  treated  will  escape 
the  stage  of  suppuration.  I  must,  however,  advise  great  skepticism  in 
regard  to  this  assertion.  Those  who  are  familiar  with  the  history  of 
smallpox  will  recall  the  fact  that  a  similar  treatment  was  introduced  as 
far  back  as  the  time  of  Edward  II.  of  England,  whose  son,  it  is  said, 
was  "  treated  for  smallpox  by  being  put  into  a  bed  surrounded  with  red 
blankets  and  a  red  counterpane,  gargling  his  throat  with  mulberry  wine, 
and  sucking  the  red  juice  of  pomegranates."  It  is  perhaps  unnecessary 
to  make  any  further  comment  on  this  treatment  than  to  repeat  the  very 
charitable  criticism  of  Gregory,  who  said,  "  Let  us,  then,  avoid  the 
errors  of  our  ancestors  without  reproaching  them." 

When  the  eruption  is  slow  in  making  its  appearance,  as  sometimes 
happens  in  children  with  a  feeble  circulation  and  a  depressed  condition 
of  system,  heat  should  be  applied  and  hot  stimulating  drinks  given.  A 
bath  quite  warm,  followed  by  enveloping  the  patient  in  blankets,  is 
often  very  satisfactory  in  its  results.  Convulsions  in  this  condition  are 
very  common,  and  when  they  occur  demand  the  free  use  of  the  remedies 
already  mentioned.  As  the  eruption  progresses  to  the  vesicular  stage 
there  is  always  considerable  burning  and  itching  of  the  skin.  This 
may  be  relieved  to  some  extent  by  oleaginous  applications.  When 
there  is  very  much  swelling,  especially  about  the  face,  arms,  and  hands, 
and  the  burning  pain  is  severe,  there  is  nothing  that  gives  so  much 
relief  as  frequent  applications  of  cold  compresses  or  cloths  wrung  out 
in  cold  water  and  kept  constantly  applied.  For  the  intense  pain  fre- 
quently experienced  in  the  palms  of  the  hands,  tips  of  the  fingers,  and 
soles  of  the  feet  cold  applications,  even  iced  compresses,  are  also  very 


TREATMENT.  551 

serviceable,  yet  I  liave  seen  rather  Itcttci-  results  follow  the  use  of  (|iiit(' 
warm  a|)])li('ati(>ns,  such  as  warm  hand  and  foot  baths  or  hot  {)()ulticcs. 
If  these  agents  fail  and  the  patient  is  unable  to  sleep,  opiates  may  be 
resorted  to.  A  little  morphine  or  de(id(n'ized  tincture  of  opium  often 
acts  like  a  charm. 

For  the  relief  of  the  distressing  symptoms  resultinii-  from  inlhimma- 
tion  and  swelling  of  the  mucous  membrane  (»f  the  mouth,  fauces,  and 
larynx,  mouth-washes  and  gargles  are  recpiired,  such,  for  example,  as 
solutions  of  chlorate  of  potassium,  boric  acid,  tincture  of  myrrh,  glyce- 
role  of  tannin,  and  the  like.  The  milder  demulcent  decoctions  of  flax- 
seed, gum  arable,  and  slippery  elm  bark  will  often  be  found  decidedly 
palliative.  I  frequently  use  with  much  advantage  flaxseed  tea  sweet- 
ened with  white  sugar  and  slightly  acidulated  with  lemon  juice.  Ice 
cold  lemonade  is  generally  relished  by  the  patient.  Great  relief  is  some- 
times experienced  by  small  pieces  of  ice  being  held  in  the  mouth  and 
allowed  to  dissolve  slowly.  Careful  and  frequent  cleansing  of  the  mouth 
usually  affords  considerable  relief  and  enables  the  patient  to  swallow 
with  greater  ease.  This  may  be  accomplished  In-  the  nurse  covering  her 
index  finger  with  a  soft  linen  rag,  dipping  it  into  acidulated  water  or 
boric  acid  solution,  and  thoroughly  cleansing  the  entire  buccal  cavity. 
If  this  be  followed  by  spraying  the  mouth  and  fauces  with  a  weak  solu- 
tion of  cocaine,  swallowing  will  sometimes  be  rendered  easier  in  cases 
of  dys])iiagia. 

The  nervous  symptoms  are  frecjuentlv  so  prominent  during  the 
eruptive  stage  as  to  demand  treatment.  Such  symptoms  as  persistent 
insomnia  and  violent  delirium  are  most  common.  Not  infrequently  this 
condition  is  attended  by  a  flushed  face  and  bounding  pulse,  in  which  case 
a  saline  purge  and  an  ice  bag  to  the  head  may  be  of  service.  Sulphate 
of  morphine  and  tartar  emetic,  in  doses  of  \  grain  of  each,  repeated  every 
two  hours  until  a  few  doses  have  been  taken,  will  frequently  cjuiet  the 
delirium  and  produce  sleep.  Of  course  some  one  of  the  bromides  and 
hydrate  of  chloral  are  to  be  preferred  in  the  larger  proportion  of  cases. 
Care  must  be  taken,  however,  not  to  use  narcotics  too  freely,  lest  the 
patient  lapse  into  coma  or  sink  into  collapse.  When  the  delirium  is 
violent  or  maniacal,  it  will  be  necessary  to  use  some  means  of  physical 
restraint  to  prevent  the  patient  injuring  himself  or  others,  especially  if 
he  be  large  and  muscular. 

Smallpox  is  by  far  most  fatal  during  the  stage  of  suppuration.  The 
chief  indications  for  treatment  at  this  stage  are  to  mitigate  the  suppura- 
tive fever,  to  disinfect  the  exudation  from  the  pustules,  and  to  oppose 
by  every  possible  means  the  tendency  to  death  from  exhaustion.  If  the 
patient  can  be  carried  safely  through  this  stage  and  the  early  part  of  the 
stage  of  desiccation,  his  recovery  may  be  reasonably  expected,  unless 
some  serious  complication  should  arise. 

When  the  temperature  is  \evy  high  the  ice  bag  should  be  kept  on  the 
head  and  sponging  with  cool  or  tepid  water  resumed.  In  warm  weather 
the  temperature  of  the  patient  may  sometimes  be  reduced  by  covering 
him  with  a  sheet  wruno-  out  in  cool  Mater  and  renewing;  it  everv  few 
minutes.  Occasionall}  cold  apj^lications  are  not  well  borne,  in  which 
case  tepid  water  may  be  tried.  Cool  immersion  baths  have  not  met  with 
anything  like  the  same  results  in  variola  as  in  typhoid  fever.    Some  one 


552  SMALLPOX  AND   VARIOLOID. 

of  the  antipyretics  of  the  coal  tar  series  will  often  be  found  useful,  I 
have  frequently  used  phenacetin,  in  doses  of  2  or  3  grains  every  two 
hours  until  several  doses  have  been  given,  with  good  results.  When 
this  drug,  however,  is  discontinued  the  fever  usually  recurs,  but  during 
the  short  interval  from  intense  fever  the  patient  is  often  able  to  take  a 
little  more  nourishment  than  he  would  otherwise  do,  and  sometimes 
enjoys  an  hour  or  two  of  refreshing  sleep.  On  account  of  the  depressing 
eifect  occasionally  seen  from  the  use  of  these  drugs  it  is  advisable  to 
give  stimulants  at  the  same  time. 

To  allay  the  intolerable  itching  and  to  correct  the  offensive  odor 
resulting  from  decomposition  of  the  purulent  material  that  exudes  from 
the  pustules  certain  local  applications  will  be  found  of  great  service. 
Antiseptic  Avashes  may  be  used,  such  as  a  solution  of  boric  acid  (1  :  20), 
of  carbolic  acid  (1  :  100),  or  of  bichloride  of  mercury  (1  :  2000).  When 
the  odor  is  highly  offensive  great  benefit  may  be  derived  by  keeping  the 
patient's  face,  hands,  and  other  parts  of  the  body,  if  necessary,  con- 
stantly mopped  with  a  solution  of  hypochlorite  of  sodium.  I  frequently 
use  with  ad\'antage  a  5  per  cent,  solution  of  Labarraque's  liquid,  direct- 
ing that  not  only  the  patient,  but  the  bedding  also,  be  sprayed  every 
little  while  by  means  of  an  atomizer.  A^arious  antiseptic  oleaginous 
preparations  are  also  useful.  There  is  nothing  more  convenient  and, 
upon  the  Avhole,  more  serviceable  than  equal  parts  of  olive  oil  and  lime 
water  containing  a  little  carbolic  acid  or  oil  of  eucalyj^tus.  This  should 
be  applied  freely  three  or  four  times  a  day  with  a  large  camel's  hair 
brush.  I  have  been  using  lately  with  considerable  benefit  an  ointment 
composed  of  aristol  15  or  20  parts  to  100  parts  of  vaseline.  Two 
drachms  of  liquor  sodse  chloratse  to  an  ounce  of  lard  are  also  service- 
able. Likewise  I  have  used  with  advantage  antiseptic  dusting  powders, 
such  as  15  parts  of  aristol  to  100  parts  of  talc  or  powdered  starch. 

It  is,  I  think,  scarcely  necessary  to  speak  at  length  of  the  various 
means  which  have  been  recommended  from  time  to  time  for  the  preven- 
tion of  pitting,  for  not  even  the  highly  vaunted  methods  when  put  to  a 
critical  test  have  been  found  worthy  of  the  praise  given  them.  To 
accomplish  this  purpose  it  is  necessary  that  the  pustular  stage  of  the 
eruption  should  be  either  prevented  or  greatly  modified,  for  the  suppu- 
rative process  is  always  attended  by  destruction  of  derm  tissue,  and  any 
loss  of  this  tissue  is  inevitably  followed  by  scarring.  After  consider- 
able experience  with  many  of  the  most  highly  lauded  ectrotic  measures, 
so  called,  I  have  come  to  the  same  conclusion  as  Gregory,  that  there  is 
no  peculiar  method  yet  known  for  the  prevention  of  pits  and  scars : 
"The  masks  and  ointments  formerly  in  use  for  that  purpose,  and  so 
highly  vaunted,  are,  in  reality,  more  hurtful  than  beneficial."  A  little 
cold  cream,  vaseline,  benzoated  lard,  or  lanolin,  containing  some  anti- 
septic, is  all  that  can  be  recommended. 

As  the  vital  powers  of  a  patient  suffering  from  confluent  variola  are 
severely  taxed  during  the  stage  of  suppuration,  it  is  important  that  a 
supporting  plan  of  treatment  should  be  adopted.  This  is  quite  obvious 
when  we  consider  how  great  the  quantity  of  purulent  material  generated 
must  be.  Watson  has  estimated  that  it  amounts  to  quarts.  Besides 
this  excessive  strain  upon  the  system,  the  vast  irritation  resulting  from 
inflammation  of  almost  the  entire  cutaneous  integument  is  very  exhaust- 


TREATMENT.  553 

ing  ill  its  effects,  being  comparable  only  t(j  that  w  liidi  results  from  an 
extensive  burn.  The  first  evidence  of  flagging  of  the  vital  forces  is 
usually  a  sudden  subsidence  of  the  swelling  and  redness  of  the  face  and 
hands,  causing  the  skin  to  become  ])ale  and  the  juistules  to  shrink  or 
present  a  collapsed  ai)pearaiK'e.  If  this  condition  continues,  the  ])ulse 
becomes  rapid  and  feeble,  the  tongue  i)ro\vn  and  dry,  and  subsultus 
tendinuni,  general  tremors,  and  delirium  rapidly  supervene.  It  is  ad- 
visable to  anticipate  these  symptoms  by  the  early  employment  of  sup- 
porting measures.  AVheii  maturation  of  the  pustules  begins  the  patient 
should  receive  a  liberal  amount  of  nutrients  and  stimulants.  Milk, 
pei)toiiizcd  if  necessary,  should  be  given  at  frequent  intervals,  I  usu- 
ally insist  that  an  adult  })atient  suticring  from  a  severe  form  of  variola 
shall  receive  during  each  twenty  four  hours  from  2  to  3  quarts  of  un- 
skimmed milk,  2  to  3  raw  eggs,  and  6  to  12  ounces  of  good  whiskey, 
the  latter  being  given  in  the  form  of  milk  punch.  The  eggs  may  be 
well  beaten  and  drank  with  the  milk  or  they  may  be  given  in  the  form 
of  eggnog.  It  is  important  that  these  supporting  agents  should  lie  faith- 
fully continued  during  the  night  as  well  as  the  day,  for  when  prostra- 
tion is  extreme  the  tendency  to  sink  into  collapse  seems  greatest  be- 
tween midnight  and  morning.  AVhen  milk  and  whiskey  cannot  be 
taken  in  sufficient  quantity,  or  when  there  is  great  repugnance  to  these 
articles,  bouillon  with  eggs,  a  well  prepared  beef  tea,  nutritious  broths, 
and  a  liberal  amount  of  wine  may  be  given  instead.  As  a  stimulant 
in  cases  of  profound  prostration  Curschmann  esteems  very  highly  the 
Stokes  cognac  mixture,  prepared  as  follows  : 

E..  Cognac  optimi, 

Aquse  destillatse,  da.  f^xv  ; 

Vitelli  ovi,  Xo.  i., 

Syrupi,  f^5vj. — M. 

Sig.  Give  a  tablespoonful  at  frequent  intervals. 

Usually  but  few  drugs  are  required  at  this  stage  of  the  disease.  The 
less  the  stomach  is  taxed  with  the  ingestion  of  drugs,  and  the  more  com- 
pletely its  labor  is  limited  to  the  important  function  of  sustaining  the 
vital  forces  and  the  nutrition  of  the  body,  the  greater  ■s\-ill  be  the  chances 
of  recovery.  If  the  bowels  should  be  confined,  rather  than  give  purga- 
tives, enemas  should  be  used.  Sulphate  of  quinine  is  usually  serviceable 
in  tonic  doses.  "When  the  heart  action  is  weak,  sulphate  of  strychnine 
and  digitalis  will  be  found  most  useful.  Carbonate  of  ammonium  is  also 
useful  in  eases  of  threatened  cardiac  failure.  In  case  of  great  restless- 
ness and  insomnia  narcotics  may  be  cautiously  given  hypodermically  or 
by  the  rectmn.  The  occurrence  of  diarrhoea  should  receive  prompt 
attention. 

In  cases  of  varioloid  usually  very  little  treatment  is  required  after 
the  initial  stage  has  passed,  as  this  form  of  the  disease  rarely  ends 
fatally.  On  the  other  hand,  hemorrhagic  variola  almost  always  termi- 
nates fatally  in  spite  of  the  best  treatment.  The  drugs  usually  employed 
are  the  mineral  acids,  ergot  or  ergotin,  sulphate  of  quinine,  and  tinc- 
ture of  the  chloride  of  iron,  together  with  the  external  use  of  styptics 
and  cold  compresses  ;  but  these  agents  are  recommended,  I  regret  to  say, 


554  SMALLPOX  AND    VARIOLOID. 

more  in  conformity  with  general  usage  than  with  any  expectation  of 
effecting  a  cure.  Transfusion  has  also  been  tried,  but  the  results  have 
not  been  encouraging. 

The  various  complications  liable  to  arise  should  be  treated  on  general 
principles,  according  to  their  nature  and  the  indications  presented.  Fu- 
runcles and  abscesses  should  be  opened  as  soon  as  they  form,  and  the 
latter  especially  should  receive  antiseptic  treatment.  An  effort  should 
be  made  to  prevent  the  occurrence  of  the  serious  forms  of  eye  compli- 
cations by  washing  from  the  conjunctiva  all  purulent  material  as  fast  as 
it  forms.  This  may  be  accomplished  by  carefully  injecting  under  the 
lids  a  solution  of  boric  acid  (10  or  15  grains  to  an  ounce  of  water),  using 
a  small  syringe  or  dropper.  The  eyes  should  be  carefully  watched,  and 
when  a  corneal  ulcer  appears  it  should  at  first  be  treated  by  the  appli- 
cation of  cold  compresses.  Besides  thorough  cleansing  a  solution  of  10 
to  15  grains  of  boric  acid  and  2  to  4  grains  of  atropine  to  an  ounce  of 
distilled  water  should  be  instilled  into  the  eye  once  or  twice  daily.  I 
have  occasionally  touched  the  ulcers  very  delicately  with  a  stick  of 
nitrate  of  silver  brought  to  a  fine  point,  as  recommended  by  some 
authors,  but  with  no  decided  benefit.  Indeed,  in  spite  of  treatment, 
the  ulcerative  process  too  often  continues  until  the  ^^sion  is  entirely 
destroyed. 

Convalescence  from  smallpox  may  be  hastened  by  tonics  and  a  liberal 
diet.  The  compound  tincture  of  cinchona  is  useful  at  times  to  increase 
the  appetite,  although,  as  a  rule,  convalescents  eat  heartily.  In  cases 
of  great  emaciation  and  exhaustion  iron,  cod  liver  oil,  and  the  malt 
liquors  are  very  useful.  If  there  should  be  a  constant  occurrence  of 
boils  or  a  furuncular  diathesis,  some  benefit  may  be  derived  from  the 
administration  of  Fowler's  solution  or  sulphide  of  calcium.  The  sepa- 
ration of  the  scabs  may  be  hastened  by  the  free  use  of  glycerin  or  cos- 
moline  and  warm  baths.  If  warty  nodules  remain  on  the  face  after  the 
scabs  have  fallen  off,  their  removal  may  be  hastened  by  touching  them 
once  or  twice  daily  with  tincture  of  iodine. 


VACCINIA. 

By  WILLIAM  M.  WELCH,  M.  D. 


Synonyms. — Latin,  Vaccinia  or  Variolse  vaccinae  (Jenncr) ;  English, 
Cowpox  or  Kinepox  ;  French,  Vaccine  ;  German,  Kuhpocken,  Impf- 
pocken,  or  Schutzblattern  ;  Italian,  Vaccina  ;  Spanish,  Vacuna. 

Definition, — Vaccinia  is  a  disease  communicable  only  bv  inocula- 
tion, and  is  characterized  by  one  or  more  skin  lesions,  according  to  the 
number  of  insertions  of  the  specific  virus,  running  through  the  stages 
of  papulation,  vesiculation,  and  pustulation,  ending  in  desiccation  and 
falling  of  the  crusts  at  the  end  of  the  third  week.  The  process  is 
attended  by  very  little  if  any  febrile  reaction,  and,  when  completed, 
confers  immunity  against  smallpox. 

History. — Toward  the  middle  of  the  eighteenth  century  an  impres- 
sion arose  among  the  common  people  employed  in  the  dairies  of  England 
that  a  certain  disease  of  cows  known  as  cowpox  would,  when  accidentally 
communicated  to  the  milkers,  afford  them  protection  against  smallpox. 
This  belief  gradually  increased  until,  at  length,  in  1774,  a  Gloucester- 
shire farmer,  named  Benjamin  Jesty,  became  so  fully  convinced  of  the 
prophylactic  power  of  cowpox  that  he  ventured  to  inoculate  his  wife  and 
two  sons  with,  presumably,  some  of  the  virus  from  the  teats  of  a  cow  suf- 
fering from  the  disease.  But  the  subject  received  no  scientific  considera- 
tion until  it  attracted  the  attention  of  Edward  Jenner,  a  country  physician 
of  Berkeley,  England,  Avhere  dairy  farms  were  numerous.  When  he 
was  yet  a  medical  student,  Jenner's  interest  was  elicited  in  the  matter 
by  hearing  a  countrywoman  remark  that  she  could  not  take  smallpox 
because  she  had  been  infected  with  cowpox.  Later,  when  a  practitioner 
of  medicine,  he  took  great  pains  to  inquire  into  the  facts  upon  which 
this  tradition  was  founded,  and  he  soon  became  convinced  that  there 
was  a  reality  about  it ;  but,  setting  a  good  example  to  all  investigators, 
he  continued  his  researches  for  several  years,  and  xilemonstrated  most 
conclusively  the  value  of  his  discovery  before  publishing  hi^;  observa- 
tions to  the  world. 

The  first  practical  demonstration  of  the  new  inoculation,  as  it  was 
called,  was  made  by  Jenner,  May  14,  1796,  in  a  peasant  lad  named 
James  Phipps,  aged  eight  years,  whom  he  inoculated  with  virus  taken 
from  a  vesicle  on  the  hand  of  a  dairymaid,  who  had  been  accidentally 
infected  by  milking  a  cow  affected  with  cowpox.  Wishing  to  test  the 
protective  efficacy  of  the  vaccine  disease,  Jenner  tried,  on  the  first  day 
of  July  following,  to  give  this  lad  smallpox  by  inoculating  him  with 
variolous  matter,  but  failed.  He  repeated  the  test  several  months  later 
with  the  same  negative  result.  After  continuing  his  investigations  for 
two  years  longer,  and  accumulating  a  mass  of  evidence  that  was  simply 


556  VACCINIA. 

incontrovertible,  Jenner  published,  in  London,  June,  1798,  his  observa- 
tions in  a  paper  entitled  "  An  Inquiry  into  the  Causes  and  Effects  of 
the  Variolse  Vaccinae,  etc." 

It  must  not  be  supposed  that  the  great  and  important  truth  promul- 
gated in  this  paper  was  accepted  without  opposition.  On  the  contrary, 
it  was  doubted  by  some  and  ridiculed  by  others.  Some,  indeed,  carried 
their  opposition  so  far  as  to  attack  the  honesty  and  veracity  of  Jenner. 
Still  others,  even  more  bitter  in  their  opposition,  caricatured  the  effect 
of  the  inoculation  by  representing  man  transformed  into  a  horrid  monster 
presenting  some  of  the  characteristics  of  both  man  and  the  bovine  animal. 
But  the  force  of  Jenner's  facts  was  such  that,  in  spite  of  this  detraction, 
it  was  not  long  until  his  discovery  was  known  and  welcomed  in  every 
civilized  country  in  the  world,  and  the  experience  of  a  century  affords 
a  most  complete  confirmation  of  all  that  was  claimed  for  it  by  its  dis- 
coverer. 

The  new  inoculation  was  introduced  into  America  by  Benjamin 
Waterhouse,  the  first  professor  of  the  theory  and  practice  of  medicine 
in  Harvard  College.  The  first  person  subjected  to  its  influence  was  his 
eldest  son,  aged  five  years.  This  occurred  July  8,  1800.  Observing 
that  the  vaccinia  in  this  child  passed  through  the  regular  course,  as 
described  by  Jenner,  he  took  virus  from  this  case  and  with  it  inoculated 
the  rest  of  his  children.  After  the  vaccine  disease  had  run  its  course, 
he  proceeded  to  test  its  efficacy  against  smallpox  by  taking  his  children 
into  the  smallpox  hospital  and  exposing  them  freely  to  the  contagium  of 
that  disease.  Finding  they  resisted  the  contagium  in  the  natural  way, 
he  had  them  inoculated  with  variolous  matter.  This  also  failed  to  pro- 
duce the  disease.  He  then  very  truly  remarked,  "  One  fact,  in  such 
cases,  is  worth  a  thousand  arguments."  It  is  instructive  to  add  that 
Waterhouse  was  greatly  aided  in  his  work  of  introducing  the  new 
inoculation  in  this  country  by  Thomas  Jefferson,  then  President  of  the 
United  States.  It  was  largely  through  his  efforts  that  the  virus  of 
vaccinia  was  speedily  disseminated  throughout  the  Southern  and  some 
parts  of  the  Middle  States. 

As  the  result  of  Jenner's  discovery  the  spread  of  smallpox  has 
everywhere  been  greatly  controlled  and  the  mortality  from  that  disease 
enormously  diminished.  In  England  and  Wales,  where  the  registration 
records  are  perhaps  more  complete  than  in  most  countries,  it  was  found 
that  before  the  introduction  of  vaccination  the  annual  mortality  from 
smallpox  was  at  the  rate  of  3000  deaths  in  every  million  of  the  popu- 
lation. Since  the  adoption  of  this  protective  measure  the  ratio  of  deaths 
to  the  population  from  that  disease  has  constantly  diminished.  Accord- 
ing to  Moore,^  only  15  deaths  Avere  caused  by  smallpox  in  England 
during  the  year  1890.  While  this,  undoubtedly,  is  an  unusually  small 
number,  yet  during  the  ten  years  from  1881  to  1890,  inclusive,  the 
average  annual  rate  of  mortality  from  that  disease  was  only  one  seven- 
tieth part  of  what  it  was  during  the  pre-vaccination  period.  Further- 
more, it  has  been  found  that  where  vaccination  in  infancy  has  been 
carefully  and  systematically  practised,  as  in  Germany,  for  example,  the 
mortality  from  smallpox  among  children,  instead  of  being  enormous,  as 
formerly,  has  become  almost  nil. 

^  Text-Book  of  the  Eruptive  and  Continued  Fevers. 


ETIOLOGY. 


557 


Tlu'  protection  oonforrocl  by  vaccinia  has  not  only  greatly  diniinishod 
the  iiuinhcr  of  cases  ot"  sinall])ox,  l)Ut  has  very  consiiU'rahly  reduced 
i\\v  death  rati"  anionu'  those  attacked.  Moore'  oives  statistics  which 
show  that  in  Shettiehl,  thn-in*^-  tlie  outbreak  of  1887-}S)S,  of  4151  vacci- 
nated patients  200  died,  a  death  rate  of  4.8  per  cent.  ;  while  of  552 
unvaccinated  patients,  274  died,  a  death  rate  of  4f».(j  per  cent.  A 
report  bv  Grinishaw  of  Dublin  on  the  unusually  widespread  and  malig- 
nant epidemic  of  smallpox  which  occurred  in  1871-72  shows  the  com- 
parative death  rate  in  sevi'ral  hospitals  aniono-  the  vaccinated  and  un- 
vaccinated patients  to  have  been  as  follows  :  In  Cork  Street  H<tspital, 
of  vaccinated  patients,  10.8  per  cent,  died,  and  of  the  unvaccinated, 
71.8  per  cent.;  in  Hardwicke,  11.2  per  cent,  of  the  vaccinated,  and 
78.57  per  cent,  of  the  unvaccinated  ;  in  Cork,  5.5  per  cent,  of  the  vac- 
cinated, and  58  per  cent,  of  the  unvaccinated  ;  in  London  Smallpox 
Hospital  14.9  per  cent,  of  the  vaccinated,  and  6(3.2  per  cent,  of  the  un- 
vaccinated ;  in  Hampstead  (London),  11.4  per  cent,  of  the  vaccinated, 
and  51,2  per  cent,  of  the  unvaccinated ;  in  Homerton,  5.9  per  cent,  of 
the  vaccinated,  and  37.7  per  cent,  of  the  unvaccinated. 

It  has  been  very  clearly  shown  that  the  degree  of  vaccinal  protection 
is  proportionate  to  the  perfect  evolution  of  vaccinia.  Marson  and  others 
of  large  experience  have  found  that  smallpox  is  less  fatal  among  patients 
who  bear  unmistakable  evidence,  in  the  form  of  typical  scars,  that  the 
vaccine  disease  had  run  a  perfect  course.  While  Jenner  never  said 
very  much  about  the  character  of  the  scar,  he  nevertheless  constantly 
insisted  that  the  vaccinal  process  should  observe  a  certain  definite  course, 
^vhich  he  carefully  described,  in  order  that  the  protection  should  be 
perfect.  As  tending  to  show  that  the  degree  of  protection  can  be  meas- 
ured to  a  considerable  extent  by  the  quality  of  the  vaccine  scars  borne 
by  persons,  the  writer  presents  the  result  of  his  own  experience  in  the 
following  table  : 


Vaccinated  in  infancy — good  scars 
"  "      — fair  scars 

"  "      — poor  scars 


cases.  Deaths.  P-ar 


Post-vaccinal  cases  . 
Unvaccinated  cases 
Unclassified  cases    . 


Total 


1474 

124 

8.41 

701 

101 

14.4 

1104 

296 

26.81 

3279 

521 

15.88 

1926 

1059 

54.98 

116 

25 

21.55 

5321      1605 


30.16 


Etiology. — It  is  generally  believed  that  vaccinia,  etiologicallv  con- 
sidered, is  closely  related  to  variola.  Jenner  was  evidently  of  this 
opinion  when  he  applied  to  it  the  name  variolae  vaccinae.  The  disease 
as  it  occurs 'in  the  cow  has  been  thought  to  be  in  reality  smallpox 
robbed  of  its  virulence  by  passing  through  the  system  of  the  bovine 
animal.  This  theory  has  led  a  number  of  very  able  investigators  to 
attempt  to  produce  co's\t)Ox  at  will  by  inoculating  cows  with  variolous 
matter.  Among  the  names  of  such  investigators  may  be  mentioned  as 
most  prominent  those  of  Ceely,  Reiter,  Badcock,  Thiele,  and  Yoigt. 

'  Loc.  cU. 


558  VACCINIA. 

Some  of  these  men  present  strong  claims  of  success,  while  others  have 
unquestionably  failed,  and,  even  worse  than  that,  have  inoculated 
variola  back  into  the  human  subject  by  using  the  virus  from  a  vesicle 
raised  by  variolating  the  cow.  Reiter  met  with  this  unfortunate  result, 
and  so  also  have  some  other  experimenters.  The  writer  must  therefore 
advise  great  skepticism  in  regard  to  the  assertions  that  vaccine  virus 
may  be  produced  at  will  by  this  method.  Under  no  circumstance 
should  such  virus  be  inoculated  into  the  human  subject  until  it  has 
passed  through,  so  to  speak,  a  series  of  bovine  animals  and  the  local 
process  has  been  found  by  close  and  careful  comparison  to  be  iden- 
tical with  that  of  undoubtedly  true  vaccinia  in  the  heifer. 

Vaccinia  usually  occurs  in  the  human  subject  as  the  result  of  inten- 
tional inoculation  with  a  strain  of  virus  that  was  originally  taken  from 
a  cow  sutFering  from  what  is  commonly  called  spontaneous  cowpox. 
This  term  is  not  intended  to  imply  that  the  disease  develops  in  the  cow 
independently  of  contagium,  but  rather  that  it  appears  without  any  known 
source  of  origin.  This  affection  is  believed  to  have  been  more  prevalent 
among  cows  in  Jenner's  time  than  at  present.  When  once  the  disease 
was  introduced  among  a  herd  of  cows  on  a  dairy  farm  it  was  found  to 
spread  from  one  to  another,  and  thus  continue  for  months,  and  even 
years,  if  new  stock  were  continually  added  to  the  herd.  As  the  disease 
was  particularly  prone  to  attack  heifers  during  their  first  lactation,  it  is 
evident  that  the  infection  was  principally  conveyed  from  one  cow  to 
another  by  the  hands  of  the  milker.  It  is  doubtful  whether  the  disease 
ever  spreads  among  bovine  animals  in  any  other  way  than  by  inocula- 
tion. By  this  means  cowpox  may  be  communicated  from  one  bovine 
animal  to  another  through  an  indefinite  series,  and  the  supply  of 
vaccine  virus  thus  produced  need  be  limited  only  by  the  demand  or 
the  number  of  animals  inoculated.  It  is  well  known  to  the  propagators 
of  bovine  virus  that  the  disease  cannot  be  communicated  a  second  time 
to  the  same  heifer. 

Jenner's  theory  of  the  origin  of  cowpox  was  that  it  results  from 
grease  in  the  horse.  It  must  not  be  understood  that  he  ascribed  the 
origin  of  cowpox  to  the  ordinary  eczematous  affection  that  so  commonly 
occurs  in  horses'  heels  as  the  result  of  uncleanness,  and  called  "  grease  " 
by  hostlers,  but  to  a  rare  and  peculiar  form  of  eruptive  disease  described 
by  the  French  as  eaux  aux  jambes.  He  believed  that  cowpox  was  due  to 
the  accidental  conveyance  of  the  virus  of  grease  to  the  teats  of  a  cow 
by  a  milker  whose  business  was  also  to  care  for  horses'  heels  when 
affected  with  that  disease.  Jenner  admitted,  however,  that  he  was  not 
able  to  prove  the  correctness  of  this  opinion  by  "  actual  experiments  con- 
ducted immediately  under  his  own  eye,"  but  believed  that  the  evidence 
he  collected  was  sufficient  to  establish  it  as  a  fact.  It  is  not  improbable 
that  the  grease  spoken  of  by  Jenner  was  in  reality  a  localized  eruption 
of  equina,  or  horsepox,  for  such  a  disease  is  said  to  exist  among  horses. 
Depaul  claimed  he  had  demonstrated  that  this  affection  was  capable  of 
giving  rise  to  cowpox  in  the  cow  by  inoculation.  But,  after  all,  it  must 
be  said  that  while  Jenner's  theory  has  not  been  disproved,  it  has  not 
been  fully  confirmed,  and  that  the  theory  that  regards  spontaneous  cow- 
pox  as  a  disease  sui  generis  in  the  bovine  animal  is  probably  correct. 
It  seems  probable  that  there  is  in  the  vesicles  of  vaccinia  some  special 


I'ATIIOLOUICAL   ASATOMY.  559 

bacillus  wliifli  lu-ts  as  the  iiitccting  priiu-ipk-,  Init  tliii.s  tar  U(nie  lia.s  been 
described.  The  only  micro-organisms  seen  that  are  at  all  liable  to  serve 
as  the  infecting  agents  are  certain  cocci,  but  there  is  nothing  peculiar 
about  them  ;  they  cannot  even  be  distinguished  from  the  bacteria  found 
in  the  vesicles  of  variola. 

Pathological  Anatomy. — The  lesi(ms  of  vaccinia  are  limited  to 
that  part  of  the  skin  where  the  vesicles  develop.  At  the  point  of  in- 
oculation of  the  vaccine  virus  the  papillary  layer  of  the  derm  at  first 
becomes  congested,  and  in  the  course  of  three  to  five  davs  a  slight 
inflammatory  action  is  set  up,  followed  by  an  exudation  of  Ivmph,  As 
the  lymph  increases,  the  epidermis  is  detached  and  lifted  from  the  other 
layers  of  the  skin,  and  forms  the  roof  or  upper  covering  of  the  vesicle. 
The  squamous  cells  of  the  epidermis  are  not  entirely  destroyed  bv  the 
accumulation  of  lymph,  but  are  stretched  and  forced  out  of  their  normal 
relation  to  each  other,  so  as  to  form  cavities,  or  rather  partition  walls, 
within  the  vesicle.  It  is  a  well  known  fact  that  the  vesicle  is  not  uni- 
locular, but  multilocular  ;  hence  it  cannot  be  entirely  emptied  nor  de- 
stroyed by  a  single  puncture. 

The  lymph  at  first  is  thin  and  pellucid,  but  later  it  becomes  opaque 
and  viscid.  Examined  microscopically,  it  is  found  to  be  a  mixture  of 
fibrin,  corpuscular  elements,  and,  as  the  process  advances,  certain  detri- 
tus from  tissue  changes,  and  even  pus  corpuscles.  In  addition  to  this 
a  large  number  of  small  spherical  bodies,  or  micrococci,  may  be  seen, 
and  these  constitute,  as  is  generally  believed,  the  virulent  element  of  the 
lymph.  In  the  human  subject  the  lymph  is  clearer,  more  limpid,  and 
more  soluble  than  in  the  animal,  and  hence  that  from  the  former  may 
be  used  for  transmitting  the  vaccine  disease  with  greater  certainty  of 
success. 

A  slight  depression,  termed  umbilication,  is  usually  seen  in  the 
vesicle,  even  at  an  early  stage  of  its  development.  If  carefully  ex- 
amined, it  will  be  found  that  the  centre  of  the  pock  where  the  depression 
exists  has  already  undergone  desiccation  ;  this  prevents  central  disten- 
tion of  the  vesicle,  so  that  growth  takes  place  by  peripheral  enlargement. 
As  the  process  of  evolution  advances,  the  deeper  layers  of  the  skin 
become  involved  and  its  connective  tissue  suiFers  by  inflammatory  and 
idcerative  action.  In  some  cases  the  inflammatory  action  even  extends 
to  the  subcutaneous  tissue  or  may  give  rise  to  a  necrotic  condition  of  the 
skin.  But  all  results  of  this  kind  when  excessive  should  be  regarded 
as  inflammatory  complications  rather  than  as  essential  features  of  true 
vaccinia. 

The  scab  which  forms  as  the  ultimate  result  of  the  evolution  of  the 
pock  shows,  when  examined  microscopically,  not  only  the  organisms 
already  mentioned  as  present  in  the  lymph,  but  also  blood  corpuscles, 
pus  corpuscles,  broken-down  epithelium,  and  other  debris.  As  a 
sequence  of  the  destruction  which  has  taken  place  in  the  connective 
tissue  elements  of  the  deeper  layers  of  the  skin  a  permanent  cicatricial 
lesion  remains.  The  cicatrix  is  to  a  great  extent  peculiar  and  quite 
characteristic.  One  that  is  perfectly  typical  presents  well  defined  mar- 
gins, is  reticulated  or  foveolated,  and,  without  much  stretch  of  the 
imagination,  looks  as  if  it  had  been  stamped  into  the  skin  by  a  sharply- 
cut  die.     It  has  been  said  that  genuine  pocks  are  frequently  not  fol- 


560  VACCIXIA. 

lowed  by  scars,  but,  without  denyiug  this  absolutely,  the  writer  would 
advise  that  such  assertions  should  be  regarded  with  some  degree  of 
skepticism. 

Symptoms  axd  Course  of  the  Dlsease. — Vaccinia  in  the  human 
subject,  as  already  stated,  is  always  produced  by  inoculation.  During 
the  first  two  or  three  days  after  the  insertion  of  the  vaccine  virus  no 
symptoms  are  observed  beyond  those  incident  to  the  slight  abrasion 
of  the  skin  made  by  the  operator's  knife.  On  the  third  or  fourth  day 
very  faint  redness  may  be  seen  around  the  site  of  the  inoculation.  This 
redness  gradually  increases,  while  at  the  same  time  a  distinct  papule  is 
formed,  which  becomes  slightly  more  prominent  by  increasing  in  area 
rather  than  height.  On  the  fifth  day  the  lesion  begins  to  assume  a 
vesicular  condition.  This  is  usually  seen  first  at  the  margin  of  the  seat 
of  inoculation.  The  vesicle  gradually  increases  in  size,  and  the  lymph 
that  it  contains  is  at  first  thin  and  perfectly  transparent.  On  the  eighth 
day  the  vesicle  reaches  its  greatest  perfection  :  it  is  then  consideraljly 
elevated  above  the  surface  of  the  skin,  and  presents  a  pearly  or  yellow- 
ish appearance.  When  examined  closely  it  will  be  found  to  have,  even 
at  an  early  stage  of  its  development,  an  umbilicated  form  similar  to  that 
seen  in  the  vesicles  of  variola.  About  this  time  there  appears  around 
the  vesicle  an  inflammatory  circle  which  is  called  the  areola.  During 
the  ninth  and  tenth  days  the  redness  increases  and  the  inflamed  skin 
becomes  tense  and  painful,  and  streaks  of  redness  often  extend  a  con- 
siderable distance  from  the  lesion  (Plate  IX).  When  the  action  is  in- 
tense a  few  papillary  elevations  appear  near  the  vesicle.  Occasionally 
the  cellular  tissue  becomes  involved  in  the  inflammatory  action.  Fre- 
quently, indeed,  the  glands  of  the  axilla  swell  and  become  painful,  pro- 
vided that  the  inoculation  has  been  done,  as  is  customary,  on  the  arm. 

At  the  same  time  mild  constitutional  symptoms  appear.  Slight  rigors 
sometimes  occur,  followed  by  very  moderate  elevation  of  the  temperature. 
It  is  not  often  that  the  temperature  rises  more  than  one  or  two  degrees 
above  the  normal.  There  are  apt  to  be  malaise,  impaired  appetite,  and 
disturbed  sleep  ;  but  none  of  these  symptoms  continue  very  long.  In 
recording  very  carefully  the  constitutional  disturbance  observed  in  his 
first  case  of  induced  vaccinia,  Jenuer  says  :  "  On  the  seventh  day  he  (a 
boy  aged  eight  years)  complained  of  uneasiness  in  the  axilla,  and  on  the 
ninth  he  became  a  little  chilly,  lost  his  appetite,  and  had  a  slight  head- 
ache. During  the  whole  of  this  day  he  was  perceptibly  indisposed,  and 
spent  the  night  with  some  degree  of  restlessness,  but  on  the  following 
day  he  was  perfectly  well."  It  cannot  be  doubted,  however,  that  many 
children  pass  through  tlie  regular  course  of  vaccinia  without  any  appar- 
ent systemic  disturbance  ;  while,  on  the  other  hand,  it  sometimes  hap- 
pens, especially  in  secondary'  inoculations,  that  the  symptoms,  both  con- 
stitutional and  local,  are  very  severe.  It  occasionally  happens  in  severe 
cases  of  primary  vaccinia  that  a  cutaneous  erujDtion  appears  at  this  stage 
of  the  disease.  This  eruption  consists  of  numerous  maculae  similar  to 
measles,  and  covers  almost  the  entire  body.  On  account  of  its  com- 
paratively frequent  association  with  the  vaccine  process  it  has  been 
called  roseola  vaccinosa.  It  seldom  continues  longer  than  two  or  three 
days.     Fever,  of  course,  accompanies  this  s}Tnptom. 

On  the  eleventh  or  twelfth  day  the  pock  begins  to  fade.     In  its  declin- 


PLATE    IX. 


Vaccinia  on  the  Tenth  Day. 


COMPLICATIOSS  A XI)  SEQUELS.  561 

iug  stage  its  contents  become  opaqne,  tlesiecation  appears  in  its  centre, 
and  the  areola  shades  oif  into  two  or  three  concentric  circles,  varying- 
in  color  from  a  pale  red  to  a  deep  red  or  livid  tinge.  Bv  the  tifteciitli 
day  desiccation  is  usually  completed,  altliough  the  crust  does  not  fall 
off  nor  can  it  be  easily  removed  until  the  end  of  the  third,  and  fre- 
quently not  until  the  end  of  the  fourth,  week.  The  completed  crust  is 
of  a  mahogany  color,  rough  on  its  exterior,  thin  at  it  centre  and  periph- 
ery, with  a  thick  circular  ridge  between.  The  scar  is  at  first  red,  but 
in  the  course  of  a  few  months  becomes  paler  than  the  surrounding  skin. 
It  is  pitted  or  foveolated,  and  not  unfrequently  presents  radiating  Ijands 
or  stria'  of  cicatricial  tissue. 

As  the  analogy  between  cowpox  and  smallpox  is  in  most  respects 
very  close,  and  as  variola  frequently  differs  in  the  duration  and  severity 
of  its  local  manifestations,  so  also  it  must  not.  be  expected  that  the 
local  lesions  of  vaccinia  will  invariably  follow  the  typical  course  just 
described.  In  some  cases  the  course  of  the  disease  is  undoubtedly 
shorter  and  milder,  while  in  others  it  is  longer  and  severer.  Xo  devia- 
tion, however,  should  occur  in  the  evolution  of  the  pock  ;  that  is  to 
say,  it  should  pass  through  the  stages  of  papulation,  vesiculation,  and 
pustulation.  The  vesicle  may  be  delayed  in  making  its  appearance  or 
tardy  in  its  development.  It  has  been  known  to  appear  as  late  as  one 
month  after  the  inoculation  was  done,  and  then  develop  and  run  regu- 
larly through  its  course.  Likewise  the  constitutional  symptoms  are  not 
uniform  ;  they  may  not  be  present  at  all,  or,  if  j)resent,  are  so  mild  as 
to  pass  unobserved. 

Passing  over  the  numerous  irregularities  of  the  vaccine  lesion 
described  by  the  earlier  writers,  it  is  deemed  necessary  to  refer  only  to  a 
single  spurious  variety  which  has  grown  more  frequent  of  late  years — 
namelv,  the  red  raspberry  excrescence,  as  it  is  commonly  termed.  This 
growth,  when  seen,  usually  appears  from  three  to  seven  days  after  the 
introduction  of  the  virus,  beginning  as  a  red  elevation  at  the  site  of 
inoculation,  quite  similar  in  appearance  to  the  papule  of  true  vaccinia, 
but  instead  of  advancing  to  the  vesicular  stage  it  remains  hard,  dense, 
bright  red  in  color,  and  nodular  in  form,  looking  not  unlike  a  small 
nsevus.  A  thin  fragile  crust  forms  on  its  surface,  but  when  this  is 
removed  the  lesion  continues  to  present  the  same  general  appearance 
just  described.  It  is  very  persistent,  remaining  usually  for  weeks  or 
even  months  ;  no  areola  forms  around  it  at  any  time,  and  it  L^  not  fol- 
lowed by  a  scar. 

This  peculiar  excrescence  was  described  by  some  of  the  earlier 
writers  on  vaccination,  but  during  the  long  period  in  which  humanized 
virus  was  used  exclusively  it  was  not  observed.  Since  the  introduction 
and  general  employment  of  animal  vaccine  virus  it  has  frequently  been 
seen.  It  seems  therefore  that  it  occurs  as  the  result  of  inoculating  the 
human  subject  with  some  unknown  form  of  inert  or  non-sjiecific  mate- 
rial taken  from  a  vaccinated  bovine  animal.  That  this  is  a  spurious 
form  of  the  vaccine  disease,  and  utterly  devoid  of  protective  power 
against  either  variola  or  vaccinia,  the  w^riter  has  had  ample  opportuni- 
ties of  proving. 

Complications  and  Sequel.^:. — The  complications  lialde  to  rise 
in  the  course  of  vaccinia  are   not  muuerous.     Those  due  to  excessive 

Vol.  I.— 36 


562  VACCINIA. 

inflammatory  action  of  the  skin  are  most  common  ;  but  they  usually 
occur  as  the  result  of  undue  traumatism,  or  injury  to  the  pock  and  the 
accidental  introduction  of  septic  material,  or  some  pre-existing  cuta- 
neous disease,  or  some  dyscrasia.  In  children  with  a  strongly  marked 
scrofulous  diathesis,  lymphangitis  and  lymphadenitis,  more  or  less 
severe,  not  unfrequently  result.  Likewise,  where  there  is  a  tendency  to 
eczema,  that  aifection  sometimes  follows  the  maturation  of  the  pock. 
In  the  early  days  of  vaccination  it  was  thought  that  any  existing 
cutaneous  disease,  however  mild,  was  not  only  liable  to  be  aggra- 
vated by  vaccinia,  but  that  its  presence  was  likely  to  interfere  with 
the  most  perfect  development  of  the  vaccine  lesion.  This  belief,  the 
writer  thinks,  is  not  altogether  warranted  by  experience.  It  is,  of 
course,  desirable  that  a  child  should  be  free  from  any  disease  whatever 
when  vaccinated,  but  when  there  is  danger  of  variolous  infection  no 
cutaneous  disorder,  not  even  that  resulting  from  the  acute  exanthemata, 
should  interfere  with  the  prompt  performance  of  the  operation. 

There  are  a  few  diseases  of  a  specific  character  that  may  be  trans- 
mitted by  vaccination,  especially  when  proper  care  is  not  exercised. 
Impetigo  contagiosa  is  said  to  have  been  communicated  by  the  use  of  a 
vaccine  crust  taken  from  a  person  in  whom  that  disease  coexisted  with 
vaccinia.  Erysipelas,  also,  has  been  known  to  follow  vaccination,  but 
it  must  be  admitted  that  this  is  a  rare  complication  at  the  present  day. 
The  Ma-iter  is  familiar  with  a  few  instances  in  which  it  occurred  many 
years  ago  as  the  result  of  carelessly  using  decomposed  humanized  crusts. 
It  is  generally  believed,  however,  that  the  more  frequent  source  of  ery- 
sipelas is  secondary  infection,  resulting  from  the  presence  of  the  conta- 
gium  of  that  disease  in  the  surroundings  of  the  patient. 

Of  all  possible  complications,  the  most  serious  is  syphilis.  For  a 
long  time  it  was  doubted  whether  this  disease  could  be  communicated 
by  vaccination,  but  since  the  careful  study  of  the  subject  and  of  cases 
by  M.  Viennois  of  France  and  Jonathan  Hutchinson  of  England  the 
truth  of  the  matter  has  come  to  be  recognized  by  the  profession  gener- 
ally. It  was  at  first  thought  possible  to  convey  syphilis  by  vaccination 
only  when  vaccine  lymph  was  taken  from  syphilitic  subjects  in  such 
careless  manner  as  to  permit  of  its  contamination  by  blood,  but  it  has 
been  shown  by  Ricord  and  Jonathan  Hutchinson  that  vaccine  lymph  is 
never  entirely  free  from  blood. 

While,  therefore,  it  is  possible  to  transmit  this  dreaded  disease  in 
this  way,  the  danger  has  been  greatly  exaggerated.  It  has  fallen  to  the 
lot  of  but  few  to  see  cases  of  vaccino-S}q)hilis.  It  is  a  well  known  fact 
that  the  inherited  form  of  the  disease  usually  manifests  itself  during  the 
first  two  or  three  months  of  infantile  life  ;  therefore,  by  carefully  observ- 
ing the  health  of  the  infant,  and  declining  to  take  virus  from  any  child 
under  four  months  of  age,  the  risk  of  communicating  syphilis  by  vac- 
cination would  be  entirely  nil.  Besides,  it  is  easy  now  to  allay  the 
fears  of  the  most  timid  in  regard  to  this  matter  by  the  employment  of 
vaccine  lymph  from  the  heifer,  since  that  animal  is  known  to  be  insus- 
ceptible to  syphilis. 

There  are  only  two  sequelse  that  follow  vaccinia — one  is  immunity 
from  variola,  and  the  other  is  the  scar.  The  scar  is  usually  character- 
istic, but  in  very  exceptional  cases  the  writer  has  known  it  to  assume 


THE  TECHyiQUE  OF   VACCiyATIOX.  563 

the  aj^pearance  of  a  keloid  un-owtlt.     In  these  cases  bovine  virus  had 
been  employed. 

The  Tpxiiniquk  of  Vaccination. — llumdnized  Viru.s. — Previous 
to  the  introduction  of  animal  vaccination  in  this  country  and  the  pro])a- 
^ation  of  bovine  lymph  humanized  virus  was  em])loved  exclusivelv. 
In  Jenner's  time  it  was  the  habit  to  use  this  virus  in  the  form  of  Ivmph 
from  the  vesiele.  Jenner  believed  that  only  the  -uperticial  Ivmph  should 
be  employed,  while  others  contended  that  it  should  be  taken  from  the 
floor  of  the  vesicle.  Time,  however,  has  shown  that  the  lymph  from 
all  parts  of  the  vesicle  is  equally  efficient.  The  time  of  taking  the  Ivmph 
is  undoubtedly  of  much  greater  importance.  Experience  has  long  since 
shown  that  the  proper  time  to  take  it  is  from  the  fifth  to  the  eighth 
day,  since  at  a  later  period  it  is  quite  sure  to  become  mixed  with  inflam- 
matory products.  Xo  lymph  should  be  taken  after  the  formation  of 
the  areola.  Jenner's  instruction  on  this  point  was  verv  explicit  and 
emphatic,  and  indeed  considered  so  important  that  it  Mas  called  the 
golden  rule  of  vaccination.  It  was  this  :  "  Never  to  take  the  virus 
from  a  vaccine  pustule  for  the  purpose  of  inoculation  after  the  efflor- 
escence is  firmed  around  it.  I  wish  this  efflorescence  to  be  considered 
as  a  sacred  boundary  over  which  the  lancet  should  never  pass." 

Xo  form  of  virus  is  more  certain  to  succeed,  and  surely  none  gives 
better  results,  than  fresh  lymph  taken  from  a  vesicle  on  the  eighth  dav 
of  its  development.  This  will  often  succeed  in  producing  vaccinia  after 
every  other  variety  of  virus  has  failed.  Unfortunately,  the  lymph  does 
not  retain  its  virulence  very  long  in  a  dried  state,  except  in  the  form  of 
crust,  and  arm-to-arm  vaccination,  which  is  the  most  successful  method 
of  using  it,  is  but  rarely  practicable  in  this  country.  Attempts  have 
been  made  to  preserve  the  lymph  in  capillary  tubes  hermetically  sealed, 
but  it  has  been  found  that  its  virulent  property-  is  difficult  of  preserva- 
tion in  this  way.  The  crust  is  the  only  form  of  humanized  virus  that 
is  readily  accessible  or  that  can  be  depended  on  when  it  is  necessary  to 
preserve  it  for  a  long  time.  Formerly  the  crust  Avas  the  common  source 
of  vaccine  supply,  but  it  has  been  supplanted  almost  entirely  by  vaccine 
h-mph  from  bovine  animals.  Direct  observation,  however,  has  fully 
convinced  the  writer  that  the  former  virus,  especially  that  which  has 
been  long  humanized,  is  far  more  trustworthy  than  the  latter  as  a 
prophylactic  agent  after  exposure  to  the  contagium  of  variola.  This 
is  not  only  because  of  the  well  known  fact  that  himianized  virus  suc- 
ceeds more  readily  than  the  bovine  lymph  usually  found  in  the  market, 
but  also  because  it  is  prompter  in  its  action,  produces  a  vesicle  that 
reaches  maturity  earlier,  and  thus  affords  speedier  protection. 

Animal  Vaccine. — By  animal  vaccine  is  meant  the  vaccine  that  is 
produced  in  calves  or  yoiuig  heifers  by  the  continued  propagation  of 
virus  taken  originally  from  a  case  of  spontaneous  cowpox.  It  is  neces- 
sary to  consider  only  three  forms  of  this  vaccine — the  liquid  lymph, 
dried  lymph,  and  the  crust.  The  liquid  lymph  is  active  when  it  can  be 
used  direct  from  the  calf,  but  when  stored  in  capillary  tubes  it  soon  loses 
its  virulence.  Some  crusts  are  active,  but  most  of  them  are  inert. 
Besides,  they  contain  a  good  deal  of  debris  and  matter  liable  to  undergo 
decomposition  ;  hence  they  should  never  be  used.  The  dried  hTuph, 
therefore,  is  the  form  generally  employed,  and  this  is  usually  served  to 


564 


VACCINIA. 


the  profession  on  ivory  points,  sometimes  on  slips  of  quills.  It  should 
be  kept  cool  and  free  from  moisture. 

In  performing  vaccination  the  upper  layer  of  the  skin  should  be 
slightly  abraded,  so  that  the  virus  may  be  brought  in  contact  with  the 
absorbents.  This  may  be  done  by  means  of  an  ordinary  lancet  or  an 
ivory  point  containing  the  bovine  lymph.  An  instrument  not  too  sharp 
is  preferable  for  the  ojjeration,  as  the  horny  layer  of  the  cuticle  should 
be  scraped  or  scratched  rather  than  incised.  Too  much  oozing  of  blood 
is  undesirable.  Immediately  the  virus  should  be  well  rubbed  on  the 
abraded  surface.  If  dried  vaccine  from  the  bovine  animal  be  used,  it 
should  first  be  perfectly  dissolved.  In  using  humanized  virus  in  the 
form  of  a  crust  or  scab,  a  small  fragment  should  be  cut  off  and  crushed 
to  a  fine  powder  between  two  pieces  of  glass,  such  as  microscope  slides, 
then  moistened  with  sterilized  w^ater  and  brought  to  the  consistence  of 
mucilage.  Of  course  the  skin  of  the  patient  at  the  site  of  the  inocula- 
tion should  be  properly  cleansed  with  some  antiseptic  solution  before 
the  operation,  and  the  lancet  sterilized. 

Apart  from  the  objection  arising  from  the  presence  of  the  scar,  it  is 
not  important  on  what  part  of  the  cutaneous  surface  the  inoculation  is 
done.  The  region  most  frequently  selected  is  the  arm  near  the  insertion 
of  the  deltoid  muscle.  This  part  is  easily  accessible,  while  at  the  same 
time  it  is  comparatively  free  from  muscular  contraction  and  lymphatic 
glands.  After  the  operation  it  is  advisable  to  keep  the  arm  bare  for  a 
few  minutes.  The  practice  of  applying  court  plaster  should  be  con- 
demned. To  avoid  irritation  from  the  clothing  there  is  no  objection  to 
using  some  one  of  the  shields  devised  by  instrument-makers,  although 
they  are  not  usually  required. 


Cases. 

Deaths. 

Percentage 
of  deaths. 

Unvaccinated 

Claiming  to  have  been  vaccinated  ;   no  visible  scar  .    . 
Vaccinated  from  one  to  seven  days  before  the  appear- 
ance of  the  variolous  eruption 

1668 
258 

59 

95 

909 
150 

25 

17 

54.49 
58.13 

42.37 

Vaccinated  longer  than  seven  days  before  the  vario- 
lous eruption  appeared 

17.89 

Vaccinated  in  infancy — one  good  scar 

"       "       —  "    fair     "         

"       "       —  "    poor  "         

820 
451 

874 

70 

70 

256 

8.53 
15.. 52 
29.29 

Total  number  showing  one  scar 

2145 

396 

18.46 

Vaccinated  in  infancy — two  good  scars 

"       "       —  "   fair       ''       

"       "       —  "   poor    "        ....... 

287 
114 
102 

20 
14 

24 

6.97 
12.28 
23.53 

Total  number  showing  two  scars 

503 

58 

11.53 

Vaccinated  in  infancy — three  good  scars 

"        "        —    "     fair      "         

"       "        —    "     poor    "         

122 
49 
51 

10 

4 

13 

8.19 

8.16 

25.49 

Total  number  showing  three  scars    ...... 

222 

27 

12.16 

Vaccinated  in  infancy — four  or  more  good  scars    .    .    . 
Vaccinated  in  infancy — four  or  more  fair  scars     .    .    . 
Vaccinated  in  infancy — four  or  more  poor  scars    .    .    . 

251 
81 
97 

24 
10 
11 

9.56 
12.34 
11.34 

Total  number  showing  four  or  more  scars  .    .    . 

429 

45 

10.49 

RK 1  'J  CCIN.  1  770  .V.  565 

The  opinion  has  been  advanced,  more  especially  by  Marson  of  Lon- 
don, that  tlicdcLiree  of  vaccinal  protection  in  an  individnal  is  directly  pro- 
portionate to  the  ninnlxT  ol'  insertions  made.  This  o})inion  was  based 
upon  his  very  extended  experience  with  snudl{)ox,  in  which  he  found 
that  the  disease  was  less  severe  and  less  fatal  in  })ro]K)rtion  to  the  num- 
ber of  vaccine  scars  borne  by  each  jxitient.  According-  to  his  statistics, 
the  death  rate  among-  patients  showing  one  sear  was  7.5  per  cent,,  two 
sears  4.125  ]>er  cent.,  three  sears  1.75  per  cent.,  four  or  more  scars  0.75 
per  cent.  Among  those  presenting  uniformly  typical  scars  the  death 
rate  was  still  less.  The  writer's  experience  on  this  point  does  not  en- 
tirelv  agree  Avith  that  of  Marson's,  as  mav  be  seen  in  the  preceding 
table. 

According  to  the  writer's  experience,  the  qualitij  of  vaccine  scars  is 
a  far  more  reliable  indication  of  the  degree  of  protection  than  the  guan- 
titij.  The  table  shows  that  when  the  scars  are  typical  it  makes  no  dif- 
ference whether  they  are  single  or  multiple,  the  protection  being  practi- 
cally the  same.  There  is  no  doubt  that  vaccinia  characterized  bv  a  single 
typical  vesicle  confers  immiuiity  against  smallpox  ;  it  is  impossible  for 
multiple  vesicles  to  do  more.  However,  as  a  safeguard  against  failure 
when  the  danger  of  variolous  infection  is  imminent,  it  is  advisable  in 
vaccinating  to  make  more  than  one  insertion. 

The  age  at  which  it  is  proper  to  vaccinate  a  child  is  a  matter  of  some 
importance.  Unless  some  circumstance  should  arise  requiring  vaccina- 
tion t<;>  be  done  earlier,  it  is  advisable  to  defer  the  operation  until  the  child 
is  three  months  old.  The  most  suitable  age  is  from  three  to  six  months. 
It  is  not  well  to  postpone  the  operation  longer,  else  the  systemic  dis- 
turbances arising  from  teething  may  be  added  to  the  irritation  from  the 
vaccination,  and  thus  increase  the  discomfort  of  the  child.  But  where 
there  is  actual  danger  of  exposure  to  the  contagium  of  smallpox,  denti- 
tion should  not  interfere  with  vaccination,  nor  should  a  newborn  infant 
be  considered  too  young  to  undergo  the  operation. 

Reyaccination. — Experience  has  demonstrated  the  fact  that  in  a 
certain  number  of  persons  the  protection  from  vaccinia  in  infancy  is 
permanent,  while  in  others  it  gradually  diminishes,  and  after  the  lapse 
of  a  number  of  years  frequently  disappears  entirely.  This  fact  has 
been  determined  by  noting  the  large  number  of  persons  in  adolescent 
and  adult  life  Avho  are  susceptible  of  revaccination  ;  also  by  observing 
that  in  all  epidemics  of  smallpox  a  large  proportion  of  the  cases  occur 
among  persons  who  were  vaccinated  in  infantile  life.  The  statistics  of 
smallpox  hospitals  in  this  country  and  in  England  show  that  from  41 
to  78  per  cent,  of  the  admissions  are  post-vaccinal  cases.  It  is  very 
difficult  to  determine  the  proportion  of  persons  vaccinated  in  infancy 
that  fail  of  permanent  protection,  but  it  is  believed  to  be  not  far  from 
75  per  cent.  Some  years  ago  a  very  careful  observation  in  a  certain 
American  city  showed  that  of  2362  persons  revaccinated  with  reliable 
virus  (no  child  under  twelve  years  old  with  a  good  scar  being  in- 
cluded in  this  number),  77.1  per  cent,  were  susceptible  to  some  form 
of  vaccinia. 

AVe  have  no  means  of  ascertaining  the  age  or  period  of  life  at  which 
the  protection  from  vaccinia  in  infancy  is  liable  to  diminish  or  cease 
entirely,  except  by  applying  the  test  of  revaccination  or  by  noting  at 


566 


VACCINIA. 


what  age  after  primary  vaccination  any  considerable  nnraber  of  persons 
suifer  from  smallpox.  Data  tending  to  demonstrate  the  latter  may  be 
found  in  the  following  table  : 


Under  one 
year. 


One  to  seven 
years. 


Seven  to  four- 
teen years. 


Fourteen  years 
and  upward. 


Unvaccinated 

Vaccinated 

j  Unvaccinated 

Vaccinated  in  infancy — good  scars 

"  "  fair  scars  . 

"  "  poor  scars 

Total  number  vaccinated  . 

Unvaccinated 

Vaccinated  in  infancy — good  scars 

"  "  fair  scars  . 

"  "  poor  scars 

Total  number  vaccinated  . 

Unvaccinated 

Vaccinated  in  infancy — good  scars 

"  "  fair  scars  . 

,"  '  "  poor  scars 

Total  number  vaccinated  . 


Cases. 

Deaths. 

Percentage 
of  deaths. 

89 
2 

60 

67.41 

467 

221 

47.32 

11 
10 
15 
36 

242 

1 
1 

10. 
6.66 

2 

5.55 

72 

29.75 

55 
23 
59 

2 

2 
9 

3.63 

8.69 

15.25 

137 
1111 

13 

9.48 

693 

122 

96 

286 

62.37 

1406 

664 

1027 

8.67 
14.45 

27.84 

3097        504 


16.27 


Among  the  5321  cases  of  smallpox  admitted  to  the  Municipal  Hos- 
pital of  Philadelphia  since  the  institution  has  been  under  the  writer's 
care,  now  exactly  twenty  five  years,  only  two  vaccinated  patients  under 
one  year  old  were  admitted.  One  of  these  was  a  child  eleven  months 
old  who  had  been  vaccinated  two  months  previously  and  showed  a  good 
scar.  The  eruption  consisted  of  only  six  small  vesicles,  and  the  child's 
health  was  scarcely  disturbed.  The  other  patient  had  the  disease  so 
indistinctly  marked  that  it  was  almost  impossible  to  feel  certain  of  the 
diagnosis  of  varioloid.  An  exceedingly  modified  form  of  smallpox  was 
occasionally  seen  among  well  vaccinated  children  between  tlie  ages  of 
one  and  seven  years,  but  no  deaths  occurred  except  when  there  was  a 
serious  complication.  The  child  that  died,  whose  case  is  classified 
under  the  head  of  "fair  scars,"  was  a  foundling  about  a  year  old, 
badly  nourished  and  very  feeble,  wdth  a  disordered  digestion.  The 
eruption  consisted  of  only  a  very  few  small  vesicles.  Death  really 
resulted  from  inanition.  Very  little  need  be  said  of  the  cases  classified 
in  this  age-period  under  the  head  of  "  poor  scars,"  as  the  vaccination  in 
them  had  been  in  good  part  either  imperfect  or  spurious. 

Between  the  ages  of  seven  and  fourteen  years  it  is  found  that  the  post- 
vaccinal cases  increased  considerably,  and  occasionally  death  occurred, 
even  when  the  infantile  vaccination  was  quite  thorough.  At  fourteen 
years  of  age,  or  the  period  of  puberty,  and  thereafter,  the  protection  is  apt 
to  diminish,  and  often  disappears  entirely.  These  facts  lead  to  the  con- 
clusion that  when  there  is  danger  of  exposure  to  smallpox  all  vaccinated 
children  who  have  reached  the  age  of  seven  years  should  be  revaccinated  : 
also  that  re  vaccination  should  be  practised  systematically  at  the  age  of 
puberty  whether  smallpox  be  present  or  not.  When  the  primary  vac- 
cination is  not  done  until  the  child  is  seven  or  eight  years  old,  the  pro- 


REVA  C(  'fX.  I  TfON.  567 

toction  is  more  likely  to  he  penuaneiit ;  still,  it  is  advisable  to  sui)je<'t  sueh 
cliildreii  to  the  test  of  revaceinatioii  at  tlu;  period  of  life  just  mentioned. 
The  writer  believes  that  it  may  be  laid  down  as  a  rule  that  if  a  ehild  l)e 
successfidly  vaccinated  in  infancy,  and  auain  at  the  atic  of  puberty,  the 
protection  will  be  permanent.  The  exceptions  to  this  rule,  however, 
niav  be  sufficient  to  warrant  a  repetition  of  the  vaccination  whenever 
there  is  great  danger  of  variolous  infection. 

The  question  is  often  asked,  What  constitutes  a  successful  revaccinij- 
tion  ?  This  is  a  question  about  which  there  is  some  diversity  of  opinion. 
Many  believe  that  unless  the  vesicle  and  areola  observe  the  coui-se  of 
true  vaccinia  the  effect  is  merely  local  and  devoid  of  prophylactic 
power.  But  it  is  evident  on  a  little  reflection  that  th(>re  is  no  more 
reason  why  we  should  expect  the  vaccine  disease  produced  by  revaccina- 
tion  to  be  typical  than  that  we  should  expect  smallpox  after  vaccina- 
tion to  run  the  typical  course  of  variola  vera.  If  there  be  modified 
smallpox  or  varioloid  after  vaccination,  so  should  there  be  modified 
vaccinia  or  vaccinoid.  From  these  premises  the  conclusion  may  be 
deduced  that  as  varioloid  confers  immunity  against  a  recurrence  of 
smallpox,  so  also  does  the  modified  form  of  vaccinia  resulting  from 
revaccination  remove  from  the  individual  whatever  suscei)tibility  to 
the  disease  may  be  present. 

As  to  the  value  of  revaccination  there  can  be  no  question.  Bousquet 
savs  very  truly  that  there  never  has  been  an  epidemic  of  smallpox  since 
the  general  employment  of  Jenner's  discovery  which  has  not  proved  the 
virtues  both  of  vaccination  and  revaccination.  He  adds  :  "  The  success 
of  revaccination  is  at  the  same  time  the  effect  and  proof  of  the  wants 
■  of  the  system  ;  .  .  .  .  when  it  succeeds,  it  not  only  proves  that  the 
protective  power  of  vaccination  is  diminished,  but  it  supplies  a  remedy 
for  this  diminution."  Among  the  earliest  and  most  conclusive  proofs 
of  the  value  of  revaccination  are  the  statistics  furnished  by  the  AViirtem- 
berg,  Bavarian,  and  especially  the  Prussian  armies.  Of  14,284  revac- 
cinated  soldiers  in  AViirtemberg,  only  1  case  of  smallpox  occurred  in 
five  years;  and  only  3  among  26,964  revaccinated  civilians.  During 
three^  severe  epidemics  in  Copenhagen  not  a  single  case  of  varioloid 
occurred  among  persons  who  had  been  revaccinated.  Also,  during  a 
very  malignant  epidemic  which  a  number  of  years  ago  nearly  decimated 
Li^ge  it  is  said  that  none  of  those  who  underwent  revaccination  suffered 
from  the  disease. 

Perhaps  the  mos!  conclusive  proof  of  all  is  that  found  in  the  statis- 
tics of  smallpox  hospitals.  After  an  experience  of  thirty  years  in  the 
hospital  of  London,  Marson  stated  that  but  few  patients  were  admitted 
during  that  time  who  had  been  revaccinated  with  effect,  and  that  these 
suffered  from  varioloid  in  a  very  mild  form.  During  this  long  service 
it  was  his  custom  to  revaccinate  all  the  nurses  and  sei'vants  who  had  not 
had  smallpox  on  their  coming  to  live  at  the  hospital,  and  not  one  of 
these  contracted  the  disease.  At  a  time,  however,  when  a  large  number 
of  w^orkmen  were  employed  about  the  hospital  most  of  them  consented 
to  be  revaccinated,  but  there  were  a  few  that  declined  ;  of  the  latter  two 
took  smallpox,  while  of  the  former  all  escaped.  During  the  writer's 
experience  of  twenty-five  years  no  resident  physician,  nurse,  nor  any 
other   employe   of  the  Municipal  Hospital  of  Philadelphia  who  had 


568  VAOCimA. 

been  revaccinated  before  commencing  duty  has  suffered  from  small- 
pox. Perhaps  an  exception  should  be  made  in  the  case  of  a  female 
nurse  who  was  revaccinated  on  the  day  of  commencing  work,  and  in 
whom  the  vaccine  disease  was  almost  typical.  In  the  course  of  about 
two  weeks  one  or  two  variolous  vesicles  appeared  on  her  forehead  near 
the  edge  of  her  hair.  Preceding  this  symptom  there  had  been  very 
slight  febrile  reaction  for  a  day  or  two,  but  she  was  at  no  time  incapaci- 
tated from  performing  her  usual  duties. 

As  the  limits  of  this  article  will  not  permit  of  a  more  extended 
resume  of  the  evidence  in  support  of  revaccination,  the  writer  must 
conclude,  believing  that  the  testimony  in  its  favor  already  adduced 
is  too  strong  to  admit  of  its  neglect.  In  view  of  all  the  accumulated 
facts  in  favor  of  vaccinal  protection,  it  does  not  seem  entirely  visionary 
to  assume  that  if  vaccination  were  efficiently  performed  in  infancy  and 
systematically  repeated  at  the  age  of  puberty,  if  not  earlier,  Jenner's  so 
called  dream — that  vaccination  is  capable  of  extirpating  smallpox  from 
the  earth — would  verily  become  a  realization.  But  whether  this  agent 
will  ever  be  so  universally  and  wisely  employed  as  to  confer  on  mankind 
its  greatest  possible  benefit  is  doubtful. 


VARICELLA. 

Bv  WILLIAM  .M.  WELCH,  M.  D. 


Synonyms. — English,  Chickenpox,  Waterpock,  or  Glasspock  ;  Ger- 
man. AVasserpoc'ken,  Windblattern,  or  Schafpocken  ;  Frencli,  La  Yero- 
lette  nr  Verricelle  ;  Latin,  Yarioki  notha  .-^eu  spuria  ;  Italian,  Rava- 
glione. 

Definition. — Varicella  is  a  contagious  eruptive  disease,  occurring 
chiefly  in  childhood,  characterized  by  slight  fever  of  short  duration,  and 
rapidly  developing  vesicles  which  begin  to  desiccate  on  the  fourth  or 
fifth  day,  leaving  occasionally  persistent  scars. 

HiSTOKY. — Xo  clear  or  exact  description  of  varicella  appears  to 
have  been  given  by  writers  previously  to  the  seventeenth  century, 
although  the  disease  was  evidently  known  before  that  time.  Rhazes 
described  a  mild  eruptive  affection  resembling  smallpox,  but  which  gave 
no  protection  against  that  disease.  This  affection  was  doubtless  vari- 
cella. The  first  accurate  description  of  the  eruption  of  varicella  was 
given  by  Riverius  in  1646.  Still  later  in  the  same  century  Morton  also 
called  attention  to  the  disease,  and  stated  that  it  was  vulgarly  called 
chickenpox  in  England.  But  these  and  other  authors  of  that  period, 
while  recognizing  something  peculiar  about  this  affection,  regarded  it 
as  an  exceedingly  mild  form  of  smallpox.  The  credit  of  first  calling 
attention  to  the  fact  that  variola  and  varicella  are  different  diseases, 
each  resulting  from  a  distinct  contagium,  belongs  to  Heberden  of  Eng- 
land. His  classic  paper  on  this  subject  was  published  in  1767  in  the 
first  volume  of  the  Transactions  of  the  Koyal  College  of  Physicians  of 
London,  and  was  long  regarded  as  the  standard  work  on  varicella. 
Although  Heberden  believed  in  the  specific  nature  of  this  malady, 
yet  he  called  it  varioke  pusUke.  The  term  varicella  did  not  come 
into  general  use  until  after  1770,  when  universal  attention  was  directed 
to  the  disease  ;  but,  strange  to  say,  it  was  not  until  the  early  part  of  the 
present  century  that  the  individuality  of  varicella  was  generally  recog- 
nized. In  1820,  however,  Thomson  of  Edinburgh,  and  still  later  Hebra, 
the  celebrated  professor  of  dermatology  in  the  Vienna  L^niversity,  re- 
vived the  exploded  doctrine  of  its  identity  with  smallpox.  But  not- 
withstanding the  great  Meight  of  Hebra's  authority-  and  the  persistency 
with  Mhich  he  advocated  this  doctrine,  he  has  not  succeeded  in  creat- 
ing doubt  in  the  minds  of  any  considerable  number  of  clinicians  and 
authors.  Nothing,  indeed,  is  easier  than  to  prove  that  his  teaching  in 
regard  to  the  relation  of  these  diseases  is  erroneous. 

Etiology. — Varicella  is  a  disease  almost  peculiar  to  early  childhood. 
The  vast  majority  of  cases  occur  between  the  ages  of  one  and  ten  years. 
L^nlike  measles  and  scarlet  fever,  but  quite  similar  to  variola,  chicken- 

569 


570  VARICELLA. 

pox  not  infrequently  attacks  infants  at  the  breast  under  six  months  of 
age.  Some  authors  believe  that  the  susceptibility  to  the  disease  dimin- 
ishes after  the  tenth  year  and  ceases  entirely  after  puberty.  Thomas 
of  Leipzig  thinks  that  this  may  be  the  correct  explanation  of  the  very 
infrequent  occurrence  of  the  disease  among  older  children  and  adults. 
He  says  he  never  saw  an  adult  suffer  from  varicella.  There  is  no  doubt, 
however,  that  the  disease  is  by  no  means  uncommon  among  persons  in 
mature  life.  This  fact  is  amply  attested  by  the  experience  of  those  who 
are  connected  with  hospitals  for  infectious  diseases.  Attacks  in  adult 
life  would  doubtless  be  far  more  frequent  were  it  not  that  in  the  vast 
majority  of  persons  the  susceptibility  is  destroyed  by  the  occurrence  of 
the  disease  in  early  childhood.  The  aifection  rarely  if  ever  occurs  more 
than  once  in  the  same  individual.  I  believe  I  have  never  known  a 
person  to  suffer  from  a  second  attack  of  varicella.  Trousseau,  however, 
says  that  second  attacks  are  not  uncommon. 

Like  all  acute  exanthemata,  varicella  at  times  appears  sporadically, 
and  then  again  it  prevails  in  epidemic  form.  It  is  hardly  ever  entirely 
absent  in  large  cities.  The  seasons  do  not  influence  its  prevalence,  ex- 
cept that  the  opening  of  kindergartens  and  schools  in  the  fall  of  the 
year  often  marks  the  beginning  of  moderate  epidemics.  The  epidemics 
never  assume  the  proportion  or  intensity  of  those  of  variola  and  scarlet 
fever,  but  are  frequently  so  mild  as  scarcely  to  attract  the  attention  of 
physicians.  While  smallpox  is  often  absent  in  a  community  for  several 
years  at  a  time,  at  least  where  vaccination  is  carefully  and  systematically 
performed,  varicella  is  met  with  annually,  especially  in  thickly  populated 
districts.     Unlike  smallpox,  its  spread  is  not  limited  by  vaccination. 

The  cause  of  varicella  is  a  peculiar  contagium.  It  must  be  admitted 
that  nothing  definite  is  known  in  regard  to  the  nature  of  the  specific 
virus,  but  there  is  no  doubt  that  it  owes  its  specificity  to  a  micro-organ- 
ism. The  infecting  agent  enters  the  system  doubtless  through  the  re- 
spiratory tract.  From  what  is  known  of  variola,  one  would  suppose 
that  the  infecting  principle  of  varicella  should  be  present  in  the  vesi- 
cles, yet  it  is  questionable  whether  the  disease  has  ever  been  communi- 
cated by  inoculation.  While  a  very  few  positive  results  have  been 
reported  by  Hesse  and  Steiner,  negative  results  have  followed  the  very 
careful  attempts  at  inoculation  by  such  men  as  Heim,  Vetter,  Czakert, 
Fleischmann,  Thomas,  and  Boyce  of  Europe,  and  J.  Lewis  Smith  of 
this  country. 

The  period  of  incubation  in  varicella  is  perhaps  more  variable  than 
in  the  other  exanthemata.  AVhile  it  is  often  difficult  to  fix  exactly  the 
time  when  the  contagium  enters  the  system  in  any  given  case,  yet  it  has 
been  found  that  when  the  disease  breaks  out  in  a  private  family  or  an 
institution  for  children  the  time  that  elapses  between  the  appearance 
of  the  eruption  in  the  first  and  second  cases  is  usually  from  thirteen  to 
seventeen  days.  This  may  therefore  be  regarded  as  about  the  usual 
period  of  incubation,  although  a  much  shorter  period  has  been  reported 
by  some  observers. 

It  is  evident  from  these  considerations  that  there  is  a  wide  difference 
etiologically  between  varicella  and  variola — so  wide,  indeed,  as  to  afford 
of  itself  conclusive  proof  that  the  diseases  are  essentially  different. 
Most  conclusive   in   favor   of  this   opinion  are  the  facts  that  varicella 


/'.  I  TlIOLOaiCAL  A SA  TOMY.  571 

of't(Mi  ])i'ovails  ill  ('oiuinuiiitics  wlioiv  variola  is  absent  ;  that  the  con- 
ta*iiiun  of  varicella  never  ^ives  rise  to  variola  in  the  nnproteeted,  l)nt 
always  to  a  disease  presentinu;  the  same  eharactcristics  as  the  original 
atteotion ;  that  an  attack  of  varicella  confers  no  protection  aofainst 
snialli)ox,  nor  vice  vcrxCi ;  that  varicella  occurs  with  identical  synij)tonis 
and  equal  facility  amoni>-  the  vaccinated  and  unvaccinated  ;  and  that  vac- 
cination, however  recent  and  thorouuh,  does  not  destrov  the  susce])ti- 
bilitv  to  varicella. 

Patiiologk'AL  Anatomy. — The  only  pathological  condition  ])resent 
in  varicella  is  that  which  results  from  the  peculiar  exanthem.  The  lesions 
a]^pear  on  almost  every  part  of  the  body,  and  consist  of  vesicles  varv- 
ino-  ill  si/e  from  that  of  a  millet  seed  to  a  silver  dime.  They  develop 
rapidly  upon  hyperjomic  spots,  which  are  but  slightly  if  at  all  infil- 
trated. The  deeper  layers  of  the  derm  ai'c  usually  not  involved,  dilfer- 
ing  in  this  respect  from  the  lesions  of  variola.  The  vesicles  begin  to 
form  in  the  centres  of  the  hypersemic  spots  and  grow  by  peripheral 
extension  until  their  full  size  is  attained.  They  are  usually  surrounded 
by  an  areola  which  is  frequently  quite  broad.  It  is  rare  that  the  initial 
hyjiememia  is  present  longer  than  a  few  hours  before  the  vesicles  liegin 
to  form. 

Undoubtedly  the  lesions  are  exudative  in  character.  As  the  exuda- 
tion of  serum  takes  place  in  these  morbid  areas  the  superficial  epi- 
dermic layer  is  raised  from  the  deeper  layers  of  the  derm,  and  thus  a 
distinct  vesicle  is  formed.  Varicella  not  being  a  fatal  disease,  opportu- 
nities for  carefully  investigating  the  anatomical  structure  of  the  vesicle, 
as  displayed  in  sections,  do  not  occur.  There  is  reason  to  believe,  ho^v- 
ever,  that  the  vesicle  is  not  originally  a  single  cell,  but  contains  delicate 
septa  dividing  it  into  compartments.  These  septa  or  partition  walls  not 
infrequently  give  way  at  an  early  stage  of  the  exudative  process,  per- 
mitting the  contents  of  the  vesicle  to  run  partly  or  wholly  together. 
Owing,  doubtless,  to  the  superficial  character  of  the  vesicles  and  the 
rapidity  and  profuseness  of  the  exudation,  the  umbilication  so  common 
in  variola  never  occurs. 

The  vesicles  at  first  contain  a  serous  fluid  as  clear  as  water.  Later, 
owing  to  the  slight  admixture  of  pus  cells,  this  fluid  assumes  an  opales- 
cent or  whey-like  appearance.  In  those  vesicles  which  run  a  more  pro- 
tracted course  the  proportion  of  pus  cells  is  greater,  but  not  so  great  as 
in  the  pustules  of  variola.  The  contents  are  usually  slightly  alkaline  in 
reaction.  The  duration  of  the  vast  majority  of  the  vesicles  is  brief. 
Either  from  partial  absorption  of  their  contents  or  some  mechanical 
cause,  such  as  rubbing  or  scratching,  the  vesicles  collapse,  and  desicca- 
tion begins  when  the  process  has  not  continued  longer  than  two  or 
three  days.  In  the  undisturbed  vesicles  desiccation  usually  commences 
in  their  centres,  giving  rise  to  a  depression  that  is  sometimes  mistaken 
for  umbilication.  In  the  milder  cases  the  scabs,  which  are  small,  fall 
off  quickly,  and  are  not  followed  by  scars.  But  when  the  course  of  the 
vesicles  is  ])rolonged  there  is  sometimes  destruction  of  the  lower  layers 
of  the  derm,  and  permanent  scars  result.  The  number  of  scars  from 
an  attack  of  varicella,  however,  is  never  very  large.  The  mucous 
membrane  of  the  mouth  and  fauces  suffers  only  very  moderately  from 
the  eruptive  process. 


672 


VARICELLA. 


Symptoms. — The  stage  of  incubation  of  varicella  is  seldom  attended 
by  symptoms.  In  the  majority  of  cases  the  first  symptom  noticed  is 
the  appearance  of  the  vesicles.  This  is  not  only  the  testimony  of  care- 
ful and  observing  mothers,  but  has  been  confirmed  by  medical  observa- 
tion iji  institutions  where  opportunities  have  been  afforded  to  witness 
outbreaks  of  the  disease.  Occasionally,  however,  there  may  be  seen  a 
short  initial  or  precursory  stage  of  not  more  than  a  few  hours'  dura- 
tion ;  but  even  in  such  cases  the  febrile  reaction  is  usually  insignificant, 
as  the  temperature  is  not  apt  to  rise  higher  than  one  or  two  degrees 
above  the  normal  point.  Exceptional  cases  sometimes  occur  among 
children  in  whom  the  onset  of  the  disease  is  marked  by  slight  rigors, 
considerable  elevation  of  temperature,  moderate  headache,  and  vomit- 
ing. I  have  reason  to  believe  from  my  experience  that  such  a  pre- 
cursory stage  is  not  uncommon  in  adults. 

If  a  case  of  varicella  be  carefully  examined  at  the  very  earliest  stage 
of  the  eruption,  the  skin  lesions  will  be  found  to  consist  of  small  roseo- 
lar  spots.  According  to  some  writers,  these  spots  appear  first  on  the 
hairy  scalp,  face,  and  neck,  but  not  infrequently  they  may  be  seen  quite 
as  early,  or  even  earlier,  on  the  trunk  and  extremities.  A  very  favorite 
locality  is  the  back.  They  are  of  the  nature  of  maculae  rather  than 
papulae,  and  hence  do  not  convey  to  the  sense  of  touch  the  feeling  of 
denseness  or  firmness,  as  do  the  papulae  of  variola.  In  the  course  of  a 
very  few  hours  distinct  vesicles  appear  in  the  centres  of  these  reddish 
puncta  or  rose-colored  spots.  These  vesicles  at  first  contain  perfectly 
clear  serum,  and  do  not  look  unlike  small  blisters  resulting  from  a 
moderate  sprinkling  of  the  skin  with  boiling  water. 


Fig.  48. 


Varicella  on  the  fifth  day  of  eruption. 

AVhile  the  contents  of  the  vesicles  at  first  is  perfectly  clear  or  trans- 
parent, it  very  soon  assumes  a  turbid  or  milky  appearance  from  the 
admixture  of  pus  cells ;  but  it  never  becomes  so  distinctly  purulent  as 
in  variola.  The  vesicles  vary  very  greatly  in  size.  The  average  size 
IS  that  of  a  split  pea,  though  some  of  them  become  as  large  as  a  silver 
dime,  or  even  much  larger,  while  others  remain  as  small  as  lentil  seed. 
They  do  not  all  appear  at  once,  but  come  out  in  successive  crops.  That 
is  to  say,  soon  after  the  first  vesicles  have  appeared  there  may  be  seen 
on  the  skin  faint  red  points  which  rapidly  develop  into  vesicles,  and 


COMI'L  U  'A  TIOSS.  573 

SO,  a^'iiin,  rt).sc'(.)la  iiiul  \cr-iclr.-  appear  hilwecu  i\\v<v  Ic.-ion.-.  Many  ol" 
the  vesicles  have  but  a  brief  existence,  and  it  is  therefore  not  unusual 
to  find  them  in  every  possible  sta<re  of  develoj)nient.  For  example, 
when  the  eriij)tion  has  fully  appeared  some  of  the  older  vesicles  may 
be  seen  in  a  state  of  desiccation,  while  otiiers  have  colla[>scd  and  are 
drying,  and  still  others  remain  distended  by  sero-j)uridcnt  Huid. 

The  vesicles  are  either  acuminate  or  ol(>])ular  in  form.  They  never 
assume  that  peculiar  form  of  umbilication  which  is  so  characteristic  of 
the  eruption  of  variola.  It  is  true  when  the  vesicles  are  fully  developed 
very  many  have  a  dc])ression  in  tlieir  centres,  but  this  depression  is  the 
result  of  commencing-  desiccation,  rather  than  that  their  epidermic  cover- 
ing is  held  down  by  sweat  glands  or  their  follicles,  as  in  variola. 

The  vesicles,  as  already  stated,  usually  run  a  very  rapid  C(jurse. 
Within  a  day  or  two  after  they  are  first  seen  many  of  the  vesicles  will 
be  found  to  have  grown  flaccid,  either  from  partial  absorptif»n  of  their 
contents  or  rupture  of  their  epidermic  covering,  and  when  in  this  con- 
dition they  speedily  dry  up  and  disappear,  sometimes  without  the  for- 
mation of  scabs.  In  those  M'hich  do  not  disappear  in  this  way  desicca- 
tion begins  usually  in  their  centres.  Even  Avhen  desiccation  has  thus 
begun  it  is  not  unusual  for  several  of  the  vesicles  to  continue  to  enlarge 
by  peripheral  extension  until  they  attain  the  circumference  of  a  silver 
dime,  and,  in  some  cases,  that  of  a  silver  quarter  dollar.  Tliese  larger 
vesicles  usually  reach  their  utmost  limit  of  development  M-ithiil  a  period 
of  four  or  five  days,  then  begin  to  fade,  but  the  scabs  which  form  are 
often  so  firmly  attached  that  they  do  not  fall  oif  spontaneously  before 
the  end  of  the  second  week.  After  the  scabs  have  fallen  there  commonly 
remains  upon  the  site  of  the  vesicles  slight  pigmentation  of  the  skin, 
but  this,  in  most  eases,  gradually  fades  away  without  leaving  permanent 
scars.  It  is  only  in  those  vesicles  which  run  a  protracted  course  and  are 
accompanied  by  ulcerative  action  that  scar  formation  results.  There- 
fore, when  scars  result  at  all  they  are  few  and  scattered ;  never  do  they 
follow  so  large  a  proportion  of  the  vesicles  of  varicella  as  they  do  pus- 
tules of  variola. 

The  mucous  membrane  is  only  very  moderately  attacked  in  varicella. 
Small  and  ill-defined  vesicles  may  be  seen  on  the  soft  and  hai'd  palate, 
the  tongue,  the  mucous  membrane  of  the  buccal  cavity  and  of  the 
nares.  When  they  occur  in  these  parts  they  are  always  sparse,  and 
rarely  extend  to  the  larynx  and  trachea.  They  sometimes  appear  on 
the  mucous  membrane  of  the  external  genitalia  of  girls  or  on  the 
prepuce  of  boys,  and  make  urination  painful.  I  have  never  known 
the  vesicles  to  appear  on  the  conjunctiva;  occasionally,  however,  they 
may  be  seen  on  the  margin  of  the  eyelids  and  slightly  affect  the  con- 
junctiva  at   its  continuity  with  the  skin. 

Complications. — Complications  rarely  occur,  and  sequelse  are  quite 
unknown.  A  peculiar  form  of  gangrene  of  the  skin  has  been  met  with, 
especially  in  Ireland.  Dr.  Whitley  Stokes  of  Dublin  described  this 
affection  in  1807,  and  applied  to  it  the  name  pemphigus  gangrcpnosus. 
It  has  also  been  described  by  various  other  writers  as  dermatitis  gcin- 
gnenosa.  More  recently  (in  1881)  Mr.  Jonathan  Hutchinson  called 
attention  to  this  dangerous,  though  fortunately  rare,  complication, 
and    proposed    for  it  the  name    varicella   gangrenosa.     It    is  not  im- 


574  VARICELLA. 

probable  that  this  malady  is  met  with  only  in  children  having  a 
tendency  to  the  development  of  so  called  spontaneous  gangrene.  It 
is  said  to  occur  more  frequently  among  weakly  and  ill  nourished 
children,  though  it  is  not  confined  to  them.  A  very  clear  descrip- 
tion of  the  disease  has  been  given  by  Dr.  Eustace  Smith.  He  says  :  ^ 
"  In  gangrenous  varicella  the  vesicles,  instead  of  drying  up  in  the 
ordinary  way,  become  black  and  get  larger,  so  that  a  number  of 
rounded  black  scabs,  with  a  diameter  of  half  an  inch  to  an  inch,  are 
scattered  over  the  surface  of  the  body.  If  a  scab  be  removed,  it  is  seen 
to  cover  a  deep  ulcer.  Around  it  the  skin  is  of  a  dusky  red  color.  All 
the  vesicles  do  not  take  on  the  gangrenous  action,  so  that  we  find  many 
varicellous  scabs'  of  ordinary  appearance  mixed  up  with  the  blackened 
crusts.  The  gangrenous  process  often  penetrates  deeply  through  the 
skin  to  the  muscles,  but  under  some  of  the  scabs  the  ulceration  is  more 
shallow.  These  cases  are  very  fatal.  Mr.  Warrington  Haward  has 
reported  the  case  of  a  weakly  baby  twelve  months  old  who  weighed 
onlv  six  pounds  and  a  half.  The  child  was  attacked  with  gangrenous 
varicella  and  died  in  a  few  days  of  pyaemia,  with  secondary  abscesses  in 
the  lungs."  Cases  have  also  been  reported  in  which  gangrene  attacked 
the  scrotum,  and  proved  almost  as  destructive  to  that  tissue  and  as  fatal 
to  the  patient  as  when  the  same  complication  occurs  in  variola. 

Diagnosis. — Eczema  pustulosum  and  impetigo  contagiosa  have  been 
thought  l)y  some  to  resemble  varicella,  but  the  points  of  resemblance 
are  so  slight  as  rarely  to  introduce  into  the  question  of  diagnosis  an 
element  of  confusion.  The  only  disease  with  which  varicella  is  liable 
to  be  confounded  is  smallpox  in  some  of  its  varieties. 

There  is  usually  no  difficulty  in  diiferentiating  between  variola  vera 
and  varicella,  but  between  the  latter  disease  and  certain  forms  of  vario- 
loid the  difficulty  is  often  very  great  and  mistakes  are  not  uncommon. 
The  teaching  of  most  authors  that  varicella  is  a  disease  peculiar  to 
childhood  is,  I  think,  responsible  for  many  errors  of  diagnosis,  inas- 
much as  it  tends' to  create  a  belief  that  in  adults  eruptions  resembling 
varicella  always  indicate  smallpox.  It  should  be  borne  in  mind  that 
the  former  disease  is  by  no  means  infrequent  in  adolescence  or  in 
adult  life. 

It  ^vill  often  prove  helpful  to  know  whether  or  not  the  patient  has 
ever  been  vaccinated.  When  a  vesicular  eruption  suddenly  appears  in 
a  child  who  has  recently  been  successfully  vaccinated,  variola  can  be 
excluded  from  the  question  of  diagnosis  with  a  considerable  degree  of 
certainty.  So  also  variola  can  be  reasonably  excluded  when  such  an 
eruption  appears  in  an  unvaccinated  child  without  having  been  preceded 
by  severe  constitutional  symptoms,  such  as  are  peculiar  to  the  initial 
stage  of  that  disease.  In  children,  however,  older  than  ten  years,  and 
also  in  adults  who  have  been  vaccinated  in  infancy,  the  variolous  erup- 
tion is  often  so  greatly  modified  as  to  bear  considerable  resemblance  to 
the  lesions  of  varicella.  It  is  this  class  of  cases,  in  which  the  eruption 
shows  no  distinct  characteristics,  that  not  unfrequently  taxes  to  the 
utmost  the  skill  of  the  diagnostician.  Although  difficult,  it  is  im- 
portant that  a  correct  diagnosis  should  be  made,  since  in  the  one  case 
the  contagium  generated  is  usually  innocent,  while  in  the  other  it  is  fre- 
1  Eustace  Smith,  Diseases  of  Children,  1884,  p.  49. 


DT A  GNOSIS.  575 

qiientlv  disnstrous  in  its  results.  Wlicii,  howovcr,  a  history  of  exposure 
to  either  <>t'  these  eontagia  can  l)e  obtained,  the  diagnosis  becomes,  of 
course,  e(iiii])ai"atively  easy. 

In  dilVerentiatinu-  between  variohi  and  varieelhi  it  is  very  important 
to  note  the  behavior  of  the  fever.  In  the  former  the  temperature 
suddenly  rises,  after  a  decided  chill  or  repeated  ri<;ors,  to  a  considerable 
elevation.  It  not  infrequently  rises  during  the  first  twenty-four  hours 
of  the  illness  to  105°  F.,  and  continues  high  four  or  five  days  or  until 
the  eruj)tion  has  fully  appeared.  In  varicella  the  temperature  rarely  or 
never  rises  so  high,  and  no  elevation  is  usually  noticed  at  all  until  the 
vesicles  have  appeared.  Even  in  modified  smallpox  or  varioloid  the 
temperature  is  apt  to  be  high  at  first,  and  this  symptom  almost  always 
precedes  the  eruption  from  two  to  four  days.  There  is  no  secondary  or 
suppurative  fever  in  varicella,  as  in  variola.  It  is  true  that  in  mild 
cases  of  varioloid,  which  variety  of  smallpox  varicella  more  closely  re- 
sembles, there  is  likewise  no  secondary  rise  of  temperature ;  hence  other 
points  of  differentiation  must  be  considered  in  such  cases. 

It  frequently  happens  in  smallpox,  especially  in  the  modified  forms 
of  the  disease,  as  well  as  in  varicella,  that  no  reliable  history  of  initial 
fever  can  be  obtained,  so  that  in  very  many  cases  the  diagnosis  must  be 
made  from  the  appearance  of  the  exanthem  alone.  It  is  therefore  im- 
portant to  bear  in  mind  that  the  exanthem  of  varicella  appears  at  first 
in  the  form  of  distinct  vesicles  containing  clear  serum  ;  that  they  are 
usually  seen  first  in  greatest  number  on  portions  of  the  body  covered  by 
clothing,  especially  on  the  back ;  that  they  make  their  appearance  in 
successive  crops,  and  vary  ver}'  greatly  in  size  ;  that  their  epidermic 
covering  is  delicate,  and  can  be  easily  broken  by  the  finger  nail ;  that 
manv  of  them  enlarge  by  peripheral  extension,  while  desiccation  is  seen 
in  their  centres,  causing  a  central  depression ;  that  they  run  their  course 
in  two  to  four  days,  and  form  thin,  brown  scabs ;  and  that  but  few  of 
them  are  follow^ed  by  permanent  scars.  On  the  other  hand,  the  exanthem 
of  smallpox  first  appears  in  the  form  of  papulae,  which  are  slowly  trans- 
formed into  vesicles,  and  then  into  pustules  ;  the  papulae  are  dense  and 
hard,  and,  to  the  sense  of  touch,  seem  like  grains  of  sand  buried  in  the 
cutis  ;  the  eruption  prefers  the  exposed  surface  of  the  body,  such  as  the 
face,  arms,  and  hands,  being  often  only  sparsely  seen  on  the  trunk ;  the 
lesions  usually  begin  on  the  face  and  are  slow  in  spreading  over  the 
body,  but  they  never  come  out  in  successive  crops ;  the  vesicles  are 
dense  and  firm,  especially  on  the  exposed  surface  of  the  skin,  and  can- 
not be  readily  obliterated  by  the  finger  nail  ;  they  do  not  vary  so 
greatly  in  size  as  in  varicella  ;  they  are  umbilicated  by  their  epider- 
mic covering  being  slightly  drawn  inward,  rather  than  by  desiccation 
commencing  in  their  centres  ;  the  exanthem  requires  from  six  to  twelve 
days  to  pass  through  its  various  stages,  and  ends  by  the  formation  of 
comparatively  thick,  dark  crusts  ;  and  most  of  the  lesions,  especially 
those  on  the  face  and  hands,  are  followed  by  permanent  scars. 

AVhile  the  s%Tnptoms  just  enumerated  are  peculiar,  respectively,  to 
chickenpox  and  smallpox,  and  while  there  should  be  no  difficulty  in 
diagnosticating  any  case  in  which  either  series  of  symptoms  is  complete, 
yet  it  must  be  admitted  that  there  are  intermediate  cases  in  which  the 
symptoms  are  so  at\q)ical  that  they  cannot  be  readily  assigned  to  either 


576  VARICELLA. 

category.  It  may,  however,  be  said,  in  a  general  way,  that  a  mildly 
febrile  exanthem  appearing  without  prodromal  symptoms,  being  dis- 
tinctly vesicular  from  the  beginning,  and  commencing  to  desiccate  on  the 
second  or  third  day,  should  be  regarded  as  varicellous  ;  and,  on  the  other 
hand,  an  acute  exanthem  preceded  by  an  initial  stage  in  which  the  tem- 
perature was  high,  beginning  as  papules  and  ending  in  vesicles  or  vesico- 
pustules,  even  though  the  period  of  evolution  be  short,  should  be  re- 
garded as  variolous.  At  any  rate,  it  would  be  wise,  for  the  safety  of 
the  public,  to  regard  such  a  case  as  suspicious.  If  it  should  happen  in 
a  case  in  which  the  diagnosis  cannot  be  clearly  determined,  that  vac- 
cination had  never  been  performed,  it  would  be  well  to  apply  this  test, 
for  it  is  well  known  that  variola  renders  an  individual  immune  to  vac- 
cinia, and  that  varicella  does  not. 

Prognosis. — The  prognosis  in  varicella,  even  in  infantile  life,  is 
uniformly  favorable.  The  disease  frequently  runs  so  mild  a  course  that 
the  family  physician  is  not  summoned,  or  perhaps  he  may  be  called  to 
decide  as  to  the  character  of  the  eruption  rather  than  to  prescribe  for 
the  patient.  A'^aricella,  per  se,  never  proves  fatal.  Some  concurrent 
affection  might  arise  to  threaten  the  life  of  the  patient,  but  no  compli- 
cation is  especially  liable  to  occur.  It  is  true,  gangrene  of  certain  parts 
of  the  cutaneous  integument  has  been  met  with  as  a  result  of  the  vari- 
cellous process,  but  this  is  apt  to  occur  only  in  children  with  some 
peculiar  tendency  to  gangrene.  The  appearance  of  such  a  compli- 
cation would  naturally  be  viewed  with  deep  concern. 

Treatment. — As  recovery  invariably  results  from  varicella,  but 
very  little  is  required  in  the  way  of  treatment.  The  patient  should  be 
confined  to  the  house,  and  even  to  the  bed,  for  a  few  days,  or  until  the 
fever  subsides  and  the  eruption  has  completed  its  course.  The  adop- 
tion of  proper  hygienic  measures,  such  as  regulating  the  temperature 
of  the  room,  providing  the  patient  with  suitable  diet,  and  giving  atten- 
tion to  bathing,  is  usually  all  that  is  required.  A  mild  diaphoretic  or 
febrifuge  mixture  may  be  given,  and  also  bromide  of  potassium  if  the 
child  be  restless  and  sleepless.  If  there  be  much  itching  or  irritation 
of  the  skin,  cocoa  butter  or  an  antiseptic  unguent  may  be  applied 
locally.  It  is  advisable  to  prevent  rubbing  or  scratching  of  the  vesi- 
cles, especially  those  on  the  face,  as  such  injury  increases  the  liability  to 
pitting.  The  disease  being  quite  innocent,  it  is  usually  unnecessary  to 
adopt  any  special  measures  to  prevent  its  spreading.  When  the  patient 
has  recovered  it  would  be  well  to  subject  the  bedchamber  to  the  ordi- 
nary process  of  housecleaning. 


SCARLET  fever; 

liv   p.   GERVAIS   ROBINSON,   M.D. 


Synonyms. — Scarlatina ;  Scarlet  rash  ;  Scharlach  (German) ;  Scar- 
latine  (French). 

Definition. — Scarlet  fever  is  an  acnte,  highly  infectious  disease,  due, 
we  may  fairly  believe,  to  the  presence  in  the  body  of  a  specific  organ- 
ism. Thougli  the  malady  presents,  in  its  clinical  manifestations,  more 
variations  than  any  other  exanthem,  there  are  certain  symptoms  which 
are  so  frequently  present  as  to  be  characteristic  :  there  is  a  punctiform 
scarlet  rash  upon  the  skin  which  terminates  in  a  lamellar  desquamation ; 
an  angina  which  is  usually  well  marked  ;  a  fever  of  varying  degree  ;  and 
a  noticeable  immunity  from  future  attacks. 

Etiology. — Scarlet  fever,  like  other  diseases  of  its  class,  has  ever 
followed  in  the  path  of  commerce.  It  seems  to  have  been  first  intro- 
duced into  this  country  in  1735.  From  the  coast  it  crept  inland  until 
all  the  inhabited  portions  of  the  land  were  affected.  It  is  curious  to 
note  that  scarlatina  when  introduced  into  a  virgin  soil  does  not  seem  to 
possess  the  same  virulence  which  is  displayed  by  measles  and  smallpox 
under  similar  conditions.  The  writers  who  first  described  the  disease 
in  the  United  States  regarded  it  as  a  mild  affection.  In  this  country, 
as  in  all  other  portions  of  the  civilized  world,  scarlet  fever  has  now 
become  endemic  in  the  large  cities ;  from  these  as  foci  from  time  to  time 
epidemics  arise. 

Periodicity. — Many  facts  have  been  adduced  to  sho^v  that  epidemics 
of  scarlatina  observe  periodicity,  but  so  many  exceptions  to  such  a  law 
can  be  cited  that  it  may  be  doubted  if  it  in  reality  exists. 

Peculiarities  of  Epidemics. — No  contagious  disease  varies  so  widely 
in  the  severity  of  the  various  epidemics  as  scarlet  fever.  Willan  speaks 
of  epidemics  differing  as  much  as  "  a  fleabite  and  the  plague."  Syden- 
ham thought  scarlatina  so  mild  an  affection  that  it  hardly  deserved 
the  name  of  a  disease.  Two  years  later  Morton  found  the  same  epi- 
demic exceedingly  severe.  In  the  epidemic  of  1863  in  London  one 
fourteenth  of  the  entire  death  rate  was  due  to  scarlet  fever.  In  Stutt- 
gart in  an  epidemic  which  occurred  in  1846  not  one  death  was  reported. 
Copland,  writing  in  1858,  said  :  "There  is  no  kind  of  fever  which  dis- 
plays a  greater  diversity  in  its  nature  and  complications,"  and  the  expe- 
rience of  all  observers  will  bear  out  this  statement. 

Season. — Although  scarlet  fever  is  present  in  large  cities  at  all 
seasons  of  the  year,  it  is  generally  most  prevalent  in  the  autumn  and 
winter. 

^  In  the  preparation  of  this  article  tlie  writer  begs  to  express  his  obligations  to  Dr. 
C.  F.  Hersman  for  valuable  assistance. 

Vol.  I. — 37  577 


578 


SCARLET  FEVER. 


Below  is  presented  a  table  showing  the  number  of  cases  and  deaths 
in  the  city  of  St.  Louis  for  the  past  four  years  : 

For  Municipal  Year  ending  March  31,  1890. 


April  .  . 
May  .  . 
June  .  . 
July  .  . 
August  .  . 
September 
October 
November 
December 
January  . 
February  . 
March 


Cases.       Deaths. 

Cases.      Deaths. 

April 

May 

June 

July 

August 

69             8 

97            9 

102           11 

81             3 

144          10 

172            4 

October 

November 

December 

January     

February  

March 

258           21 
253          15 
237          18 
171          10 
141            3 
157            8 

September 

Total 

1882         120 

Total 


Year  of  1891 :         Year  of  1892 :  Year  of  1893 :  Year  of  1894 : 

Cases.       Deaths.    Cases.      Deaths.    Cases.      Deaths.    Cases.      Deaths. 


103 
142 
115 

82 
114 
114 

99 
119 
135 
125 

99 

89 


12 
6 
4 
8 
6 
5 
7 

16 
4 


1336 


94 


69 
73 
59 
44 
66 
71 
74 
83 

139 
94 

113 
63 


6 
3 

2 

6 

5 

7 

15 

16 

12 

23 

6 


948    109 


60 

65 

86 

50 

60 

108 

156 

128 

109 

91 

66 

77 


5 
13 
12 
13 
9 
5 
22 
13 
24 
25 


1056 


153 


84 
75 
41 
19 
45 
61 
65 
64 
75 
87 
57 
56 


731 


55 


A  reference  to  this  table  shows  that,  though  scarlet  fever  has  been  dis- 
tributed throughout  the  seasons  of  the  year  with  more  uniformity  than 
has  often  been  observed  elsewhere,  yet  the  preponderancy  of  cases  in 
autumn  and  winter  is  preserved.  Many  writers  have  attempted  to  show 
that  this  seasonal  prevalence  is  dependent  on  the  temperature,  moisture, 
electrical  conditions,  amount  of  ozone  present,  etc.,  but  the  proofs  of 
such  relations  at  present  rest  on  the  vaguest  grounds.  It  may  be  that 
when  the  cause  of  scarlatina  is  better  known  something  in  its  life  his- 
tory will  explain  this  fact.  In  the  mean  time,  certain  factors  may  be 
■cited  as  partial  explanation.  In  the  autumn  and  winter,  in  our  climate, 
the  surface  of  the  body  is  exposed  to  frequent  chillings,  among  the  poor 
often  for  long  periods,  and  with  them  sufficient  food  is  more  difficult  to 
obtain  at  these  seasons  than  at  other  times  of  the  year.  Fodor  has 
found  that  some  bacteria  introduced  into  animals  reduced  by  hunger 
and  cold  are  more  apt  to  thrive  than  when  inoculated  upon  the  same 
animals  in  good  condition.  Furthermore,  in  the  autumn  and  winter 
lesions  of  the  respiratory  mucous  membrane  are  especially  frequent,  and 
it  is  probable  that  the  poison  of  scarlatina  usually  enters  the  body  by 
inhalation  Then  at  this  time  of  the  year  there  are  more  oj)portunities 
for  personal  contact  among  children,  especially  by  confinement  in  schools 
with  large  numbers  of  other  children.  Hershey^  states  that  70  per 
cent,  of  scarlet  fever  cases  come  from  infection  at  school. 

As  might  be  expected,  scarlet  fever  generally  shows  the  highest 
mortality  in   those   years   when   the   most   widespread   epidemics   are 

1  Medical  News,  April  22,  1894. 


ETIOLOUY.  579 

pri'st'iit,  and  at  those  seasons  of  the  year  when  cases  are  most  nunier- 
ons.  Bnt  here,  a<i'ain,  the  disease  shows  a  wonderf'nl  variahility.  It 
not  nneoninionly  liapjn'ns  tliat  (hn'in<>;  an  extensive  epidemic  tlie  rela- 
tive mortality  is  less  than  in  ordinary  years,  and,  as  Hehra  has  shown, 
it  will  often  happen  that  the  malady  is  as  intense  at  one  season  as  at 
another.  This  may  be  illnstrated  from  the  table  of  the  mortality  of 
scarlet  fever  in  St.  Lonis,  ji:iven  above.  In  1890  there  was  the  greatest 
nnmber  of  eases,  with  a  mortality  of  G.'>  ])er  cent.,  while  in  1894  there 
M'as  a  small  number  of  eases,  with  a  mortality  of  7.5  per  cent. 

Age. — Scarlet  fever  is  essentially  a  disease  of  childhood.  Though  no 
age  is  exempt,  the  majority  of  cases  occur  in  the  first  ten  years  of  life. 
After  this  the  liability  to  contract  the  disease  decreases  rapidly  with 
each  succeeding  decade.  The  liability  to  attack  is  at  its  height  in  the 
fifth  year.  The  report^  of  the  Registrar  General  of  England  for  1886 
contains  so  much  of  value  in  this  connection  that  it  is  here  reproduced. 
The  report  is  based  upon  nearly  half  a  million  deaths  from  scarlatina 
occurring  in  England  and  Wales  from  1859  to  1885 ;  on  17,795  cases 
admitted  during  1874-85  into  the  London  Fever  Hospital  and  the 
^Metropolitan  Asylum  hospitals  at  Stockwell  and  Hammerton  ;  on  5000 
in  Christiania  from  1870-82 ;  and  on  the  returns  of  all  known  cases  of 
scarlet  fever  for  some  large  towns  in  England  where  notification  of  in- 
fectious diseases  has  been  for  some  time  compulsory.  The  conclusions 
drawn  from  a  study  of  this  yast  material  are — 

(1)  The  mortality  is  at  its  maximum  in  the  third  year  of  life,  and 
after  this  diminishes  with  age — at  first  slowly,  afterward  rapidly. 

(2)  This  diminution  is  due  to  three  contributory  causes  :  («)  the 
increased  proportion  in  the  population  at  each  successive  age-period  of 
persons  protected  by  a  previous  attack ;  (b)  the  diminution  of  liability 
to  infection  in  successive  age-j^eriods  of  those  who  are  as  yet  unpro- 
tected ;  (e)  the  diminishing  risk  in  each  successive  age-period  of  an 
attack,  should  it  occur,  proving  fatal. 

(3)  The  liability  of  the  unprotected  to  infection  is  small  in  the  first 
year  of  life,  increases  to  a  maximum  in  the  fifth  year  or  soon  after,  and 
then  becomes  rapidly  smaller  with  advance  of  years. 

(4)  The  chance  that  an  attack  will  terminate  fatally  is  highest  in 
infancy,  and  diminishes  rapidly  with  years  to  the  end  of  the  twenty- 
fifth  year,  after  which  an  attack  is  again  somewhat  more  dangerous. 

(5)  The  female  sex  throughout  life,  the  first  year  possibly  excepted, 
is  more  liable  to  scarlatina  than  is  the  male  sex. 

(6)  The  attacks  in  males,  though  fewer,  are  more  likely  to  terminate 
'fatally. 

(7)  Hence  the  longer  an  attack  is  deferred  the  less  likely  is  it  to 
occur  at  all  and  the  less  likely  is  it  to  end  fatally. 

It  is  no  doubt  true  that  the  exemption  of  the  first  year  of  life  from 
attack  is  more  apparent  than  real :  the  child  at  the  breast  is  more  pro- 
tected from  exposure  than  those  old  enough  to  run  about  and  mingle 
with  other  children.  The  author  has  observed  in  his  own  family  a 
severe  case  in  a  child  nine  months  of  age,  followed  by  general  dropsy. 
That  advance  in  years  does  really  bring  immunity  Murchison  tries  to 
prove  by  stating  that  if  the  mortality  in  England  and  Wales  is  calculated 

^  A  Contribution  to  the  Xatural  History  of  Scarlet  Fever,  Gresswell,  p.  172. 


580  SCARLET  FEVER. 

at  6  per  cent.,  then  the  number  of  cases  of  scarlet  fever  in  these 
countries  is  less  than  one  half  the  births,  so  that  a  large  number  reach 
adult  life  who  have  not  been  protected  by  an  attack  in  childhood. 

Congenital  Scarlatina. — Several  cases  have  been  reported  of  congenital 
scarlet  fever.  On  the  other  hand,  Murchison  has  observed  two  healthy 
children  born  from  mothers  suffering  with  scarlet  fever.  Although  it 
must  always  be  difficult  to  determine  the  presence  of  the  rash  of  scarlet 
fever  in  newborn  babies,  whose  skins  are  already  red  and  often  des- 
quamate soon  after  birth,  still,  as  many  authenticated  cases  are  on 
record  in  which  similar  diseases  have  been  present  at  birth,  we  may 
believe  that  it  is  possible  for  children  to  be  born  with  scarlatina.  Nor 
are  the  observations  of  authors  that  sometimes  children  unaffected  are 
born  of  affected  mothers,  while  at  times  the  disease  is  transmitted  to 
the  foetus,  insusceptible  of  reconciliation.  Normally,  the  placenta  acts 
as  a  filter,  keeping  back  from  the  foetus  formed  elements  from  the 
maternal  circulation.  Bacteria  are  thus  generally  not  allowed  to  pass 
into  the  foetal  circulation,  but  under  some  circumstances,  as  has  recently 
been  shown,  through  a  pathological  condition  in  the  placenta  disease 
germs  may  pass  to  the  foetus.  It  has  been  observed  that  a  babe  while 
suckled  by  a  mother  affected  with  scarlet  fever  has  escaped  the  disease. 
It  is  possible  that  this  phenomenon  has  relation  to  certain  recent  obser- 
vations which  go  to  show  that  the  milk  of  animals  attacked  by  certain 
infectious  diseases  may  acquire  an  antitoxic  j^roperty. 

Sex. — The  statistics  gathered  by  the  Registrar  General  of  England, 
quoted  above,  show  that  the  female  sex  is  more  liable  to  scarlatina  than 
the  male,  but  such  figures  are  often  misleading.  Indeed,  most  authori- 
ties are  agreed  that  sex  in  itself  exerts  no  influence  on  predisposition. 
Richardson  ^  has  expressed  his  opinion  thus  :  "  Male  and  female  are 
alike  susceptible  if  they  are  alike  exposed." 

Race. — It  is  not  possible,  on  account  of  the  confusion  which  exists 
in  nomenclature  and  the  inadequate  returns  from  many  countries  in 
regard  to  scarlet  fever,  to  determine  what  effect  race  has  upon  jjredis- 
position  and  upon  the  severity  of  the  disease.  According  to  D'Alves,^ 
scarlet  fever  attacked  the  Brazilian  Indians  with  great  intensity. 
Murchison  states  that  scarlet  fever  makes  no  distinction  among  the 
different  races  living  in  New  Zealand.  It  has  been  stated  that  scarla- 
tina does  not  occur  among  the  Japanese.  Ashmead  "^  has  reported  a  case 
occurring  in  a  Japanese  living  in  Brooklyn.  The  writer  is  of  the  opinion, 
judging  from  his  own  experience,  that  scarlatina  is  less  common  among 
negroes  than  among  whites,  but  it  is  difficult  to  decide  this  point  on 
account  of  the  uncertainty  of  the  diagnosis  in  negroes,  and  because 
they  are  not  under  such  thorough  medical  control  as  are  the  whites. 

Social  Position. — Though  social  position  exerts  no  influence  on  sus- 
ceptibility to  scarlet  fever,  it  influences  decidedly  the  severity  of  the 
affection,  the  mortality  being  less  among  the  rich  than  among  the  poor. 
This  can  be  explained  on  the  ground  of  better  attention,  food,  and 
hygiene  in  the  case  of  the  well  to  do. 

LoGolity. — It  has  never  been  proven  that  residence  in  cities  or  in 

^  Natural  History  of  Scarlatina,  Gresswell,  p.  175. 

'^  Cyclopedia  of  the  Practice  of  Medicine,  \'^on  Ziemssen',  vol.  ii.  p.  185. 

^  jSfew  York  Medical  Journal,  Jan.  10,  1894. 


ETIOLOd  Y.  581 

the  i-ouiitry,  the  iiatuiv  of  the  soil,  or  the  altitude  have  any  iiitluenee 
upon  predisposition. 

IntfuciK'c  of  Previous  Hcdlth. — The  previous  state  of  health  is  of 
douhti'ul  influence  upon  predisposition  to  searlet  fever,  though  it  would 
seem  but  reasonable  that  those  whose  physiolo»i;ieal  resistanee  has  been 
diminished  should  fall  a  more  ready  prey.  Loesehner  and  Koestlin 
state  that  scarlatina  very  often  follows  in  the  wake  of  measles.  It  is 
probable  that  a  weakened  condition  of  the  (>;eneral  health  from  other 
diseases  predisposes  to  scarlet  fever.  Thus,  Ehler '  states  that  in  Ice- 
land in  1779  the  majority  of  the  lepers  perished  during  a  scarlet  fever 
oi)idemii'. 

Occupation. — Occupation  has  no  eifect  u])on  ])redisposition.  Certain 
callings  are  attended  by  more  abundant  opportunities  for  infection  than 
others.  Murchison  states  that  almost  one  third  of  all  the  patients 
received  into  the  London  Fever  Hospital  are  nurses  and  servants  from 
families  Avhere  scarlatina  is  prevailing. 

ISusccptihilifi/  in  General. — The  susceptibility  to  scarlet  fever  is  much 
less  universal  than  to  measles  or  smallpox.  It  not  uncommonly  hap- 
pens that  only  one  child  of  a  family  will  develop  the  disease,  though  all 
have  been  equally  exposed.  It  has  been  noticed  that  where  one  of  two 
toAvns  between  which  there  is  constant  intercourse  has  been  attacked  the 
other  has  escaped  for  a  long  time.  A  person  may  live  immune  in  an 
aifeeted  neighborhood,  and  on  removing  to  a  distant  place  may  develop 
susceptibility  luider  no  more  favorable  circumstances  for  infection  than 
those  by  which  he  was  previously  surrounded.  Unlike  measles,  scarlet 
fever  on  entering  a  community  for  a  long  time  exempt  does  not  attack 
all  those  not  already  protected ;  the  same  vagaries  of  susceptibility  are 
noted  here  as  under  other  circumstances.  It  has  been  observed  that  the 
longer  an  epidemic  lasts  the  more  likely  are  those  who  at  first  escaped 
to  yield  to  the  attacks  of  the  disease.  The  variations  in  the  intensity 
of  scarlatina  are  as  unaccountable  as  are  the  irregularities  in  suscepti- 
bility. Two  children  in  the  same  family  may  contract  the  disease  from 
presumably  the  same  source  ;  one  may  have  scarlatina  in  its  mildest 
form,  while  the  other  perishes  under  a  malignant  attack.  It  is  a  fact 
worthy  of  notice  that  in  some  families  a  special  susceptibility  to  scarlet 
fever  is  manifested.  Instead  of  one  or  two  children  being  attacked,  the 
whole  family  is  rapidly  affected.  Under  such  circumstances  the  disease 
may  assume  so  severe  a  form  that  many  of  the  cases  terminate  fatally. 
The  writer  is  acquainted  with  a  family  in  which  out  of  12  cases  occur- 
ring in  a  week  7  died. 

Pree/nanci/,  Puerperal  State,  Wounds. — Many  authors  hold  that  preg- 
nancy increases  the  liability  of  women  to  scarlet  fever.  On  the  other 
hand,  observers  of  wide  experience  (Trousseau)  have  seen  no  pregnant 
woman  attacked  during  extensive  epidemics.  The  belief  has  long  been 
held  that  women  in  the  puerperal  state  are  especially  liable  to  scarlatina. 
It  is  but  fair  to  conclude  that  in  their  exhausted  condition  such  women 
would  be  more  readily  attacked  by  any  infectious  disease ;  but  it  must 
not  be  forgotten  that  the  statistics  brought  forward  to  prove  this  increased 
susceptibility  to  scarlatina  are  largely  from  hospitals,  where,  especially 
in  former  days,  the  virus  of  scarlet  fever  always  existed,  so  that  it  w^as 

1  Tfie  Medical  Week,  Nov.  30,  1894. 


582  SCARLET  FEVER. 

often  more  a  question  of  exposing  a  large  number  of  lying-in  women  to 
infection  than  of  susceptibility  being  increased  by  childbed.  Another 
source  of  error  lies  in  the  great  similarity  of  certain  septicsemic  rashes 
which  may  attend  the  puerperium  to  scarlet  fever. 

It  used  to  be  quite  common,  after  surgical  operations,  to  see  a  scar- 
latiniform  rash  develop.  In  some  of  the  English  hospitals  this  has 
occurred  with  such  frequency  as  to  necessitate  the  closure  of  the  wards 
for  a  time.  When  we  consider  how  tenacious  of  life  is  the  virus  of 
scarlet  fever,  and  how  inadequate  in  former  years  was  the  disinfection 
of  instruments  and  dressings,  we  can  readily  believe  that  some  of  these 
cases  were  real  scarlet  fever.  No  doubt  most  such  cases  have  been  rashes 
accompanying  septic  infection.  Hutchinson  ^  reports  a  case  of  a  woman 
who  on  the  fifth  day  after  an  amputation  died  of  what  seemed  to  be  real 
scarlet  fever.  No  case  of  scarlatina  had  occurred  recently  in  the  hospital^ 
but  on  inquiry  it  was  found  that  the  disease  had  been  in  the  woman's 
family  several  months  before.  Hutchinson  thinks  that  in  this  case  the 
germs  of  the  malady  were  present  in  the  woman  when  admitted,  and 
were  aroused  to  activity  by  the  disturbance  following  the  operation. 

The  Contagium. — Today  no  one  doubts  the  infectious  nature  of  scarlet 
fever,  though  not  many  years  ago  there  were  those  who  argued  against 
this  idea.  The  virus  is  of  so  volatile  a  nature  that  merely  coming  for 
a  moment  into  the  presence  of  one  aifected  with  the  disease  suffices  to 
reproduce  it  in  a  susceptible  person.  Not  only  is  the  malady  immedi- 
ately infectious,  but  the  contagium  may  be  conveyed  by  fomites.  These 
fomites  may  consist  of  the  human  or  other  animal  body,  of  food,  of  letters 
or  papers  or  books,  of  merchandise — in  fine,  of  almost  any  article  that 
may  pass  from  person  to  person  in  the  exigencies  of  daily  life.  Palante 
notes  the  case  of  a  woman  who,  after  remaining  only  a  moment  in  the 
room  of  a  scarlatinous  patient,  returned  home,  a  distance  of  six  miles^ 
and  gave  the  disease  to  her  children.  Several  cases  are  on  record  in 
which  a  domestic  animal  occupying  the  room  of  a  patient  has  conveyed 
the  disease.  Hamilton^  mentions  that  during  an  outbreak  of  scarlet 
fever  in  Dublin  two  children  who  were  ill  were  isolated  in  the  top  of  a 
house  and  every  precaution  taken  to  prevent  the  spread  of  the  malady 
to  healthy  members  of  the  family.  After  a  fortnight  other  children, 
who  had  been  kept  in  the  basement,  took  the  disease,  and  it  was  found 
that  a  cat,  which  had  been  in  the  habit  of  spending  the  day  with  the 
sick  children  and  the  night  with  the  well,  had  conveyed  the  contagium. 
A  letter  written  in  the  room  of  a  scarlet  fever  patient  has  often  con- 
veyed sickness  and  death  to  distant  homes.  Books  in  libraries  for  cir- 
culation among  the  poor  are  frec^uently  used  to  relieve  the  tedium  of 
recovery  from  scarlatina  and  become  ready  carriers  of  the  disease. 
Time  and  again  milk  stored  in  the  chamber  of  a  person  ill  of  scarlet 
fever  has  initiated  an  epidemic  of  the  disease.  The  tenacity  of  the 
virus  is  great,  and  it  has  often  happened  that  it  has  been  revived  after 
lying  dormant  for  long  periods.  Von  Hildenbrand's  classical  coat 
retained  its  contagiousness  for  a  year  and  a  half.  Duffin  ^  records  an 
instance  where  the  paper  had  been  left  on  the  walls  after  a  case  of 
scarlet  fever  had  occurred  in  a  room.     New  paper  was  put  on  several 

^  Archives  of  Surgery,  April,  1893.  ^  JBritish  Medical  Journal,  June  3,  1894. 

^  The  Clinical  Journal,  April  5,  1894. 


ETIOLOGY.  583 

times  without  rcniovino-  the  oUl.  Finally,  a  new  family  came  and  took 
down  all  these  layers  of  paper,  liberating  the  scarlet  fever  })oison  and 
causing  an  outbreak  in  the  family.  An  almost  indefinite  number  of 
instances  illustrating  the  longevity  of  this  poison  might  be  collected 
from  the  literature  w^ere  it  important  or  necessary  to  produce  further 
examples. 

Mode  of  Communk'ai'wn. — It  is  usually  considered  that  the  virus 
enters  the  body  through  the  respiratory  mucous  membranes.  The  fact 
that  the  stress  so  often  falls  upon  the  pharynx  early  in  the  disease  might 
be  looked  upon  as  pointing  in  this  direction.  Kaposi  states  that  children 
with  chronic  tonsillitis  are  more  prone  to  the  malady,  and  this  gives 
additional  support  to  the  idea  that  the  respiratory  tract  generally  affords 
the  site  of  entrance.  Some  have  supposed  that  the  virus  enters  with 
the  food  or  drink.  That  it  may  at  times  gain  entrance  in  other  ways  is 
proved  by  inoculation  experiments.  The  disease  has  been  produced  by 
inoculation  with  blood,  epidermic  scales,  serum  from  vesicles,  and  nasal 
and  pharyngeal  secretions.  Miquel  ^  claimed  to  be  able  to  produce  a 
local  reaction  comparable  to  vaccination  by  the  inoculation  of  serum 
from  vesicles,  the  subjects  of  this  treatment  being  then  found  to  be 
refractory  to  scarlet  fever.  But,  as  a  rule,  the  disease  when  produced 
by  inoculation  has  been  more  severe  than  that  arising  spontaneously,  so 
that  it  has  not  to  the  present  time  been  possible  to  use  this  method  to 
procure  immunity. 

Tinmunity. — As  in  other  exanthems,  so  in  scarlet  fever,  one  attack 
confers  immunity  from  future  attacks.  Whatever  the  scientific  explana- 
tion of  this  immunity  may  ultimately  prove  to  be,  it  certainly  involves 
some  profound  change  in  the  system,  for  it  usually  persists  throughout 
life.  There  are  exceptions  to  this  rule  :  a  few  wtU  authenticated  in- 
stances of  repeated  attacks  are  on  record.  In  the  popular  estimation 
repeated  attacks  are  more  numerous  than  they  can  be  shown  to  be  in 
fact — this  largely  on  account  of  errors  in  diagnosis.  Thus,  a  child  has 
German  measles  or  some  erythema  and  the  attending  physician  pro- 
nounces it  scarlet  fever :  when  the  child  really  develops  scarlatina  it  is 
regarded  as  a  second  attack.  jSIany  writers  of  wide  experience  have 
never  seen  an  undoubted  instance  of  a  second  attack.  It  has  often  been 
noticed  that  during  an  epidemic  of  scarlet  fever  many  persons,  both 
those  who  have  had  the  disease  and  those  not  so  protected,  suffer  from 
angina,  wdiich  has  frequently  been  regarded  as  scarlatinous.  Because 
this  sore  throat  occurs  at  the  same  time  as  scarlatina  does  not  show  that 
it  is  the  result  of  the  germ  of  that  disease.  Indeed,  it  has  been  shown 
that  the  severe  forms  of  throat  trouble  which  often  manifest  themselves 
in  scarlatinous  patients  are  the  result  of  secondary  infection.  These 
anginas  are  undoubtedly  contagious,  and  thus  a  great  number  of  the 
sore  throats  seen  during  an  epidemic  of  scarlet  fever  may  be  entirely  in- 
dependent of  that  disease.  Such  instances,  then,  cannot  be  admitted  as 
constituting  second  attacks  of  scarlatina.  In  some  cases  which  are 
characterized  by  an  unusually  prolonged  febrile  stage,  in  the  second  or 
third  week  an  erythema  again  appears  upon  the  body  :  to  such  cases 
Thomas  gives  the  name  "  pseudo-relapses."  In  other  instances  after 
convalescence  is  begun  a  rash  accompanied  by  other  morbid  symptoms 

'  Maladies  de  la  Peaii,  Kaposi,  p.  267. 


584 


SCARLET  FEVER. 


appears  ;  to  this  condition  Thomas  apjilies  the  term  "  relapse."  Some 
observers  have  thought  that  repeated  attacks  of  scarlet  fever  constituted 
a  family  peculiarity-.  Troganowsky  ^  found  that  in  two  of  his  cases  of 
second  attacks  both  parents  had  experienced  the  disease  twice.  Mur- 
chison  has  observed  relapses  in  two  sisters.  It  is  said  that  relapses  and 
second  attacks  are  generally  mild  in  character. 

Time  of  Greatest  Infectiousness  and  Length  of  the  Period  of  Infec- 
tion.— At  which  period  of  its  evolution  scarlet  fever  is  most  contagious 
is  a  question  which  has  never  been  definitely  decided.  It  would  seem 
probable  that  the  virus  was  being  liberated  in  greatest  quantity  when 
the  disease  was  at  its  height.  This  is  not  so  important  a  question,  how- 
ever, as  is  the  inquiry,  Is  scarlet  fever  contagious  at  all  periods  of  the 
disease,  and  if  so  how  long  does  the  contagiousness  last  ?  The  answer 
to  the  first  part  of  this  question  is  rendered  more  difiicult  by  the  vary- 
ing suscej)tibility  to  the  disease  and  by  the  great  tenacity  of  the  virus. 
If  a  child  in  the  period  of  incubation  is  brought  into  contact  with 
another  child,  and  the  second  child  fails  to  contract  the  disease,  this  will 
not  show  that  scarlet  fever  is  not  contagious  in  the  period  of  incubation, 
since  the  exposed  individual  may  have  been  one  of  those  not  decidedly 
susceptible.  Again,  if  the  disease  occurs  in  one  child  in  a  family  who 
is  at  once  isolated  and  kept  so  till  all  signs  of  sickness  have  disappeared, 
and  if  when  this  child  joins  the  others  another  case  appears,  this  does 
not  prove  that  the  original  case  was  liberating  the  poison  at  the  time  of 
his  restoration  to  the  family  circle,  for  we  know  how  readily  objects 
about  a  patient  at  the  height  of  the  disease  may  be  infected  and  how 
difficult  it  is  to  remove  from  them  the  contagium.  Reasoning  from 
what  has  been  shown  to  be  true  in  smallpox  and  measles,  it  seems  likely 
that  in  the  period  of  incubation,  before  any  active  signs  of  illness  are 
present,  scarlatina  is  infectious.  How  long  the  possibility  of  infection 
endures  has  not  been  exactly  determined.  It  is  indeed  probable  that  this 
period  may  vary  in  different  cases.  We  would  certainly  not  overstep 
the  line  were  we  to  say  that  as  long  as  any  morbid  phenomena  attribut- 
able to  the  attack  of  scarlatina  exist  there  is  a  possibility  of  infection. 
In  fact,  it  is  likely  that  such  a  statement  does  not  cover  the  whole  truth, 
for  in  some  cases  of  diphtheria  ^  it  has  been  shown  that  Loffler's  bacillus 
can  be  demonstrated  long  after  all  clinical  evidence  of  disease  has  ceased, 
and  what  is  true  for  this  malady  may  very  well  hold  for  other  infectious 
diseases,  scarlet  fever  among  the  rest. 

Incubation. — The  incubation  period  of  scarlatina,  as  usually  stated, 
varies  within  wider  limits  than  are  assigned  to  the  same  stage  in  the  other 
exanthems.    Formerly  the  incubation  was  estimated  at  from  one  to  eight 


Committee  of  the  Clinical  Soc,  1892 

Bristowe,  1887 

Guinon,  1892 

Striimpell,  1887 


Usual  time. 


2  or  3  days. 
6  to  8  days. 
4  or  5  days. 


Minimum 
time. 


Maximum  time. 


1  day. 
Often  less. 

Less  than ") 
4  days,    j 


7  days. 
Occasionally  longer. 

7  days. 


^  f'udopedia  of  the  Practice  of  Medicine,  Von  Ziemssen,  vol.  ii.  p.  189. 
''  Medical  News,  Nov.  10,  1894. 


ETIOLOGY.  585 

days.  Kt'ct'iit  observations,  however,  seem  to  show  that  the  period  (»f' 
incubation  is  marked  by  narrower  limits.  William.s'  in  a  report  for  the 
Clinieal  Soeiety  of  London  tabuhites  the  foregoing  opinions  as  to  the 
lengtli  of  the  stage  of  ineiibation  in  scarlatina.     (See  table,  page  584.) 

Hamilton  -  from  an  experience  of  a  severe  epidemic  among  troops 
claims  that  the  period  of  incubation  of  scarlet  fever  is  three  or  four 
days.  In  some  inoculation  experiments  the  time  of  incubation  has  been 
seven  days.  Gerhardt  is  authority  for  the  statement  that,  an  abscess 
having  been  opened  with  a  knife  that  had  been  used  on  a  scarlatinous 
patient,  scarlatina  was  developed  four  days  later.  Bokai'*  reports  two 
cases  of  tracheotomy  in  which  scarlet  fever  developed  sixteen  hours 
after  exposure.  Soerensen  *  states  that  in  10  cases  operated  upon  by 
Paget  in  Avhich  scarlet  fever  developed  the  period  of  incubation  was 
one  day  in  2  cases,  two  days  in  3,  and  three  days  in  3  cases.  The  same 
author  remarks  that  in  9  out  of  12  cases  of  puerperal  scarlet  fever  the 
period  of  inculiatiou  was  three  days.  It  would  seem  probable  from 
these  figures  that  where  infection  occurs  through  a  wound  the  time  of 
incubation  is  shortened. 

On  the  other  hand,  it  may  happen  that  the  incubation  period  is 
prolonged.  Kaposi  states  that  in  rhaehitis  and  other  conditions  of  ill 
health  a  prolonged  incubation  not  uncommonly  occnrs.  Instances  have 
been  reported  in  which  the  time  of  incubation  was  several  weeks.  In 
some  of  these  instances,  where  a  case  occurs  in  a  family  and  a  second 
case  does  not  develop  for  weeks  after  the  first,  it  is  not  necessary  to 
assume  that  the  incubation  is  thus  lengthened,  but  rather  that  the 
poison  did  not,  for  some  reason,  affect  the  person  at  the  first  exposure. 
Besides,  it  is  often  difficult  or  impossible  to  exclude  opportunities  for 
infection  other  than  the  one  from  which  the  long  incubation  has  been 
-counted.  Still,  since  there  is  a  possibility  that  these  long  periods  of 
incubation  do  occur,  a  physician  would  be  wise  not  to  pronounce  a  child 
entirely  out  of  danger  till  several  weeks  have  passed  since  exposure. 

Occurrence  icith  Other  Exanthems. — It  is  quite  well  established  that 
other  acute  exanthems  may  occur  at  the  same  time  as  scarlet  fever. 
Hirschprung  narrates  2  cases,  in  each  of  which  scarlatina  and  varicella 
were  both  present.  Wolberg  reports  the  case  of  a  boy  who  was  first 
attacked  by  scarlet  fever ;  a  few  days  later  the  temperature  rose  and  a 
■crop  of  variola  vesicles  appeared.  Hardaway  has  seen  scarlet  fever 
develop  in  the  period  of  crusting  in  a  case  of  variola.  Brand  has 
noticed  the  concurrence  of  scarlatina  and  typhoid  fever.  Taylor  has 
seen  2  cases  in  which  measles,  scarlet  fever,  and  diphtheria  occurred 
simultaneously.  Many  other  such  instances  might  be  gathered,  but 
these  will  serve  to  illustrate  this  relation  of  scarlatina. 

Micro-organisms  in  Scarlatina. — Though  many  claims  have  been 
made  to  the  discovery  of  the  micro-organism  which  is  the  active  factor 
in  the  production  of  scarlatina,  no  one  of  these  has  as  yet  received 
sufficient  confirmation  to  merit  its  acceptance.  In  1882,  Ecklund 
described  certain  colorless  corpuscles  which  he  had  found  in  the  urine 
of  scarlet  fever  patients.     Similar  bodies  were  found  in  the  soil  and 

^  Practitioner,  July,  1894.  -  British  Medical  Journal,  June  3,  1S94. 

^  Pester  medicinisch-chirurgische  Presse,  v.  p.  990. 

^  Internationaler  Idinische  Rundschau,  Jsos.  6  and  7,  1889. 


586  SCARLET  FEVER. 

surface  water  of  regions  in  which  epidemics  of  scarlatina  were  prevail- 
ing. Others  have  verified  this  observation  as  far  as  the  appearance  of 
the  bodies  in  the  urine  is  concerned,  but  their  relation  to  scarlet  fever 
has  not  been  determined.  Klein  has  obtained  from  the  blood  and  tis- 
sues of  scarlatinous  patients  a  streptococcus  which  when  injected  into 
calves  and  guinea-pigs  brings  about  symptoms  resembling  those  of 
scarlet  fever.  He  has  found  a  similar  organism  in  vesicles  on  the  teats 
of  cows  to  which  an  epidemic  of  scarlatina  has  been  traced.  Edington 
and  Jamieson  have  isolated  a  bacillus  which  is  described  as  1.2  to  1.4 
micromillimetres  long  and  .4  micromillimetre  in  width.  The  bacilli 
are  found  in  the  blood  of  scarlet  fever  patients  during  the  first  two  days 
only,  and  in  the  desquamating  epidermis  after  the  twenty-first  day. 
Inoculation  upon  rabbits  caused  fever,  erythema,  and  a  subsequent 
desquamation.  Shakespeare  in  this  country  has  confirmed  these  obser- 
vations. His  account  of  certain  experiments  is  interesting:  "A  calf  was 
inoculated  and  at  the  same  time  given  some  of  the  culture  in  milk.  The 
calf  was  in  good  health  at  the  time  and  had  a  temperature  of  99.5°  F. 
Six  hours  from  the  inoculation  the  calf  developed  great  sickness,  and 
the  temperature,  taken  in  the  axilla,  registered  103°  F.  The  calf  was 
left  for  the  night,  but  in  the  morning  was  found  dead.  Small  portions 
of  the  spleen  and  kidneys  were  placed  in  Koch's  jelly  and  developed 
the  characteristic  bacilli.  With  this  a  second  calf  was  inoculated  when 
one  day  old.  The  inoculation  was  done  w^ith  scrupulous  care,  and  a 
previous  examination  showed  no  bacilli  in  the  calf's  blood.  His  tem- 
p'erature  in  the  rectum  was  99.6°  F.  The  inoculation  was  done  at  6.30 
p.  M.  The  following  morning  the  temperature  was  104°  F.  There  were 
sickness,  great  prostration,  diarrhoea,  and  soreness  of  the  throat.  In 
the  afternoon  the  skin  of  the  thorax,  upper  abdomen,  and  inner  sides 
of  the  fore  legs  presented  a  general  redness  which  increased  toM'ard 
evening.  By  the  next  day  the  animal  was  better  and  continued  to  im- 
prove. On  the  sixth  day  desquamation  set  in."  The  growth  of  the 
bacillus  used  in  these  experiments  is,  in  cultures,  very  rapid,  and  this  is 
of  interest  in  view  of  the  short  incubation  period  in  scarlatina. 

Doehle^  has  observed  in  the  blood  of  5  scarlet  fever  patients  twa 
distinct  parasites  :  (1)  Small,  flat,  spherical  corpuscles,  measuring  1 
micromillimetre,  provided  generally  with  a  whiplike  appendage  of 
about  the  same  length,  which  has  a  bulbous  extremity ;  (2)  corpuscles 
made  up  of  two  nuclei  surrounded  by  a  clear  zone  two  or  three  times 
as  large  in  area  as  the  nuclei.  This  zone  is  finely  granular  and  contains 
pigment  granules.  Movement  in  these  cells  occurs  by  contraction  of 
the  protoplasm.  They  may  be  outside  or  inside  the  red  corpuscles.  The 
author  claims  to  have  observed  these  parasites  in  the  blood  of  measles 
and  smallpox. 

These  illustrations  aiford  an  idea  of  the  diversity  of  the  bodies 
described  as  the  germ  of  scarlet  fever.  Before  we  can  accept  any  one 
of  them  as  expressing  the  truth  many  control  experiments  must  be 
brought  forward  in  substantiation. 

Scarlatina  in  the  Lower  Animals. — For  a  long  time  it  has  been  a  ques- 
tion whether  there  is  a  disease  of  lower  animals  corresponding  to  scarlet 
fever  in  man.      The  knowledge  of  the  unity  of  smallpox  and  vac- 

^  Revue  mensuelle  des  Malades  de  I'  Enfance,  July,  1894. 


I'A'rHULOUJCAL  AXATOMV.  587 

cinia  has  p;iv(Mi  additional  ii)torost  to  this  quostion.  SoaHatina  is  said 
to  liavo  bt'cii  observed  in  doi^s,  oats,  swine,  horses,  and  cows.  Ileini ' 
states  that  a  doo'  whieh  had  hun  in  the  same  bed  witli  a  child  who  had 
searlatina  had  a  fever  with  a  searlatiniibrni  rasli  which  terniinat<'d  in 
desquamation.  The  t::reatest  interest  of"  this  question  is  as  to  whether 
scarlet  fever  exists  in  cows,  for  if  it  does  wo  can  readily  see  how  the 
milk  from  infected  animals  may  spread  the  disease  to  man. 

An  epidemic  of  scarlet  fever  occurred  in  T^ondon  in  1885  which  has 
become  historical  as  the  "  Hendon  outbreak."  The  source  of  this  epi- 
demic was  traced  to  a  herd  of  cows  which  was  affected  with  a  contaj^ious 
disease  that  oould  be  inoculated  upon  healthy  cows  and  man.  From 
ulcers  upon  the  udders  Klein  isolated  an  organism  which  he  thinks 
identical  with  one  he  had  obtained  from  human  beings  affected  with 
scarlet  fever.  Others  who  have  investigated  the  Hendon  disease  have 
failed  to  agree  that  the  malady  from  wdiich  the  cattle  suffered  was  scar- 
latina. Hill-  reports  an  outbreak  of  scarlatina  at  Sutton  Coldfield, 
where  all  the  homes  invaded  had  the  same  milk  supply.  At  the  dairy 
from  which  the  milk  was  obtained  no  case  of  human  scarlet  fever  oould 
be  found.  One  cow  which  had  recently  calved  and  had  been  in  the 
herd  only  a  short  time  was  in  poor  ooiKlition,  and  indications  of  recent 
ulcerations  were  found  on  her  teats.  The  authorities  declined  to  inter- 
fere. Soon  a  number  of  fresh  oases  of  scarlatina  appeared,  and  on  a 
second  visit  to  the  dairy  the  cow  was  found  to  be  desquamating  in  ex- 
tensive patches.  There  was  an  ulcer  on  one  teat  and  an  eruption  on 
the  udder.  A  second  cow  presented  indications  of  the  same  condition. 
The  dairyman  voluntarily  ceased  selling  the  milk  and  no  further  cases 
arose. 

In  August,  1892,  an  epidemic  in  Glasgow^  ^  was  traced  to  the  milk 
supplied  from  a  certain  farm.  At  this  farm  a  child  Avas  found  suffering 
from  scarlet  fever,  but  the  date  of  sickening  made  it  probable  that  the 
child  was  one  of  the  victims,  and  not  the  source  from  which  the  milk 
was  poisoned.  The  cows  were  found  to  be  suffering  from  a  teat  erup- 
tion. Lymph  and  crusts  were  sent  to  Klein,  who  found  a  streptococcus 
resembling  one  Avhich  he  had  isolated  from  the  Hendon  outbreak. 
Lymph  from  these  cows  inoculated  on  calves  produced  two  different 
eruptions,  one  of  which  was  vaccinia,  and  the  other  of  specific  charac- 
ter, but  entirely  distinct  from  vaccinia.  These  instances  serve  to  illus- 
trate what  seems  to  be  the  belief  of  the  day,  that  there  is  a  disease  of 
cow^s  the  virus  of  which  is  capable  of  causing  scarlet  fever  when  intro- 
duced into  the  human  being.  It  must  be  said  that  by  no  means  all 
authorities  are  agreed  on  this  subject.  The  practical  point  for  the  phy- 
sician is  that  in  all  epidemics  the  origin  of  which  is  obscure  the  milk 
supply  should  be  carefully  scrutinized. 

Pathological  Axato:my. — The  most  characteristic  anatomical 
changes  of  scarlet  fever  are  found  in  the  skin  and  mucous  membranes. 
Though  a  great  number  of  pathological  conditions  are  found  in  the 
course  of  scarlet  fever,  they  have  no  essential  relation  with  this  malady, 
but  are  often  present  in  other  infectious  diseases.  An  exception  may  be 
made  in  the  case  of  nephritis,  which  occurs  with  such  frequency  as  to 

^  Cyclopedia  of  the  Practice  of  Medicine,  Yon  Zierassen,  vol.  ii.  p.  166. 
■■*  British  Medical  Journal,  July  18,  1892.  ^  Ibid.,  January  7,  1893. 


588  SCARLET  FEVER. 

deserve  a  position  as  one  of  the  most  important  of  the  anatomical 
changes  found  with  scarlatina.  If  seen  in  the  commencement,  the  rash 
of  scarlet  fever  is  found  to  begin  as  small,  pale  red  spots.  In  the 
course  of  a  few  hours  these  become  confluent.  The  affected  integu- 
ment then  presents  a  uniform  scarlet  background  dotted  thickly  over 
with  minute  points  of  a  darker  hue.  The  skin  has  a  swollen,  ceclema- 
tous  appearance.  On  pressure  the  red  color  may  be  made  to  disappear, 
but  when  the  rash  is  at  its  height  there  usually  remains  behind  a  faint 
yellowish  staining  of  the  surface.  Sometimes  it  happens  that  there  are 
points  of  a  more  purplish  color  which  pressure  will  not  dissipate,  due  to 
small  hemorrhages  into  the  skin,  and  in  rare  instances  quite  large  areas 
are  involved  in  the  hemorrhages.  The  small  red  dots  which  are  seen 
on  the  scarlatinous  skin  may  become  so  much  elevated  as  to  constitute 
small  papules,  or  in  rare  instances  minute  vesicles  appear  upon  the 
skin. 

Microscopically  the  efflorescence  is  found  to  be  due  to  a  dilatation 
of  the  capillaries  of  the  skin  caused  by  paralysis  of  the  vascular  walls. 
In  looking  at  a  section  one  is  struck  by  the  fact  that  the  epidermis  and 
papillary  body  are  folded,  while  the  cutis  is  stretched  and  relatively- 
shortened.  Unna^  explains  this  by  stating  that  while  the  cutis  was 
engorged  the  epidermis  was  gradually  stretched,  and  that  when  by  the 
section  the  cutis  was  allowed  to  recontract,  it  could  not  readily  follow. 
The  fact  that  the  cutis  is  able  to  contract,  he  thinks,  shows  that  there 
was  not  a  true  oedema  of  the  skin.  There  are  no  indications  of  an 
inflammation  in  the  strict  sense  of  the  word.  When  the  eruption  is  at 
its  height  parakeratosis  can  be  noted  in  the  epidermis.  Unna  does  not 
regard  this  as  depending  on  the  paralysis  of  the  bloodvessels,  but  rather 
as  a  result  of  disturbance  of  the  vasomotor  centres,  for  the  same  para- 
keratosis is  to  be  seen  in  scarlatina  sine  exanthemate.  The  darkened 
points  mentioned  above  are  due  to  an  unusual  dilatation  of  the  sub- 
epithelial capillaries.  These  may  represent  small  emboli  due  to  the 
localization  of  the  scarlatinal  poison.  Unna  believes  that  it  is  from 
these  points  that  the  hemorrhages  arise.  Sometimes  an  interstitial 
oedema  occurs  in  the  neighborhood  of  the  follicles,  which  in  life  causes 
the  form  of  scarlatina  known  as  scarlatina  papulata.  The  exfoliations 
and  other  alterations  in  the  epidermis  are,  according  to  Unna,  the  direct 
results  of  the  action  of  the  poison  of  scarlet  fever,  and  are  not  to  be 
regarded  as  arising  from  a  true  inflammation  of  the  skin. 

The  alterations  which  arise  in  the  throat  are  even  more  constant  in 
scarlet  fever  than  the  skin  eruption.  Some^  have  gone  so  far  as  to 
assert  that  the  essential  point  in  diagnosis  is  the  tonsillitis,  as  cases  are 
extremely  rare  where  it  does  not  exist. 

In  its  mildest  form  the  angina  presents  itself  as  a  uniform  redness 
of  the  soft  palate,  uvula,  anterior  palatine  arches,  and  tonsils.  If  the 
process  is  of  more  severity,  the  red  color  is  of  a  deeper  hue ;  there  are 
oedema  and  swelling  of  the  affected  parts  and  a  muco-purulent  discharge  ; 
the  mucous  follicles  are  swollen  and  may  rupture,  leaving  shallow  ulcers. 
The  lymphatic  ganglia  lying  over  the  tonsils  at  the  angles  of  the  jaws 
are  enlarged  and  often  tender  to  pressure.     In  more  severe  cases  the 

^  Lehrbuch  der  Spedellen  pathologischen  Anatomie,  von  Dr.  J.  Orth,  Achte  Lieferung. 
Erganzungsband,  ii.  Tlieil.  "  British  Medical  Journal,  Jan.  9,  1893. 


rATllO LOGICAL  ANATOMY.  589 

redness  and  injection  of  (lie  niiieous  inenil)nine  extend  into  the  mouth 
and  nose. 

The  nioi-l)id  ])roeess  in  the  tonsils  may  result  in  an  interstitial  infiam- 
niation  with  great  enlargem(!nt,  and  even  the  formation  of  abscesses. 
In  ordinary  cases  there  is  little  if  any  involvement  of  the  larynx,  but 
in  severe  oases  the  laryngeal  mucous  membrane  nuiy  be  affected  to 
such  a  degree  as  to  cause  stenosis  or  abscesses.'  When  the  inflam- 
mation falls  with  peculiar  intensity  upon  the  tonsils,  there  may  result 
gangrene  of  a  part  or  a  whole  of  these  organs.  In  cases  of  the 
greatest  severity  the  inflammation  extends  from  the  fauces  to  the 
cellular  planes  of  the  neck.  This  is  accompanied  by  great  infiltra- 
tion, swelling,  and  brawniness  of  the  tissues.  In  most  of  these  cases 
the  cellulitis  results  in  larger  or  smaller  collections  of  ])us.  The  infil- 
tration may  cause  such  interference  with  nutrition  that  large  masses  of 
tissue  slough.  On  the  separation  of  such  gangrenous  masses  the  muscles, 
vessels,  and  deeper  structures  of  the  neck  may  be  exposed.  If  a  large 
vessel  be  involved  in  the  slough,  rapidly  fatal  hemorrhage  may  occur. 

A  false  membrane  is  not  an  infrequent  accomj^animent  of  scar- 
latinal angina.  It  is  sometimes  confined  to  the  tonsils,  but  may  involve 
the  whole  pharynx  as  well  as  the  larynx  and  nose.  It  has  long  been  a 
(juestion  whether  such  membranes  represent  simultaneous  attacks  of 
scarlatina  and  diphtheria.  The  discovery  of  a  specific  bacillus  in 
association  Avith  diphtheria  has  done  much  toAvard  the  solution  of  this 
question.  Recent  investigations  have  shown  that  in  a  large  number  of 
the  membranous  throat  affections  accompanying  scarlet  fever  the  bacillus 
of  Luffler  cannot  be  found,  Williams^  in  35  cases  in  which  a  mem- 
l)rane  was  in  the  throats  of  scarlatinous  patients  found  Loflfler's  bacil- 
lus in  12.  In  cases  of  pseudo-membrane  which  are  not  diphtheritic 
various  micro-organisms  have  been  found.  Booker^  has  reported  ex- 
aminations of  the  membrane  from  the  throats  of  scarlet  fever  patients. 
In  none  was  Loffler's  bacillus  present.  In  all  he  found  a  streptococcus 
which  differed  from  the  streptococcus  of  erysipelas  principally  in  that 
it  did  not  live  so  long  in  culture  media.  Examinations  made  by  Jack- 
son^ and  others  by  Councilman^  also  showed  streptococci.  Bourges^ 
found  in  17  cases  of  pseudo-membrane  with  scarlet  fever  in  some  a 
streptococcus,  in  others  the  daphylococcufi  pyogenes  aureus,  the  bacterium 
coli  commune,  and  the  staphylococcus  jjyogenes  albus. 

As  Weigert  has  shown,  the  essentials  for  the  existence  of  a  false 
membrane  are  a  sufficient  necrosis  of  the  epithelium  and  a  fibrin-con- 
taining exudate.  Reasoning  from  this  fact  and  the  observations  men- 
tioned above,  we  arrive  at  the  conclusion  that  the  false  membrane 
which  occurs  with  scarlet  fever  does  not  necessarily  imply  that  diph- 
theria is  present  as  a  complication  :  such  a  condition  forms  no  neces- 
sary part  of  the  morbid  process  of  scarlet  fever,  but  is  often  due  to 
the  action  of  bacteria  which  have  been  secondarily  engrafted  on  the 
already  inflamed  throat. 

In  a  very  large  majority  of  all  scarlatina  cases  nephritis  of  one 

^  La  Semaine  medicale,  May  7,  1893. 

^  American  Journal  of  the  Medical  Sciences^,  Nov.,  1893. 

^  Johns  Hopkins  Hospital  Bulletin,  Oct.  and  Nov.,  1892. 

*  Boston  Medical  and  Surgical  Journal,  Aug.  17,  1894.  *  Ibid. 

^  "  Les  Origines  de  la  Scarlatine,"  These  inaugurale,  Paris,  1891. 


590  SCARLET  FEVER. 

grade  or  another  occurs.  This  nephritis  is  of  the  type  known  as 
glomerulo-nephritis.  In  many  cases  the  involvement  of  the  kidney  is 
only  of  slight  degree,  while  in  some  cases  it  progresses  till  a  marked 
type  of  parenchymatous  nephritis  results.  Klebs  was  the  first  to  draw 
attention  to  the  frequency  with  wdiich  scarlatinal  nephritis  was  a  glom- 
erular affection.  He  found  the  only  noticeable  condition  to  be  the  accu- 
mulation of  small  angular  nuclei  and  a  finely  granular  matter  in  Bow- 
man's capsules.  More  recent  observers  have  found  the  glomerular 
affection,  but  it  is  not  necessarily  the  only  change.  Klein  finds  the 
changes  to  consist  in  increase  of  the  nuclei  covering  the  glomeruli, 
hyaline  degeneration  of  the  tunica  intima,  and  multiplication  of  the 
nuclei  of  the  tunica  media  of  the  minute  arteries,  leucocytal  infiltration 
along  the  course  of  the  vessels,  and  parenchymatous  changes  the  inten- 
sity of  which  depends  on  the  degree  of  the  infiltration  of  the  leucocytes. 
Many  observers  describe  also  a  marked  increase  in  the  interstitial  tissue, 
and  ascribe  to  it  a  part  in  the  production  of  the  other  changes.  In  this 
connection  it  is  interesting  to  note  that  Fenwick  ^  has  extracted  from 
the  spleens  of  rapidly  fatal  cases  of  scarlet  fever  a  substance  which 
introduced  into  the  circulation  of  animals  tends  to  produce  an  acute 
parenchymatous  nephritis. 

Symptoms. — It  is  a  very  difficult  matter  to  give  a  comprehensive 
yet  succinct  account  of  the  symptoms  of  a  disease  which  presents  so 
variable  a  course  as  scarlatina.  It  will  perhaps  be  best  for  purposes 
of  description  to  divide  the  affection  into  those  cases  which  have 
an  ordinary  or  typical  course,  those  which  are  malignant,  and  those 
in  which  variations  from  the  normal  course  of  the  malady  are  to  be 
noted. 

The  Ordinary  Form. — As  a  rule,  in  the  period  of  incubation  there 
are  no  symptoms  or  they  are  so  slight  as  to  pass  unnoticed.  Some- 
times, however,  slight  malaise  is  complained  of  if  the  patient  be  old 
enough  to  give  expression  to  his  sensations,  and  if  the  temperature  be  • 
taken  a  slight  evening  rise  may  be  detected.  The  stage  of  invasion  is 
ushered  in  abruptly,  so  that  commonly  the  exact  time  of  the  beginning 
of  illness  can  be  stated.  In  a  large  proportion  of  cases  chilly  sensations 
are  experienced  in  the  commencement  of  an  attack,  and  in  some  a 
decided  rigor.  In  young  children  it  may  happen  that  a  convulsion  is  the 
first  symptom  of  illness.  The  temperature  rises  rapidly,  and  in  a  few 
hours  attains  a  considerable  degree.  It  may  reach  102°,  103°,  104°  F., 
or  even  higher.  The  increased  temperature  is  accompanied  by  those 
symptoms  which  usually  mark  fever  from  any  cause,  such  as  headache, 
loss  of  appetite,  flushing  of  the  face,  sparkling  eyes,  and  thirst.  Coin- 
cident with  the  elevation  of  the  temperature  there  is  an  increase  in  the 
rapidity  of  the  pulse,  and  it  is  a  thing  to  be  noted  that  the  pulse  rate 
in  scarlet  fever  is  out  of  proportion  to  the  height  of  the  fever. 

Vomiting  is  one  of  the  most  important  of  the  early  symptoms  of 
scarlet  fever.  It  may  occur  but  once,  but  it  is  apt  to  be  repeated  during 
the  first  day.  Smith  has  found  vomiting  present  in  162  out  of  214 
cases  of  scarlet  fever.  Thomas  states  that  it  occurs  more  frequently  as 
an  initial  symptom  of  scarlet  fever  than  with  any  other  disease  of  child- 
hood except  smallpox  and  pneumonia.  Vomiting  in  the  early  period  of 

^  British  Medical  Journal,  Aug.  19,  1894. 


SYMPTOMS.  591 

st'iirk't  lever  ha.s  been  variously  interpreted.  It  is  generally  regarded  as 
a  nervous  phenomenon,  but  by  some  it  is  thought  to  indicate  a  catarriud 
eondition  of  the  stomach.  In  rare  instanees  vomiting  may  continue 
through  the  course  of  the  disease,  constituting  one  of  the  most  embar- 
rassing symptoms,  as  it  may  seriously  interfere  with  the  administratiun 
of  food  and  medicine.  In  a  certain  })roportion  of  cases  there  is  a  mild 
diarriuva,  which  usually  ceases  after  a  day  or  two.  In  a  small  number 
of  the  more  severe  cases  this  symptom  assumes  alarming  proportions. 
At  this  period  of  the  disease  the  tongue  is  usually  coated  with  a  thick 
whitish  fur,  through  which  the  swollen  hvjienemic  papilhe  may  be  seen 
protruding.  From  the  very  onset  of  the  malady  there  is  sore  throat. 
In  adults  and  older  children  this  is  evinced  by  difficulty  and  pain  on 
deglutition.  The  different  characters  presented  by  the  throat  have  been 
sufficiently  dealt  with  under  the  heading  of  Pathological  Anatomy  (page 
588).  In  the  ordinary  cases  it  is  only  the  less  severe  forms  of  throat 
trouble  which  are  found.  The  lymphatic  ganglia  over  the  tonsils  at 
the  angle  of  the  jaws  are  enlarged  and  tender  on  pressure.  There  is 
little  evidence  at  this  period  of  any  catarrhal  involvement  of  other 
raucous  membranes. 

The  symptoms  presented  in  the  stage  of  invasion  on  the  part  of  the 
nervous  system  vary  considerably  in  different  cases.  As  already  men- 
tioned, it  is  not  uncommon  to  have  one  or  more  convulsions,  and  it 
is  worthy  of  note  that,  occurring  at  this  time,  they  are  not  of  such 
grave  significance  as  when  seen  at  a  later  date.  Nearly  always  from 
the  first  there  is  marked  prostration.  Often  the  patient  lies  in  a  dull, 
apathetic  state.  In  other  cases  restlessness  with  twitching  of  the  limbs 
occurs. 

The  Bash. — Generally  before  the  end  of  twenty-four  hours  from  the 
initial  symptoms  the  rash  makes  its  appearance.  Sometimes  it  is  not 
developed  till  the  second  day,  and  in  very  rare  cases  not  till  a  later 
,  period.  The  rash  appears  first  on  the  neck,  chest,  shoulders,  or  lateral 
parts  of  the  face  in  rather  ill  defined  patches.  The  patches  rapidly 
coalesce,  till  in  the  course  of  a  few  hours,  nearly  always  less  than  half  a 
day,  the  whole  body  is  covered.  The  lips  and  alte  nasi  generally  escape 
the  rash,  and  when  the  cheeks  are  brightly  tinged  the  contrast  between 
the  scarlet  and  white  portions  of  the  face  gives  a  peculiar  and  striking 
appearance.  The  characters  of  the  rash  have  already  been  mentioned. 
It  begins  as  small  points  of  a  red  color,  but  in  a  very  short  time  becomes 
a  diffuse  scarlet  erythema,  wdth  innumerable  points  of  a  deeper  hue 
scattered  over  the  surface.  The  rash  as  usually  seen  very  closely  resem- 
bles the  appearance  caused  by  the  application  of  a  mustard  plaster.  In 
some  cases  where  the  rash  is  rather  mild  the  original  red  points  may 
remain  discrete.  This  is  said  to  be  most  prone  to  happen  on  the  abdo- 
men. The  rash  generally  is  best  developed  on  dependent  parts  and 
regions  kept  warm,  as  on  the  back  and  at  the  flexures  of  the  joints. 
Although  the  involved  surface  may  appear  smooth  to  the  eye,  yet  if  the 
hand  be  passed  gently  over  it  a  fine  roughness  can  be  detected.  The 
scarlet  color  can  be  made  to  disappear  by  pressure,  but  returns  as  soon 
as  the  finger  is  raised.  If  sufficient  irritation  of  the  capillary  walls  be 
produced,  as  by  stroking  the  skin  roughly  with  a  pencil,  a  white  line 
persists  for  some  moments.     At  one  time  this  phenomenon  was  supposed 


592  SCARLET  FEVER. 

to  be  characteristic  of  scarlet  fever,  but  we  now  know  that  it  is  common 
to  many  erythemas.  The  surface  involved  is  hypersesthetic,  and  a  sen- 
sation of  itching  and  burning  is  often  experienced. 

The  time  required  for  the  full  development  of  the  rash  varies.  In 
mild  cases  it  may  reach  its  height  on  the  first  day.  In  other  cases  the 
full  bloom  of  the  efflorescence  is  not  attained  till  the  second,  third,  or 
even  fourth  day,  and  in  rare  cases  at  a  later  date.  When  the  eruption 
is  at  its  height  the  skin  is  tense  and  swollen  and  has  an  oedematous  look, 
especially  about  the  eyelids. 

While  the  rash  is  reaching  its  full  development  the  other  symptoms 
are  increasing  in  severity.  The  temperature  in  ordinary  cases  may 
reach  its  maximum  as  the  rash  comes  out,  a  height  of  105°  F.  being  not 
uncommon.  It  may  remain  at  this  point  till  the  rash  has  attained  its 
acme  and  then  gradually  decline.  At  other  times  there  is  a  steady 
increase  in  fever  pari  passu  with  the  progress  of  the  eruption  toward 
full  bloom.  In  rather  mild  cases,  when  the  rash  is  not  fully  developed 
till  the  second  day,  it  often  happens  that  in  the  morning  of  that  day 
there  is  a  decided  remission  in  the  febrile  movement. 

The  tongue  by  the  fourth  day  has  usually  lost  its  coating  and  has 
become  of  a  bright  red,  often  glazed,  color.  It  is  studded  over  with 
swollen  papillse  (strawberry  tongue). 

The  throat  symptoms  increase  in  severity.  Besides  the  redness  and 
oedema  already  noted,  the  tonsils  become  covered  with  a  layer  of  yellow- 
ish pus.  The  inflammation  not  infrequently  extends  forward  into  the 
buccal  caA'ity  and  upward  into  the  nose,  from  which  there  is  a  muco- 
purulent discharge. 

Usually  by  the  time  the  disease  has  reached  its  height  the  vomiting 
and  diarrhoea  which  may  have  been  present  at  first  have  ceased,  and 
constipation  exists.  The  nervous  symptoms  also  increase,  and  there 
may  be  delirium  with  restlessness  or  sometimes  profound  somnolence. 
The  pulse  remains  rapid. 

The  urine  at  the  height  of  the  malady  is  high  colored,  loaded  with 
urates,  and  diminished  in  quantity.  In  the  majority  of  cases  at  this 
time  at  least  a  trace  of  albumin  can  be  found,  and  often  it  is  consider- 
able in  amount.  Some  authors  (as  Bartels  and  Thomas)  ascribe  the 
albuminuria  of  this  period  to  the  pyrexia,  while  others  (Steiner  and 
Eisenschitz)  think  that  it  indicates  an  organic  lesion  of  the  kidney.  It 
is  the  latter  view  which  is  now  accepted.  Indeed,  this  is  the  only  log- 
ical opinion,  for  it  often  happens  that  there  are  in  the  urine  evidences 
of  renal  mischief  other  than  albumin.  Red  and  white  blood  cells  and 
hyaline  and  blood  casts  can  frequently  be  detected.  In  many  similar 
diseases  it  has  been  shown  that  nephritis  can  exist  early  in  the  illness, 
and  Klein  has  found  glomerulitis  in  scarlet  fever  as  early  as  the  second 
day.  Obermiiller  first  called  attention  to  the  presence  in  the  urine  of 
scarlatinous  patients  of  peptone.  Arslan,^  after  extended  observations, 
thinks  this  is  a  symptom  of  the  greatest  importance.  His  conclusions 
are  as  follows  :  (1)  No  peptone  is  found  in  mild  cases  ;  (2)  the  urine 
contains  peptone  in  grave  cases  associated  with  complications,  the  occur- 
rence of  the  latter  being  preceded  by  peptonuria  ;  (3)  the  presence  of 
considerable  quantities  of  peptone  is  an  unfavorable  sign ;  (4)  the  pres- 

'  Gazette  medicale  de  Paris,  Feb.  25,  1894. 


SYMPTOMS.  593 

eiice  of  peptone  is  not  inlluenccd  by  ;ill)iMnin  or  by  the  condition  nfthe 
pulse  or  tempcraturo. 

The  eruption  stays  out  in  lull  bloom  from  a  few  hours  to  one  day. 
It  fades  from  the  body  in  the  order  of  its  appearance,  often  lin<»;ering 
long'cst  on  the  backs  of  the  iiands  and  feet.  Generally  by  tlie  end  of 
the  third  day  from  the  be<;iiininii'  of  decline  the  rash  will  have  entirely 
vanished.  The  whole  duration  of  the  ei-u])tiou  is  from  three  to  seven 
davs.  Oeterloney/  by  counting-  from  the  commencement  of  fever  to 
its  subsidence,  found  the  average  duration  in  40  cases  to  be  six  and  a 
half  days. 

^^'ith  the  fading-  of  the  rash  all  the  other  symptoms  grow  better. 
The  fever  falls  by  lysis,  the  throat  heals,  the  appetite  returns,  the 
nervous  symptoms  disappear,  and  the  urine  grows  more  abundant 
and  of  lighter  color,  while  anv  albumin  which  it  mav  have  contained 
usually  disappears. 

Dcsqiiaiudfioit,  may  begin  as  early  as  the  third  day,  though  most  often 
not  till  about  the  time  of  the  fading-  of  the  rash.  In  rare  cases  it  has 
first  appeared  at  a  considerable  period  after  the  termination  of  the 
eruption.  The  character  and  amount  of  the  desquamation  depend  in 
large  degree  upon  the  severity  of  the  preceding  eruption.  Where  the 
rash  has  been  slight  the  desquamation  may  be  furfuraceous.  In  typical 
eases,  however,  it  occurs  in  large  lamellae,  and  in  severe  cases,  in  regions 
where  the  epidermis  is  thick,  as  on  the  hands,  perfect  casts  of  the 
member  may  be  exfoliated.  Desquamation  usually  continues  for  a 
week  or  ten  days,  though  it  may  be  prolonged,  and  in  some  cases  a 
second  or  even  third  desquamation  has  occurred.^ 

By  the  time  desquamation  is  completed  convalescence  is  well  estab- 
lished and  all  morbid  symptoms  have  passed  away,  save  that  the  pulse 
is  apt  to  continue  rapid,  sometimes  until  convalescence  is  far  advanced. 

Even  with  the  beginning  of  convalescence  the  disease  cannot  be 
treated  as  though  it  were  a  thing-  of  the  past,  for,  as  we  shall  see, 
although  an  attack  may  have  been  mild,  the  patient  is  more  or  less 
liable  to  serious  sequelae.  Such  unfortunate  accidents  are  especially  liable 
to  result  if  recovery  has  been  too  readily  assumed  and  the  safeguards 
which  should  have  been  thrown  around  the  convalescent  have  been  too 
soon  relaxed. 

Between  the  ordinary  form  of  scarlet  fever  which  has  been  outlined 
and  the  grave  form  to  be  described  there  are  all  grades  of  severity.  An 
eifort  has  been  made  in  the  description  to  indicate  this  and  to  keep  con- 
stantly before  the  mind  of  the  reader  the  marked  variations  in  the  course 
of  the  malady. 

3Ialignant  Forms  of  Scarlatina. — In  almost  every  epidemic  of  scarlet 
fever  there  occur  a  certain  number  of  cases  which  may  properly  be 
called  malignant  on  account  of  their  great  tendency  to  a  fatal  issue. 
In  some  epidemics  the  number  of  these  cases  is  especially  striking,  so 
that  we  are  led  to  believe  that  at  such  times  the  poison  of  scarlet  fever 
is  of  unusual  virulence. 

In  one  form  of  malignant  scarlatina  the  intoxication  is  so  severe  that 
death  may  result  on  the  first  day  of  the  period  of  invasion,  the  patient 

^  System  of  Medicine,  Pepper,  vol.  ii.  p.  506. 

^  Cyclopedia  of  the  Diseases  of  Children,  Keating,  p.  567. 

Vol.  I.— 38 


594  SCARLET  FEVER. 

being  overwhelmed  before  the  eruption  has  manifested  itself.  Where 
the  fatal  termination  is  not  so  immediate,  the  symptoms  from  the  first 
indicate  the  gravity  of  the  case.  The  manifestations  on  the  part  of  the 
nervous  system  are  severe.  There  are  intense  headache,  extreme  restless- 
ness, delirium,  convulsions,  and  not  uncommonly  the  patient  rapidly  falls 
into  a  state  of  coma.  The  fever  reaches  an  untoward  height,  a  tempera- 
ture of  107°  F.  and  even  higher  having  been  observed.  The  pulse  attains 
such  a  degree  of  rapidity  that  it  may  be  impossible  to  count  it.  Great 
irritability  of  the  stomach  is  a  frequent  symptom,  and  the  dangerous 
condition  may  be  rendered  even  more  unfavorable  by  constant  vomiting. 
In  those  who  survive  the  rash  is  slow  in  coming  out,  and  is  frequently 
of  a  more  dusky  hue  than  is  observed  in  the  ordinary  cases.  In  the 
small  proportion  of  cases  which  recover  the  whole  course  of  the  illness 
is  apt  to  be  lingering  and  tedious. 

Another  form  of  scarlatina  of  marked  malignancy  is  the  hemorrhagic 
type  of  the  disease.  The  symptoms  are  severe  from  the  onset ;  hemor- 
rhages from  the  various  outlets  of  the  body  occur.  There  may  be  epis- 
taxis,  bleeding  from  the  gums,  and  hEematuria.  When  the  eruption 
appears  it  assumes  a  hemorrhagic  form.  At  first  petecliise  are  seen  in 
the  skin,  but  these  rapidly  grow  larger,  and  the  entire  surface  may  be 
involved  in  large  hemorrhagic  areas.  Death  often  takes  place  on  the 
second  or  third  day.  Post-mortem  parenchymatous  hemorrhages  are 
found  to  have  occurred  in  the  various  organs. 

Scarlatina  anginosa  should  be  classed  among  the  malignant  varieties 
of  the  disease.  The  stress  of  the  attack  seems  to  fall  upon  the  throat. 
The  mucous  membrane  of  the  throat  presents  from  the  beginning  much 
swelling,  and  is  apt  to  show  a  cyanotic  or  livid  hue.  A  membranous 
exudation  forms,  which  may  extend  into  the  larynx,  mouth,  or  nose. 
The  lymphatics  of  the  neck  rapidly  enlarge.  Xecrosis  or  gangrene  of 
the  affected  structure  results,  and  the  breath  has  an  extremely  fetid 
odor.  The  patient  lies  semicomatose,  the  picture  of  one  suffering  from 
profound  septicaemia.  If  death  does  not  terminate  the  scene  too  early, 
there  may  be  an  extension  of  the  inflammation  to  the  cellular  planes  of 
the  neck.  The  tissties  may  become  swollen  to  such  a  degree  that  the 
neck  is  even  with  the  chin.  There  is  much  infiltration  and  brawniness, 
so  that  the  mouth  can  no  longer  be  opened  to  inspect  the  throat.  Diffi- 
culty in  breathing  may  result  from  the  swollen  condition  of  the  tonsils 
and  the  pressure  of  the  infiltrated  tissues  of  the  neck,  or  from  an  exten- 
sion of  the  trouble  into  the  larynx.  The  cellulitis  may  lead  to  the 
formation  of  abscesses  of  the  neck  or  gangrene  of  large  portions  of 
tissue  may  result,  the  separation  of  which  may  lead  to  fatal  hemorrhage. 

Variations  from  the  Ordinary  Course  of  Scarlatina. — It  has  been 
indicated  above  that  scarlet  fever  presents  a  great  number  of  variations 
from  Avhat  we  may  term  the  normal  course  of  the  disease.  Although 
it  would  be  an  endless  task  to  catalogue  all,  it  is  necessary  to  consider 
some  of  the  more  important  of  these  abnormal  forms. 

Though  no  case  of  scarlet  fever  can  be  regarded  as  entirely  free 
from  danger,  there  are  many  cases  which  are  extremely  mild.  In  these 
cases  the  febrile  symptoms  are  slight,  the  temperature  not  rising  much 
above  100°  F. ;  the  nervous  symptoms  are  absent ;  the  involvement  of 
the  throat  is  limited  to  a  slight  catarrh,  with  some  injection  and  redness 


SYMPTOMS.  595 

of"  the  tonsils  and  faiicos.  The  rash  is  never  very  distinct,  and  is  not 
of  that  briti'ht  scarlet  color  which  is  so  characteristic  of  the  eruption  in 
its  typical  I'orni,  but  has  more  of  a  ])ink  hue  and  fades  in  a  day  or  two 
after  its  appearance.  The  patient  does  not  feel  ill  enough  to  jjo  to  l^ed. 
Under  pro})er  treatment  these  cases  run  a  course  as  favorable  as  the 
sym|»tonis  are  mild,  but,  unfortunately,  it  is  this  class  of  cases  which 
is  often  dia^iuosed  "scarlet  rash,"  and  to  which  the  name  scarlatina  is 
applied  by  ignorant  persons  under  the  im|)ression  that  this  term  implies 
an  eruption  entirely  distinct  from  scarlet  fever  and  not  tlangerous. 
These  mild  cases  sometimes  are  followed  by  the  sequelae  of  scarlet  fever, 
and  demand  as  much  care  as  the  more  severe  types  of  the  disease. 

Cases  of  scarlatina  have  been  reported  in  which  thntughout  the  ill- 
ness there  was  no  rise  in  the  temperature.  It  is  very  likely  that  many 
such  instances  have  i)cen  cases  of  scarlatinoid  erythemas.  It  is  not  im- 
possible, however,  that  scarlatina  may  ruu  its  course  without  fever, 
since  the  same  apyretic  course  has  been  seen  in  typhoid  fever.  Fies- 
singer'  in  a  paper  on  this  subject  draws  these  conclusions  :  (1)  There  is 
a  form  of  scarlet  fever  in  which  the  fever  is  entirely  absent.  (2)  This 
form  may  be  observed  in  the  same  epidemic  and  alongside  the  grave 
and  pyretic  forms  ;  it  is  contagious,  and  may  give  rise  to  the  ordinals- 
form  of  the  disease,  complicated  with  Bright's  disease  or  with  pseudo- 
membranous angina.  (3)  There  is  no  local  symptom  to  differentiate 
the  apyretic  from  the  pyretic  form.  (4)  The  pulse  is  not  always  accel- 
erated in  the  apyretic  form.  (5)  The  ap^Tetic  form  is  characterized  by 
the  absence  of  general  phenomena. 

The  diagnosis  of  this  form  of  scarlatina  from  other  erythemas  must 
be  very  difficult,  and  could  be  made  only  in  the  presence  of  an  epidemic 
or  when  some  of  the  well  known  sequelae  of  scarlet  fever  follow. 

Most  authors  are  agreed  that  scarlet  fever  without  the  rash  may 
occur.  During  the  epidemic  cases  of  sore  throat  of  greater  or  less 
severity  are  observed,  after  which  desquamation  or  nephritis  follows. 
The  writer  knows  of  a  young  medical  man  who  had  never  had  scarlet 
fever,  and  who,  while  attending  some  severe  cases  of  scarlatina,  was  seized 
by  a  chill  followed  by  an  intensely  sore  throat.  On  the  second  day  the 
urine  became  bloody  and  a  hemorrhagic  nephritis  was  found  to  be  pres- 
ent. In  this  case  no  desquamation  was  observed.  In  speaking  of  this 
subject  under  the  heading  Immunity,  page  583,  attention  was  called  to 
the  fact  that  the  true  scarlatinal  nature  of  such  attacks,  however  prob- 
able it  may  seem,  is  generally  open  to  question. 

Cases  in  which  the  rash  is  present  M-ithout  the  sore  throat  have  been 
reported,  l^ut  their  occurrence  is  doubted  by  many  authorities,  and  it 
seems  to  the  author  justly  so,  for  we  know  that  there  are  a  number  of 
erythemas  which  very  closely  simulate  scarlatina,  the  chief  differential 
point  being  the  absence  of  sore  throat. 

In  some  cases  of  scarlatina  the  fever  is  peculiarly  prolonged,  and 
the  patient  falls  into  a  low  condition  to  which  the  term  typhoid  is  applied. 
In  such  cases  the  local  lesions  are  not  sufficiently  severe  to  account  for 
the  long  continuance  of  the  fever.  The  temperature  is  high,  and  may 
continue  in  a  more  or  less  remittent  form  for  several  weeks.  The  nerv- 
ous symptoms  are  marked  and  peculiar.     A  low  form  of  mental  hebe- 

^  Gazette  medicale  de  Paris,  March  4,  1894. 


596  SCARLET  FEVER. 

tude  develops,  and  the  patient  lies  partially  unconscious  with  a  dull, 
apathetic  expression,  his  hands  aimlessly  fumbling  Avith  the  bedcover- 
ing.  The  tongue  and  lips  are  dry  and  cracked  and  sordes  accumulates 
on  the  teeth.  The  likeness  to  typhoid  fever  is  still  further  carried  out  by 
the  fact  that  there  is  marked  enlargement  of  the  spleen  and  there  may  be 
diarrhoea.  It  is  stated  that  after  death  in  some  of  these  cases  Peyer's 
patches  and  the  mesenteric  glands  have  been  found  enlarged.^ 

Thomas  and  Gumprecht^  have  recorded  cases  in  which  the  fever 
persisted  for  from  eight  to  fifteen  days  beyond  the  usual  period,  but 
without  serious  symptoms.  In  these  cases  defervescence  occurred  more 
or  less  abruptly,  and  at  no  time  was  there  hyperpyrexia.  The  cause  of 
this  long  continued  fever  seemed  to  be  streptococcus  infection  which  had 
occurred  through  the  tonsils. 

Bouveret  ^  has  noted  in  some  cases  a  secondary  hyperpyrexia  which 
occurred  on  the  ninth  or  tenth  day  and  after  the  rash  had  disappeared. 
The  temperature  rose  rapidly  to  105°  or  106°  and  was  accompanied  by 
grave  nervous  symptoms. 

Talamon  *  refers  to  cases  in  which  there  was  hyperpyrexia  even  from 
the  first  day,  Avhich  persisted  for  a  period  of  eighteen  or  twenty  days. 
The  fever  was  not  dependent  upon  any  local  lesion,  but  was  the  essen- 
tial element  and  constituted  the  entire  danger.  Talamon  found  that 
cold  affusions  as  ordinarily  practised  are  worthless,  in  such  cases  the 
OJily  efficient  treatment  being  full  cold  baths  at  frequent  intervals.  In 
this  connection  the  writer  would  mention  certain  cases  that  he  has  seen 
w^hich  were  marked  from  the  first  by  a  hyperpyrexia  which  could  not 
be  controlled  even  by  cold  baths,  the  patients  rapidly  dying  from  the 
effects  of  the  high  degree  of  fever. 

Relapses. — Reference  has  been  made  to  relapses  of  scarlatina  under 
the  heading  Immunity,  page  583.  Here  it  is  only  necessary  to  mention 
that  the  form  to  which  Thomas  has  given  the  name  pseudo-relapse 
varies  in  its  course  considerably  from  the  ordinary  form  of  the  disease. 
The  rash  may  appear  only  on  limited  regions  of  the  body ;  when  it 
affects  the  face  the  region  about  the  mouth  and  nose  is  not  exempt. 
The  eruption  does  not  reach  its  full  development  on  all  the  affected 
portions  at  nearly  the  same  time,  but  progresses  in  an  irregular  manner. 
The  behavior  of  the  temperature  during  the  pseudo-relapse  is  irregular, 
and  the  maximum  of  the  rash  and  the  highest  fever  do  not  coinoide. 

Variations  in  Type. — In  general  it  may  be  said  that  marked  varia- 
tions in  the  course  of  scarlet  fever  are  caused  by  the  complications 
which  may  arise.  This  part  of  the  subject  will  be  more  particularly 
referred  to  in  speaking  of  Complications,  page  597. 

The  most  important  variations  which  occur  in  the  local  symptoms 
of  scarlet  fever  are  the  different  forms  which  may  be  presented  by  the 
eruption.  It  may  happen  that  the  rash  develops  first  ujdou  some  unusual 
site,  as  the  abdomen,  back,  or  limbs.  Again,  it  may  appear  on  the  whole 
surface  at  the  same  time.  The  rash  may  occupy  only  certain  regions, 
as  one  half  of  the  body  or  the  upper  portion,  while  the  rest  is  free.  It 
has  been  noted  occurring  on  very  limited  areas,  as  upon  a  small  part 

^  Cyclopedia  of  the  Practice  of  Medicine,  Von  Ziemssen,  vol.  ii.  p.  269. 

^  Deutsche  medicinische  Wochenschrift,  July,  1 888. 

^  Revue  de  Medecine,  April,  1893.  *  La  Medecine  moderne,  Sept.  15,  1893. 


'    COMI'LICATloys  jyjf  SEQUELyK  597 

of  the  belly,  on  tlie  neck,  or  in  the  flexnre.s  of  tlie  joints.  Some  anthors 
state  that  scarlatina  is  prone  to  avoid  paralyzed  liinl)s.  The  niinnte 
characters  of  the  erui)tion  may  also  vary.  It  may  not  be  of  the  nsnal 
scarlet  color,  bnt  a  liuhter  red,  and  in  cases  where  for  any  reason  there 
is  marked  slnuuishness  of  the  circnlation  a  very  dusky  hue  may  be 
noticed.  The  rash  instead  of  becoming  confluent  may  occur  as  small 
red  macules.  Reference  has  already  been  made  to  the  fact  that  in  most 
oases  on  passing  the  hand  over  the  surface  a  roughness  can  be  felt.  In 
some  cases  there  are  more  decided  elevations  of  the  skin,  which  can  be 
detected  by  the  eye  as  numerous  minute,  acuminate  papules  ;  to  this 
form  the  term  papular  scarlatina  has  been  apj)lied.  There  may  occur 
over  the  surface,  especially  in  regions  kept  warm,  a  crop  of  miliary 
vesicles  constituting  vesicular  scarlatina.  Should  the  contents  of  the 
vesicles  become  purulent,  we  have  the  form  of  the  disease  which  is 
<'alled  pustular  scarlatina. 

Those  grave  forms  of  scarlatina  in  wliich  extensive  hemorrhages 
occur  in  the  skin  have  been  already  described.  In  other  cases  small 
petechife  may  be  observed  at  various  points  upon  the  surface,  and  this 
feature  in  itself  does  not  indicate  malignancy  of  the  attack. 

Such  is  a  description  of  the  most  commonly  observed  departures 
from  the  usual  course  of  scarlatina.  We  must  now  consider  the  coiu- 
plications  which  may  attend  and  the  sequelfe  which  may  follow  attacks 
of  the  malady. 

CoMPLiCATioxs  AXD  Sequel.e. — It  may  be  said  that  in  scarlatina 
the  complications  are  commonly  the  results  of  unusually  intense  morbid 
action  on  the  part  of  organs  which  are  affected  in  the  normal  course  of 
the  disease.  The  line  between  complications  and  sequelae  is  not  sharply 
drawn,  and  that  which  began  as  a  complication  may  by  long  duration 
become  a  sequel.  There  is  no  stage  of  scarlet  fever  which  is  free  from 
liability  to  complications.  AVhile  they  are  most  frequent  in  severe  epi- 
demic and  grave  cases,  still,  even  in  the  mildest  case  serious  complica- 
tions may  arise.  It  may  here  be  mentioned  that  just  before  a  com- 
plication of  some  important  organ  is  discovered  the  rash,  which  has 
been  out  in  full  bloom,  will  suddenly  fade.  This  phenomenon  is  pop- 
ularly known  as  "  striking  in,"  and  among  the  laity,  and  formerly  even 
in  the  profession,  the  complication  which  existed  was  regarded  as  the 
direct  attack  of  the  rash  upon  the  affected  organ.  Hebra  first  showed 
that  "  striking  in  "  was  to  be  regarded  as  the  result  and  not  the  cause 
of  the  complication. 

Among  the  most  important  as  well  as  the  most  frequent  complications 
of  scarlatina  the  affections  of  the  nervous  system  deserve  a  place.  Those 
malignant  cases  in  which  the  patient  falls  almost  at  once  into  coma  have 
been  considered,  as  well  as  the  delirium  which  may  arise  from  hyper- 
thermia. Convulsions  occur  chiefly  at  the  beginning  and  toward  the 
close  of  an  attack  of  scarlet  fever.  In  the  first  instance  they  are  usually 
due  to  the  action  of  the  scarlatinal  poison  upon  the  nervous  centres, 
while  in  the  second  they  are  often  an  accompaniment  of  the  condition 
known  as  uraemia.  Convulsions  may  also  indicate  the  onset  of  a  grave 
complication,  and  may  thus  occur  at  any  period  of  the  disease.  All  the 
symptoms  of  an  acute  meningitis  may  be  present,  and  it  is  often  a  matter 
of  much  difficulty  to  decide  whether  that  rare  complication  really  exists, 


598  SCARLET  FEVEB. 

for  in  cases  presenting  such  a  train  of  symptoms  a  post-mortem  exami- 
nation has  not  infrequently  shown  an  absence  of  the  anatomical  features 
of  meningitis.  A  case  ^  has  recently  been  reported  in  which  persistent 
hiccough  set  in  on  the  third  day.  The  paroxysms  came  on  every  two 
or  three  minutes,  and  were  so  severe  that  eating,  drinking,  and  sleeping 
were  interfered  with.  The  attack  lasted  seven  days,  and  terminated  in 
recovery. 

The  severe  forms  of  angina  which  occur  with  scarlet  fever  have  been 
described.  In  addition  to  what  has  been  said,  it  may  here  be  mentioned 
that  necrosis  of  the  tissues  may  result  in  perforation  of  the  soft  palate  ^ 
or  an  external  opening  into  the  pharynx,  so  that  food  cannot  be  swal- 
lowed." In  cases  of  severe  cellulitis  of  the  neck  the  inflammation  may 
extend  down  into  the  mediastinum.  A  very  frequent  complication  of 
scarlatina  is  membranous  deposit  in  the  throat.  The  discussion  of  the 
significance  of  this  symptom  will  be  found  under  the  heading  Diagnosis 
(page  604). 

The  fact  that  the  Eustachian  tubes  open  into  the  pharynx  makes 
inflammation  of  the  middle  ear  a  common  complication.  The  inflam- 
mation from  the  fauces  creeps  up  into  the  tympanic  cavity,  and,  as  the 
Eustachian  tube  is  very  often  occluded,  the  products  of  inflammation 
have  no  means  of  escape.  By  the  accumulation  in  the  middle  ear  are 
caused  pain,  increase  in  fever,  and  bulging  of  the  membrana  tympani. 
When  the  Eustachian  tube  is  completely  occluded  the  pent-up  secretions 
can  escape  only  by  a  perforation  of  the  drumhead.  After  this  has 
occurred  in  favorable  cases  a  purulent  discharge  exists  for  a  shorter  or 
longer  time,  and  then  the  opening  in  the  membrane  heals  with  very 
little  permanent  injury  to  the  ear.  Unfortunately,  in  a  great  many 
cases  this  happy  result  is  not  obtained.  If  pus  be  for  long  pent  up 
in  the  tympanum,  permanent  injury  may  be  wrought  to  the  delicate 
structures  there  contained,  necrosis  of  the  small  bones  may  result,  or 
the  inflammation  may  extend  to  the  mastoid  cells.  The  mucous  mem- 
brane which  lines  the  bony  walls  of  the  tympanum  largely  contributes 
to  their  nourishment,  and  when  this  function  is  disturbed  by  the  inflam- 
mation necrosis  of  the  bone  may  result.  This  is  a  serious  condition,  as 
the  anatomical  situation  of  the  tympanum  renders  it  easily  possible  for 
other  important  structures  to  be  involved  with  it.  Septic  thrombosis 
may  occur  in  the  adjacent  sinuses  or  veins ;  meningitis  or  abscess  of 
the  brain  may  result.  Even  if  no  such  serious  accident  follows,  total 
destruction  of  the  drumhead  with  loss  of  the  ossicles  and  a  chronic 
purulent  discharge  may  be  the  final  outcome.  Where  a  gangrenous 
condition  of  the  fauces  has  existed,  gangrene  has  been  observed  to 
extend  up  the  Eustachian  tube  and  so  involve  the  ear.  When  the  ear 
is  affected  during  an  attack  of  scarlet  fever  in  children  who  are  old 
enough  to  speak,  pain  will  be  complained  of;  in  younger  children 
it  will  be  evinced  by  putting  the  hand  to  the  ear  or  by  pressing  the 
ear  against  the  pillow.  Such  actions  on  the  part  of  children  should 
always  ensure  an  examination  of  the  ears. 

It  has  been  mentioned  that  in  cases  of  any  severity  there  is  often 
more  or  less  involvement  of  the  Schneiderian  membrane.     Under  ordi- 

^  Lyon  medical,  Sept.  11,  1893.  ^  The  Medical  Weel;  Nov.  9, 1894. 

''  System  of  Medicine,  Pepper,  vol.  i.,  p.  512. 


-     COMPLICATIONS  AND  SEQUELjE.  599 

narv  cirt-umstant'cs  tlic  ni()rl)iil  j)ntt;('ss  ^ivcs  rise  to  a  piinik'iit  diri- 
oliai'tro,  and  resolves  without  any  permanent  damage  to  tlie  mucous 
membrane.  At  times,  however,  ulceration  occui-s  and  alarminu'  licmoi-- 
rhaiic  may  result. 

Infiannnatiiin  of  the  larynx  is  most  common  where  scarlet  lever  is 
eom[)licatcd  l)y  diphtheria.  Stenosis  of  the  laiynx  may  ensue  from  the 
amount  of  pseudo-membrane  formed  or  from  coincident  oedema.  Some- 
times ulceration  of  the  larynx  results. 

l^ronchitis  is  one  of  the  rarer  complications  of  scarlet  fever. 

Both  erou])ous  and  catarrhal  })neumonitis  may  occur  durinu'  the 
course  of  scarlatina,  and  are  more  likely  to  prove  fatal  when  appearing 
during  a  nephritis  than  when  manifested  earlier  in  the  disease.  Gan- 
grene of  the  lung  has  been  observed.  CEdema  of  the  lung  is  a  serious 
accident  that  may  arise  at  any  period  of  the  disease.  It  is  usually 
accompanied  by  sudden  foilure  of  the  heart's  action.  A  more  important 
complication  is  pleuritis,  which  may  develop  as  secondarv  to  some  lung 
troul)le,  but  more  often  occurs  independently,  coming  on  during  desqua- 
mation. Pleurisy  may  attain  considerable  proportions  Avithout  causing 
symptoms  which  would  attract  attention  to  its  existence,  but  its  presence 
is  usually  manifested  by  cough,  difficult  breathing,  and  pain  on  the 
atFected  side.  The  pleuritis  of  scarlet  fever,  just  as  the  other  serous 
membrane  inflammations  which  complicate  the  disease,  shows  a  tendency 
to  become  purulent.  Such  empyemas  run  the  same  tedious  course  seen 
in  those  which  arise  under  other  circumstances. 

The  involvement  of  the  buccal  mucous  membrane  which  is  observed 
in  scarlatina  amounts  usually  only  to  a  catarrh,  but  there  may  occur 
quite  severe  ulcerations  of  the  cheeks  and  gums,  and  in  rare  cases  the 
gangrenous  condition  called  noma. 

The  symptoms  on  the  part  of  the  gastro-intestinal  mucous  mem])rane 
may  be  severe.  Attention  has  already  been  called  to  the  fact  that  in 
some  cases  vomiting  is  persistent  and  becomes  a  serious  complication. 
Diarrhoea  may  also  be  a  grave  symptom.  In  rare  cases  the  gastro- 
intestinal disturbance  may  be  so  intense  early  in  the  disease  as  to  cause 
death.  In  such  cases  it  is  possible  that  a  large  dose  of  scarlatinal  poison 
has  been  taken  in  with  the  food  or  drink,  and  has  come  in  the  first  in- 
stance into  contact  with  the  gastric  or  intestinal  mucous  membrane.  In 
the  latter  part  of  an  attack  of  scarlet  fever  dysenteric  symptoms  may 
arise — tenesmus,  pain  on  pressure  over  the  colon,  and  bloody  stools. 

The  circulatory  apparatus  is  liable  to  attack.  The  heart  action  is 
usually  very  rapid  and  it  may  become  weak  and  irregular.  Post- 
mortem examination  shows  that  the  cause  for  this  is  often  found  in  a 
fatty  degeneration  of  the  muscular  fibres  of  the  organ.  In  life  such  a 
condition,  by  the  weakness  of  the  walls  of  the  heart  which  it  occasions, 
may  lead  to  acute  dilatation.  Fibrinous  coagula  sometimes  form  within 
the  cavities  of  the  heart,  and  pieces  of  these,  washing  away  in  the  blood 
stream,  may  give  rise  to  embolism  of  the  peripheral  arteries.  It  not 
infrequently  happens  that  during  scarlet  fever  murmurs  are  heard  over 
the  cardiac  region.  These  murmurs  present  different  characters  and 
depend  on  various  causes.  Some  are  hsemic  murmurs.  Some  of  them 
are  no  doubt  caused  by  a  relative  insufficiency  of  the  valves  due  to  the 
weakened  and  dilated  condition  of  the  walls  of  the  heart.     Such  abuor- 


600  SCARLET  FEVER. 

mal  souuds  disappear  as  convalescence  advances.  In  other  cases  the 
murmur  persists  and  other  signs  of   organic  valvular  lesion  develop. 

Thrombosis  of  veins  has  been  reported  as  occurring  as  a  complica- 
tion of  scarlatina.  When  this  takes  place  in  the  veins  of  the  cerebrum 
a  varied  train  of  nervous  symptoms  follows,  the  character  of  which  will 
depend  on  the  vein  aifected.  Inflammation  of  arteries  may  arise  during 
the  course  of  scarlatina.  Siredey  ^  has  reported  such  an  occurrence  in 
the  aorta.  Inflammation  of  the  pericardium,  though  not  a  common 
complication,  is  one  which  has  been  frequently  observed.  It  manifests 
the  same  symptoms  and  signs  as  when  found  under  other  circumstances. 
Kot  infrequently  the  accumulation  in  the  pericardial  sac  is  purulent. 

Peritonitis,  with  accumulation  of  pus  and  adhesions  between  the 
intestinal  coils,  is  sometimes  found  with  scarlet  fever.  The  writer  well 
remembers  a  case  in  which  all  the  symptoms  of  peritonitis — distention 
of  the  belly  with  gas,  constipation,  vomiting,  and  marked  sensitiveness 
to  pressure — came  on  toward  the  close  of  an  attack  of  scarlatina.  The 
urine  was  scanty  with  a  trace  of  albumin  and  an  occasional  cast.  So 
certain  were  those  who  had  the  case  in  charge  that  a  septic  peritonitis 
was  present  that  it  was  proposed  to  open  the  belly  for  drainage.  It  was 
decided  that  the  condition  of  the  child  was  too  bad  to  justify  such  a 
procedure.  At  post-mortem  examination  no  trace  of  peritonitis  was 
present,  but  there  was  a  nephritis  of  such  intensity  that  it  seemed 
strange  that  the  capsules  of  the  kidney  had  not  been  ruptured  by  the 
enormous  swelling  of  the  organs. 

The  affection  known  as  scarlatinal  rheumatism  is  a  synovitis  coming 
on  usually  during  the  latter  part  of  the  period  of  eruption  or  the  first 
of  desquamation.  It  attacks  most  often  the  phalangeal,  ankle,  and 
wrist  joints,  but  may  involve  any  articulation.  As  a  general  thing, 
there  is  little  swelling,  but  the  joint  is  painful  and  tender.  Some  be- 
lieve that  this  affection  is  really  rheumatism  complicating  scarlet  fever, 
but  the  writer  does  not  believe  that  this  assumption  is  necessary  to 
explain  the  symptoms  presented,  and  prefers  to  regard  scarlatinal  rheu- 
matism as  a  synovitis  clue  to  the  action  of  the  poison  of  scarlet  fever. 
It  is  thought  by  some  authors  that  the  presence  of  scarlatinal  rheuma- 
tism increases  the  liability  to  valvular  disease  of  the  heart.  Generally 
the  inflammation  of  the  joints  subsides  in  a  few  days,  but  in  rare  in- 
.stances  a  suppurative  synovitis  develops,  with  destruction  of  the  joint. 
AYhen  large  articulations  are  thus  affected  a  fatal  pyaemia  is  the  frequent 
result. 

Periostitis  may  complicate  scarlet  fever,  and  when  severe  may  lead 
to  necrosis  of  bone.  Separation  of  the  epiphyses  of  bones  ^  is  one  of 
the  rarer  accidents  which  may  occur  during  scarlet  fever. 

Myositis  is  an  unusual  complication.  It  may  be  manifested  as  a  cer- 
tain amount  of  infiltration  into  the  muscle,  with  pain  and  difficulty  of 
motion,  or  the  process  may  go  on  to  the  formation  of  abscesses. 

During  the  height  of  the  eruption  there  sometimes  occurs  a  conjunc- 
tivitis, though  this  is  not  a  common  complication.  A  keratitis  may 
develop  which  may  lead  to  the  formation  of  an  abscess  or  an  ulcer  of 
the  cornea.  Occasionally  the  whole  cornea  sloughs  and  the  eye  is 
destroyed  by  a  panophthalmitis.     A  purulent  panophthalmitis  can  also 

^  The  Medical  Week,  iSTovember  9,  1894.         ^  Canadian  Practitioner,  January,  1894. 


-     coMrucATioys  axd  sequels.  601 

occur  from  a  septic  embolus  lodjriuji;  in  tlie  eye.  When  there  is  a  diph- 
theritit'  complicatiou  in  the  throat  the  membranous  intlamination  some- 
times attat-ks  the  eve  and  may  lead  to  its  destruction.' 

That  other  infections  diseases  may  complicate  scarlatina  has  been 
mentioned  on  a  previous  pai!:e.  All  the  exanthemata  have  been  observed 
in  conjunction  with  it.  Of  course  the  gravity  of  tlie  affection  is  added 
to  by  such  complications. 

Certain  skin  lesions  may  arise  durino;  the  course  of  scarlatina.  The 
most  important  are  erysipelas,  urticaria,  herpes  simplex,  furunculus, 
and  ganurene  of  more  or  less  extensive  areas. 

Scarlatinal  Xcphritia. — Perhaps  the  most  important  complication  of 
scarlatina  is  nephritis.  By  many  nephritis  is  classed  as  a  sequel,  but 
if,  as  is  o;enerally  believed,  the  nephritis  really  finds  its  origin  in  the 
slight  affection  of  the  kidney  Avhich  occurs  at  the  height  of  the  erup- 
tive stage,  it  is  certainly  more  appropriate  to  consider  it  as  a  (.'omplica- 
tion.  As  has  been  mentioned,  if  a  careful  urinary  examination  is  made 
when  scarlatina  is  at  its  height,  it  can  usually  be  shown  that  there  is 
present  a  more  or  less  severe  inflammation  of  the  kidney.  In  the 
majority  of  cases  this  subsides  Avith  the  decline  of  the  malady,  and  if 
the  case  be  properly  cared  for  recovers  without  having  caused  any  note- 
worthy objective  symptoms.  In  a  certain  proportion  of  cases,  on  the 
other  hand,  the  inflammation  of  the  kidney  progresses,  and  in  the 
course  of  time  gives  evidence  of  its  presence  by  severe  symptoms. 
Although  nephritis  is  more  prone  to  occur  in  some  epidemics  than  in 
others,  there  is  no  case  of  scarlatina  so  mild  that  it  may  not  develop. 
Indeed,  the  very  mildness  of  a  case  of  scarlet  fever  may  render  the 
occurrence  of  nephritis  more  likely,  because  in  such  cases  the  necessary 
precautions  are  apt  to  be  neglected.  The  writer  has  seen  cases  in  which 
a  diagnosis  of  "  scarlet  rash "  had  been  made  by  an  ignorant  person, 
and  the  children  allowed  to  be  out  of  doors  during  the  whole  course  of 
the  disease,  as  they  did  not  seem  ill,  in  wliich  a  severe  nephritis  with 
general  anasarca  developed.  The  first  noticeable  symptoms  of  nephritis 
commonly  manifest  themselves  in  the  declining  period  of  scarlatina, 
during  desquamation  or  immediately  after  it,  though  cases  are  reported 
in  which  nephritis  is  supposed  to  have  first  developed  a  number  of 
Aveeks  after  an  attack  of  scarlet  fever.  Catching  cold  has  always  been 
regarded  as  the  chief  determining  factor  in  scarlatinal  nephritis.  It 
not  infrequently  happens  that  as  soon  as  the  severe  symptoms  attending 
the  rash  are  past  the  patient  is  allowed  to  be  up,  and  is  thus  exposed  to 
injurious  influences,  among  which  exposure  of  the  surface  to  varying 
degrees  of  temperature  is  certainly  one.  Probably  a  more  important 
factor  is  posture  and  the  increased  work  which  the  exertion  of  being  up 
and  around  throws  on  the  kidneys.  In  179  cases  which  GresswelP 
examined  albuminuria  returned  in  130  after  getting  up,  at  times  vary- 
ing from  twenty-four  to  thirty-one  days  after  the  beginning  of  illness. 

In  some  cases  the  onset  of  symptoms  attributable  to  nephritis  is 
abrupt.  The  fever,  which  has  declined  to  near  the  normal,  will  rise 
again,  there  will  be  headache,  perhaps  vomiting,  restlessness,  and  a  very 
.small  amount  of  highly  albuminous  and  even  bloody  urine.     In  the 

^  Atlanta  Medical  and  Surgical  Journal,  Marcli,  1891. 

^  A  Contribution  to  the  Natural  Histoi'y  of  Scarlatina,  Gresswell. 


602  SCARLET  FEVER. 

majority  of  cases,  however,  the  iuaiiguration  of  the  nephritis  is  more 
gradual.  Perhaps  the  fever  does  not  decline  so  rapidly  as  it  should,  or, 
having  reached  a  point  almost  normal,  it  may  continue  there,  this  small 
degree  of  fever  being  for  the  time  the  only  indication  that  things  are 
not  progressing  favorably,  or  it  may  be  the  fact  that  the  urine  is  grow- 
ing gradually  scantier  that  first  attracts  the  attention  to  the  presence 
of  nephritis.  Unless  a  careful  examination  of  the  urine  has  been  made 
at  frequent  intervals,  it  may  happen  that  oedema  will  be  the  first  evi- 
dence of  renal  mischief.  Dropsy  is  very  commonly  first  perceived  in 
the  eyelids  or  in  the  hands  and  feet ;  in  those  who  have  been  constantly 
in  bed  it  may  appear  first  upon  the  back.  In  a  severe  case  the  oedema 
extends  all  over  the  body,  the  skin  is  much  swollen  and  pits  on  pres- 
sure, and  often  where  the  swelling  is  greatest  there  will  be  tenderness. 
The  oedema  may  affect  other  organs.  Pulmonary  oedema  or  oedema  of 
the  glottis  may  reach  such  proportions  as  to  render  breathing  impossi- 
ble. Accumulations  of  fluids  in  the  serous  cavities  of  the  body  may 
be  so  large  as  seriously  to  interfere  with  the  function  of  important 
organs,  as  the  heart  or  lungs.  It  occasionally  happens  that  one  of  these 
internal  dropsies  is  first  to  develop,  and  the  anasarca  appears  only  at  a 
later  date,  or  it  has  been  noted  that  oedema  of  an  internal  organ — the 
lungs,  for  instance — has  been  the  only  manifestation  of  dropsy.  Oedema 
after  having  persisted  for  a  time  subsides  as  the  nephritis  grows  better, 
but  where  the  the  kidney  lesion  passes  into  a  chronic  form  the  oedema 
may  also  become  chronic. 

The  excrementitious  products  which  should  be  eliminated  in  the 
urine  accumulate  in  the  blood  during  the  nephritis,  and  often  in  such 
cpiantities  as  to  give  rise  to  alarming  symptoms.  The  term  uraemia  is 
applied  to  this  condition,  and  although  it  is  a  misnomer  it  is  retained, 
because  by  long  use  it  has  acquired  a  definite  significance.  The  symp- 
toms of  ureemia  vary  much  in  intensity.  They  may  be  manifested  only 
as  more  or  less  severe  headache,  vomiting,  restlessness,  twitching  of  the 
muscles,  or  sudden  dilatations  and  contractions  of  the  pupils.  In  more 
severe  cases  convulsions  occur,  and  these  may  be  succeeded  Ijy  coma. 
There  is  usually  a  definite  relation  between  the  ureemic  symptoms  and 
the  C|uantity  of  the  urine,  the  former  ])ecoming  more  severe  as  the  latter 
grows  less.  It  is  worthy  of  note  that  children  often  bear  uraemia  better 
than  adults,  recoveries  having  been  observed  under  the  most  unpromis- 
ing circumstances. 

The  condition  of  the  urine  in  scarlatinal  nephritis  varies  greatly  in 
different  cases.  In  the  milder  cases  it  is  slightly  diminished  in  cpian- 
tity,  while  in  severe  cases  it  may  be  as  little  as  50  c.c.  in  twenty-four 
hours,  or  anuria  may  exist  for  cjuite  long  periods.  The  specific  gravity 
is  higher  than  normal.  The  color  is  of  a  reddish  yellow,  or  may  be  red 
or  a  smoky  greenish  hue  from  the  blood  which  the  urine  contains.  The 
amount  of  albumin  varies  from  a  mere  trace  to  such  a  quantity  that  the 
urine  solidifies  on  boiling.  On  standing  there  falls  from  the  urine  a 
more  or  less  copious  sediment  made  up  of  urates  and  uric  acid  and 
formed  elements  from  the  kidney  in  varying  amounts.  Renal  epithe- 
lium may  be  found  in  differing  states  of  preservation,  some  of  the  cells 
much  swollen,  others  showing  fatty  degeneration.  In  most  cases  red 
blood  corpuscles  and  leucocytes  can  be  seen.     The  most  significant  signs 


COMPLICATIOXS  AaD  SEQUELM  OOo 

of  renal  iiiHainmatioii  are  the  easts,  of  wliich  several  different  f  »-nis 
may  I)e  found.  Hyaline  easts  are  nearly  always  j)resent,  and  at  times 
tlu'V  are  vcrv  lonn',  Hat,  and  eonvohited,  with  the  ends  unev(-n,  the  so- 
called  cylindroids.  Epithelial  easts  also  can  jrenerally  be  deni(jnstrated, 
and  when  blood  is  present  in  the  urine  blood  casts  are  formed. 
Althonjtjh  the  results  of  a  urinary  examination  usually  afford  the  most 
certain  evidence  of  nephritis,  it  sometimes  happens  tliat  marked  renal 
changes  exist  without  the  appearance  of  albumin  or  easts,  or  these  may 
occur  at  one  time  and  be  absent  at  another  examinaticju.  The  writer 
recalls  a  case  in  which  post-mortem  there  was  found  a  very  severe 
nephritis  apparently  involving  the  whole  of  both  kidneys,  in  which  in 
life  the  only  changes  in  the  urine  were  a  slight  diminution  in  quantity, 
a  small  amount  of  albumin,  and  an  occasional  hyaline  cast. 

The  course  of  scarlatinal  nephritis  presents  many  variations.  In 
ordinary  cases  in  the  course  of  a  week  or  ten  days  the  oedema  and  other 
symptoms  have  disappeared  and  convalescence  is  begun.  Careful 
urinary  examinations  will  often  show  traces  of  albumin  and  casts  for 
long  periods  even  in  these  favorable  cases.  In  rare  cases  a  small  amount 
of  oedema  persists,  the  patient  does  not  recover  health,  but  l^eeomes 
anaemic;  the  urine  constantly  contains  albumin  and  casts;  the  heart 
becomes  somewhat  hypertrophied ;  and  a  chronic  form  of  Bright's  dis- 
ease is  established.  When  death  occurs  during  an  acute  scarlatinal 
nephritis  it  is  generally  due  to  oedema  of  some  important  organ  or  to 
urtemic  poisoning.  Death  may  also  occur  from  some  acute  intercurrent 
inflammatory  trouble,  as  a  pneumonia  or  pericarditis. 

As  has  been  mentioned,  no  sharp  dividing  line  between  the  compli- 
cations and  the  sequels  of  scarlet  fever  can  be  drawn.  It  is  customary 
to  apply  the  term  sequelae  to  those  morbid  manifestations  which  appear 
after  the  activity  of  the  scarlatinal  poison  has  presumably  exhausted 
itself,  as  well  as  to  those  complications  which  persist  after  other  evidences 
of  the  malady  have  passed  away.  Only  the  most  common  and  import- 
ant of  the  sequelfe  can  be  here  considered. 

The  inflammation  of  the  throat  may  leave  in  its  wake  a  chriiuic 
h^^iertrophy  of  the  tonsils.  A  perforation  of  the  soft  palate  or  of  the 
septum  of  the  nose  may  result  from  local  gangrene. 

It  has  been  mentioned  that,  owing  to  the  inflammatory  changes 
occurring  in  the  ear  as  complications,  a  long  continued  purulent  dis- 
charge may  be  a  sequel.  When  necrosis  of  the  bony  structures  of  the 
tympanum  has  occurred,  it  may  happen  that  serious  intracranial  mis- 
chief, such  as  abscess  of  the  brain,  develops  even  long  after  the  original 
damage  was  sustained. 

In  the  eyes  total  blindness  may  result  from  the  severity'  of  the  affec- 
tions caused  by  the  scarlatinal  poison.  Chronic  interstitial  keratitis, 
iritis,  and  neuro-retiuitis  are  among  the  important  sequels  in  these 
organs. 

Tubercular  infection  of  the  lung,  larynx,  bones,  and  lymphatic 
ganglia  may  follow^  in  the  wake  of  scarlatina,  just  as  we  see  it  develop- 
ing after  other  acute  affections. 

Paralysis  of  various  muscles  or  groups  of  muscles  not  infrequently 
remains  after  an  attack  of  scarlet  fever.  This  paralysis  is  of  similar 
nature  to  that  which  comes  on  after  diphtheria  and  other  infectious  dis- 


604  SCARLET  FEVER. 

eases.  Chorea  in  a  number  of  instances  has  first  manifested  itself  after 
scarlet  fever.  When  scarlatinal  rheumatism  has  taken  the  form  of  a 
suppurative  synovitis,  permanent  ankylosis  of  one  or  more  joints  may 
result. 

Chronic  valvular  heart  troubles  are  not  infrequent  sequelae  of  the 
acute  attacks  of  endocarditis  which  complicate  scarlet  fever.  Owing  to 
the  weakening  of  the  heart  walls,  it  may  happen  that  when  the  patient 
who  has  recently  experienced  scarlatina  has  been  up  and  around  for 
a  while  an  acute  dilatation  of  the  heart  develops  with  a  relative  insuf- 
liciency  of  the  mitral  valve.  The  writer  thinks  it  probable  that  some 
of  the  reported  cases  of  oedema  coming  on  in  the  period  of  convalescence 
without  any  kidney  trouble  are  of  this  nature.  Basedow's  disease  has 
been  observed  to  occur  suddenly  after  scarlet  fever. ^ 

In  the  skin  and  its  appendages  sequelae  may  follow.  Erythemas 
more  or  less  diifuse  have  often  been  noted  after  desquamation  has  com- 
menced. Kaposi  believes  that  relapses  are  generally  to  be  thus  explained, 
the  rash  representing  a  secondary  erythema  and  not  a  scarlatinal  recru- 
descence. Erythema  nodosum,  urticaria,  herpes  zoster,  and  localized 
gangrenous  conditions  of  the  skin  sometimes  develop  after  scarlet  fever. 
An  alopecia  more  or  less  complete  may  follow,  just  as  we  find  it  after 
other  infectious  maladies,  and  in  a  few  cases  permanent  canities  has 
been  reported. 

After  an  attack  of  scarlatina  there  is  often  left  a  profound  ansemia 
which  may  last  for  a  long  time  without  any  discoverable  lesion  of  an 
important  viscus  to  account  for  it. 

Diagnosis. — It  may  be  said  that  before  the  rash  has  appeared  it  is 
impossible  to  make  a  positive  diagnosis  of  scarlet  fever,  since  at  this  time 
there  are  no  characteristic  symptoms,  such  as  occur  in  measles.  During 
an  epidemic  if  a  child  is  seen  who  has  been  vomiting  and  has  a  high 
temperature  with  catarrh  of  the  pharynx,  it  may  be  strongly  conjectured 
that  the  patient  is  suffering  from  scarlet  fever,  but  the  physician  will  be 
wise  not  to  commit  himself  positively  to  such  an  opinion.  As  a  rule, 
since  the  period  of  invasion  is  so  short,  the  physician  will  not  see  the 
case  till  the  eruption  has  appeared.  Generally  when  the  rash  has 
become  fully  developed  the  diagnosis  offers  little  difficulty.  The  height 
of  the  fever,  the  evident  illness  of  the  patient,  the  character  of  the  rash 
and  the  positions  which  it  first  occupies  upon  the  body,  the  sore  throat, 
the  enlargement  of  the  ganglia  at  the  angles  of  the  jaws,  and  the  pres- 
ence in  the  urine  of  a  trace  of  albumin  will  declare  the  nature  of  the 
disease.  In  the  malignant  cases  where  death  occurs  before  the  eruption 
comes  out  the  diagnosis  can  be  made  only  by  considering  the  height  of 
the  fever,  the  nervous  phenomena,  and  the  fact  of  the  existence  of  an 
epidemic  or  history  of  exposure,  with  the  possibility  of  excluding  other 
causes  for  the  same  train  of  symptoms.  The  chief  difficulties  in  diagnosis 
will  often  arise  in  connection  with  those  cases  which  present  irregularities 
in  their  course.  In  all  such  cases  a  point  of  the  very  highest  diagnostic 
value  will  be  to  establish  the  probability  of  infection.  In  those  rare 
cases  which  run  their  course  Avithout  fever,  to  which  reference  has  been 
made,  one  will  have  the  greatest  difficulty  in  arriving  at  a  diagnosis  of 
scarlet  fever,  for  a  rise  in  temperature  is  so  essentially  connected  with 

^  Wiener  medicinische  JSldtter,  B.  15,  H.  28. 


DIACSU^IS.  G05 

onr  ideas  of  scarlet  fever  that  its  absence  will  always  throw  dotiUt  on 
the  (lia_i>-n()sis.  If  in  addition  to  a  eharaeteristie  rash  there  were  sore 
throat  and  alhuniin  in  the  urine,  the  |)resuni])tion  woidd  l)e  in  favor  of 
scarlatina,  and  this  wouhl  be  nineh  strenj;'thened  should  lanicUar  des- 
quamation or  nephritis  dcveloj)  at  the  usual  time  ;  and  esj)ecially  would 
the  supposition  be  confirmed  should  an  ordinary  case  of  scarlet  fever 
occur  after  exposure  to  infection  from  the  anomalous  case. 

In  view  of  the  likelihood  that  scarlatina  may  occur  without  any 
eru[)tion,  it  seems  to  tlu'  Avriter  that  during-  an  epidemic  all  cases  of  sore 
throat,  especially  where  albumin  is  ])resent  in  the  urine,  should  be 
regarded  with  suspicion,  and  if  possible  treated  as  though  they  were 
cases  of  scarlatina.  This  will  no  doubt  be  a  difficult  and  often  a  thank- 
less task,  but  in  our  ])resent  state  of  knowledge  a  due  regard  for  the 
public  safety  dictates  such  a  course,  more  especially  as  the  sore  throats 
which  occur  during  an  epidemic  of  scarlatina  are  infections  whether 
they  be  scarlatinal  or  not. 

The  cases  of  scarlatina  in  which  the  nervous  symptoms  are  such  as 
to  cause  a  resemblance  to  cerebro-spinal  meningitis  can  usually  l)e  dis- 
tinguished from  the  latter  aifection  by  the  facts  that  in  scarlet  fever 
there  is  an  inflammation  of  the  throat,  while  in  meningitis  the  rash 
most  often  presents  itself  in  the  form  of  petechise. 

When  seen  after  the  first  stages  of  the  illness  have  passed  away  the 
typhoid  form  of  scarlatina  might  be  mistaken  for  typhoid  fever,  but 
the  history  of  the  onset,  and  perhaps  the  presence  of  desquamation, 
w'ould  help  to  distinguish  the  two  maladies. 

Those  cases  in  which  the  rash  comes  out  first  in  some  unusual  site 
need  not  create  confusion,  as  in  a  short  time,  under  ordinary  circum- 
stances, the  eruption  extends  all  over  the  body,  when  the  usual  jiicture 
of  scarlatina  is  presented.  More  difficulty  is  experienced  in  coming  to 
a  conclusion  wdiere  the  rash  occupies  only  limited  portions  of  the  sur- 
face, for  the  disease  is  apt  to  be  mistaken  for  an  erythema.  In  scarla- 
tina there  are  fever,  sore  throat,  strawberry  tongue,  albumin  in  the 
urine,  and  ^vhen  desquamation  occurs  it  affects  not  only  the  portions 
of  the  skin  which  have  been  involved  in  the  eruption,  but  also  those 
parts  wdiich  were  free  from  the  rash.  This  combination  of  phenomena 
could  hardly  occur  with  an  erythema. 

Especially  in  cases  where  the  rash  of  scarlet  fever  remains  discrete 
the  disease  may  be  confounded  with  measles  or  rotheln.  In  measles 
the  incubation  period  is  much  longer  than  in  scarlatina  :  the  invasion 
period  of  measles  occupies  four  days  wath  well  marked  catarrhal  symp- 
toms, but  lacks  the  sore  throat,  the  high  fever,  the  vomiting,  and  the 
nervous  phenomena  of  scarlet  fever,  while  albumin  is  absent  from  the 
urine.  The  eruption  of  measles  is  maculo-papular  and  of  a  duskier  hue 
than  the  rash  of  scarlatina  ;  the  borders  of  the  lesions  of  measles  are 
crenated,  and  they  are  often  collected  into  crescentic  groups,  while  the 
Avhole  face  is  affected  by  the  eruption,  the  region  about  the  mouth  not 
being  avoided,  as  is  the  case  in  scarlatina ;  the  rash  of  measles  stays  out 
on  the  body  in  full  bloom  a  shorter  time  than  the  eruption  of  scarlet 
fever.  The  desquamation  of  measles  occurs  as  furfuraceous  scales,  while 
in  scarlatina  large  lamellre  are  usually  thrown  off.  Finally,  the  com- 
plications and  sequelae  of  the  two  diseases  are  entirely  different. 


606  SCARLET  FEVER. 

In  rotheln  the  period  of  incubation  is  much  longer  than  in  scarlet 
fever.  Eotheln  often  has  no  invasion  stage,  the  first  evidence  of  the 
disease  being  the  rash,  and  if  there  are  premonitory  symptoms  they  are 
not  so  severe  as  those  seen  in  the  invasion  of  scarlatina.  The  rash  of 
rotheln  occurs  as  round  rose-red  spots,  with  well  defined  borders ;  it 
most  resembles  scarlatina  when  it  becomes  confluent,  but  this  generally 
occurs  only  in  patches,  and  these  lack  the  color  and  punctate  appearance 
usually  presented  by  the  eruption  of  scarlatina  ;  and,  furthermore,  rotheln 
affects'  the  region  about  the  mouth.  In  rotheln  there  is  sore  throat,  but 
it  is  generally  not  so  intense  as  the  angina  of  scarlet  fever.  In  rotheln 
there  is  slight  fever,  and  the  patient  is  often  not  at  all  ill,  but  the  opposite 
is  true  for  scarlatina.  The  tongue  of  scarlet  fever  is  characteristic,  that 
of  rotheln  is  only  coated.  The  urine  of  rotheln  is  at  most  febrile  urine, 
while  in  scarlatina  the  urine  contains  albumin  and  casts.  In  rotheln 
the  glands  along  the  course  of  the  sterno-mastoid  are  involved ;  in  scar- 
let fever  those  at  the  angles  of  the  jaws,  and,  moreover,  the  degree  of 
enlargement  of  the  glands  has  a  more  constant  relation  to  the  condition 
of  the  throat  in  scarlet  fever  than  is  noticed  in  rotheln.  After  rotheln 
desquamation  is  rare,  and  the  disease  has  no  special  complications  or 
sequelfe. 

There  is  no  likelihood  of  confounding  scarlatina  with  smallpox  after 
the  true  eruption  of  the  latter  disease  has  appeared,  but  there  are  certain 
pre-eruptive  erythemas  with  smallpox  which  might  lead  to  confusion. 
Smallpox,  when  the  eruptions  referred  to  are  apt  to  appear,  is  charac- 
terized by  severe  lumbar  pains  and  intense  headache,  while  there  is  no 
sore  throat  nor  the  peculiar  tongue  of  scarlatina.  The  erythematous 
rashes  of  smallpox  usually  occur  in  certain  regions,  especially  the  tri- 
angle of  Simon  and  the  pectoral  triangle,  and  are  very  prone  to  exhibit 
a  petechial  character. 

Accompanying  epidemics  of  influenza  rashes  have  been  observed 
which  might  cause  the  affection  to  be  mistaken  for  scarlet  fever.  In 
influenza  there  is  usually  severe  aching  pain  in  the  back  and  limbs  ;  the 
throat  is  sore,  but  generally  the  angina  is  not  so  intense  as  that  seen 
with  scarlatina ;  in  influenza  there  is  commonly  a  bronchitis  or  other 
involvement  of  the  lung.  The  rash  of  influenza  partakes  more  of  the 
character  of  measles  than  of  scarlet  fever,  usually  occurring  as  small, 
discrete  red  macules,^  The  rash  of  influenza  is  more  evanescent  and 
irregular  than  that  of  scarlatina,  often  going  and  returning  several  times 
during  the  course  of  the  malady. 

Erysipelas  could  hardly  be  mistaken  for  scarlet  fever.  The  rash 
of  erysipelas  is  limited  to  a  region  of  the  body,  often  develops  around 
a  wound,  and  does  not  present  the  punctate  redness  seen  in  scarlatina. 
There  is  also  more  hypersesthesia  of  the  affected  area  and  more  oedema 
of  the  subcutaneous  tissue  than  is  observed  with  scarlet  fever,  while 
desquamation  in  erysipelas  is  confined  to  the  region  which  has  been 
involved  by  the  eruption. 

There  are  a  large  number  of  drugs  which  ingested  cause  an  eruption 
resembling  that  of  scarlatina.  The  more  important  are  here  mentioned  : 
benzoic  acid,  boracic  acid,  salicylic  acid,  antipyrine,  arsenic,  belladonna, 
chloral,  chloralamide,  chloroform  (inhaled),  digitalis,  mercury,  hyoscya- 

1  Hardaway,  oral  communications. 


DLiGNOSIS.  607 

um>,  iodine  compouiuls,  opium  j)rep;iriiti()iis,  plK'iiacctin,  tar,  ([iiiniiie, 
rhul)arl),  strainoniiim,  strvchniiu',  sul|»lioiial,  tii])t'rciiliii.  Tlic  above 
list  iiicliuk's  only  a  sniall  iiunihcr  of  the  (Iruos  which  at  one  tiino  or 
another  have  been  observed  to  be  followed  by  a  rash  more  or  less  re- 
seml)linii-  scarlatina.  It  is  to  be  noted  that  many  substances  when 
applied  to  the  skin  are  capable  of  causing  a  scarlatiniform  erythema,  as 
mustard  for  instance.  Specially  are  certain  substances  used  in  modern 
antiseptic  surgery  capable  of  causing  such  an  eruption.  Among  these 
may  be  mentioned  carbolic  acid,  iodoform,  and  bi(;hloride  of  mercury. 
<Tenerally  the  rashes  caused  by  the  ap])lication  of  these  drugs  are  local 
in  character,  but  often  they  have  become  generalized.  liecent  French 
literature  presents  quite  a  number  of  instances  of  generalized  scarlatini- 
form eru})tions  following  the  use  of  mercury  as  a  local  application. 

The  diagnosis  of  these  drug  eruptions  from  scarlatina  will  be  most 
easily  made  by  first  ascertaining  the  fact  of  administration  of  a  drug 
capable  of  exciting  a  scarlatiniform  rash  ;  then  the  facts  that  the  drug 
eruption  is  not  preceded  by  the  prodromata  of  scarlet  fever,  and  that  it 
is  not  accompanied  by  the  sore  throat,  high  fever,  strawberry  tongue, 
and  enlargement  of  the  lymphatic  ganglia.  In  cases  where  the  history 
cannot  be  obtained  it  should  be  remembered  that  some  of  these  drugs 
produce  symptoms  peculiar  to  themselves,  which  are  not  apt  to  be 
found  with  scarlatina,  as  with  digitalis  the  slowing  of  the  heart,  with 
belladonna  the  dilatation  of  the  pupils,  salivation  with  mercury,  con- 
tracted pupil  and  drowsiness  of  opium,  pruritus  and  heightened  reflexes 
Avith  strychnine,  and  the  peculiar  odor  which  some  drugs  impart  to  the 
breath  or  urine,  as  chloroform  or  turpentine.  A  further  point  of  assist- 
ance will  be  the  fact  that  upon  the  withdrawal  of  the  drug  the  rash 
generally  subsides  more  rapidly  than  would  the  rash  of  scarlatina.  The 
■difficulty  of  differential  diagnosis  is  increased  by  the  fact  that  in  some 
rare  cases — as,  for  instance,  has  been  observed  with  chloral — there  may 
be  with  the  drug  eruption,  fever,  and  a  subsequent  desquamation. 

There  is  a  dermatosis  which  very  closely  simulates  scarlet  fever,  so 
nearly  indeed  that  it  is  called  erythema  scarlatiniforme.  It  is  not  a 
distinct  and  separate  disease,  but  occurs  as  a  concomitant  of  other  dis- 
eases. It  is  of  special  frequency  in  such  septicsemic  conditions  as  fol- 
low surgical  wounds  and  the  puerperal  state.  In  speaking  of  wound 
scarlatina  reference  has  been  made  to  this.  This  eruption  occurs  with 
other  diseases  also,  as  gonorrhoea,  diphtheria,  typhoid  fever,  rheuma- 
tism, ague,  ursemia,  and  it  has  been  induced  by  certain  foods,  as  shell- 
fish and  various  fruits.  It  may  at  times  be  impossible  to  differentiate 
this  dermatosis  from  irregular  forms  of  scarlatina.  The  following 
points  will  assist  in  the  diagnosis :  In  scarlatiniform  erythema  the  throat 
is  not  so  severely  inflamed  as  in  scarlet  fever,  nor  is  there  the  straw- 
berry tongue,  and  the  constitutional  symptoms  are  lighter.  The  dem- 
onstration of  albumin  and  casts  in  the  urine  would  speak  strongly  in 
favor  of  scarlet  fever,  except  in  those  cases  where  erythema  scarlatini- 
forme complicates  a  disease  prone  to  be  accompanied  by  nephritis.  In 
erythema  scarlatiniforme  desquamation  usually  begins  on  the  third  or 
fourth  day,  while  in  scarlet  fever  it  most  often  occurs  at  a  much  later 
date.  Finally,  erythema  scarlatiniforme  is  apt  to  occur  in  repeated 
attacks. 


608  SCARLET  FEVEB. 

Dermatitis  exfoliativa,  especially  when  it  is  ushered  in  with  high 
fever,  might  be  mistaken  for  scarlatina,  but  there  is  an  absence  of  the 
throat  symptoms  and  the  strawberry  tongue,  while  desquamation  often 
begins  before  the  rash  is  fully  developed.  Dermatitis  exfoliativa  is  a 
disease  of  adult  life,  and  any  doubts  as  to  the  differential  diagnosis 
between  it  and  scarlatina  will  in  a  short  time  be  put  at  rest  by  the 
chronic  course  of  the  former  disease. 

As  has  been  mentioned,  it  is  a  matter  of  the  highest  importance  to 
determine  whether  the  false  membrane  which  may  appear  during  the 
course  of  scarlatina  is  due  to  a  complicating  diphtheria.  Much  has 
been  written  to  show  that  certain  peculiarities  in  the  membrane,  such  as 
its  time  of  appearance,  its  locality,  its  constitution  and  character,  could 
be  used  to  make  an  exact  diagnosis,  but  a  careful  study  of  diphtheria 
has  taught  that  none  of  these  things  can  be  relied  upon  to  bring  us  to  a 
correct  conclusion.  The  microscope  in  conjunction  with  inoculation 
experiments  upon  the  lower  animals  is  today  recognized  as  the  only  true 
guide  to  the  differential  diagnosis  of  the  pseudo-membranous  throat 
affections  of  scarlet  fever. 

To  sum  up  in  a  Avord,  one  may  say  that  in  ordinary  cases  of  scarla- 
tina there  is  no  difficulty  in  diagnosis.  As  the  deviations  from  the 
normal  become  more  marked  the  difficulties  of  diagnosis  increase  pari 
passu.  In  some  few  cases  it  may  be  utterly  impossible  to  differentiate 
between  scarlatina  and  some  of  the  affections  which  are  accompanied  by 
a  scarlatiniform  erythema. 

Peognosis. — Too  much  stress  cannot  be  laid  on  the  fact  that  great 
caution  must  be  exercised  by  the  physician  in  giving  an  opinion  as  to 
the  outcome  in  a  case  of  scarlet  fever.  No  case  is  ever  a  trivial  case. 
An  attack  mild  in  its  inception  may  terminate  fatally,  for  even  the 
mildest  cases  are  liable  to  serious  complications,  the  occurrence  of  which 
cannot  be  foreseen.  It  is  almost  unnecessary  to  state  that  a  bad  prog- 
nosis attaches  to  all  the  malignant  forms  of  scarlatina. 

The  prognosis  in  general  will  be  influenced  by  the  previous  health 
of  the  patient,  by  the  social  position  and  hygienic  surroundings,  by  the 
age,  by  the  general  type  of  the  epidemic  during  which  a  case  occurs, 
and  by  the  existence  of  complications  and  their  nature. 

Children  who  have  been  weakened  by  a  previous  acute  disease  or 
those  who  are  afflicted  with  some  chronic  malady  are  less  able  to  with- 
stand the  inroads  of  a  severe  infection  like  scarlatina  than  are  those  who 
have  been  strong  and  robust. 

Social  position  has  a  very  direct  bearing  upon  prognosis.  The  poor 
are  constantly  exposed  to  want  of  food  and  proper  protection  from  the 
weather,  and  their  sanitary  surroundings  are  never  of  the  best.  These 
factors  have  their  influence  in  depraving  the  health  and  diminishing 
that  bulwark  which  nature  is  ever  striving  to  build  up  within  us,  to 
which  we  have  applied  the  name  physiological  resistance.  Besides  this, 
it  is  to  be  considered  that  during  the  attack  of  scarlatina  the  poor  cannot 
obtain  proper  attention  and  nursing. 

One  of  the  most  important  factors  in  determining  the  prognosis  is 
the  age  of  the  patient.  Although  nurslings  are  not  so  often  attacked 
as  older  children,  the  disease  among  them  often  occurs  in  a  very  severe 
form.      In  the  report  of  the  Registrar  General   of  England,   quoted 


PROGNOSIS.  609 

above,  it  appears  that  tlu-  inortulity  is  at  its  niaxiniiiiii  in  the  third  year 
of  life.  In  adults  the  mortality  is  greatest  among  puerperal  women 
and  invalids. 

The  mortality  varies  much  in  ditlerent  epidemies.  In  some  there 
occur.s  a  large  number  of  malignant  eases,  while  in  others  a  majority  of 
the  cases  run  the  ordinary  favorable  course.  In  nearly  every  epidemic, 
though  by  comparison  it  may  be  spoken  of  as  mild,  a  considerable 
death  rate  occurs.  Those  in  which  the  death  rate  is  belcjw  10  per  cent, 
might  be  called  mild,  and  epidemics  have  been  known  where  the  mor- 
tality was  as  higii  as  40  per  cent. 

The  prognosis  is  necessarily  influenced  by  the  presence  of  complica- 
tions. A  temperature  above  105°  F.  in  the  beginning  of  the  attack  of 
scarlatina  indicates  an  unusual  severity  of  the  disease,  and  is  therefore 
of  unfavorable  prognostic  significance.  Severe  nervous  symptoms, 
especially  wiien  coma  is  rapidly  ushered  in,  are  unfavorable.  Convul- 
sions in  the  early  part  of  the  malady  are  not  of  such  serious  signif- 
icance as  when  they  occur  at  a  later  date,  for  in  the  latter  case  they 
usually  indicate  ursemia  or  the  presence  of  a  grave  complication.  If 
vomiting  is  continued  beyond  the  period  of  invasion,  it  is  an  unfavor- 
able circumstance,  as  it  may  interfere  seriously  with  the  taking  of  nour- 
ishment. The  prognosis  in  the  typhoid  form  of  scarlatina  is  bad  on 
account  of  the  asthenia  caused  by  the  long  protracted  illness.  The 
prognosis  is  markedly  influenced  by  the  condition  of  the  throat.  In 
the  severe  forms  of  this  complication,  especially  when  a  gangrenous 
condition  develops,  the  chances  of  recovery  are  small.  The  presence 
of  a  membrane  in  the  throat  adds  to  the  gravity  of  the  case,  not  only  as 
indicating  one  of  the  severer  forms  of  inflammation,  but  because  it  may 
be  of  diphtheritic  origin :  if  an  examination  shows  the  presence  of 
Loffler's  bacillus,  the  prognosis  is  rendered  very  grave.  The  coexist- 
ence of  another  exanthem  or  other  infectious  disease  with  scarlet  fever 
diminishes  the  chances  of  recovery  in  proportion  to  the  severity-  of  the 
superadded  disease.  Serious  involvement  of  the  respiratory  tract  or 
pericarditis  renders  the  outlook  unfavorable.  Ordinarily  scarlatinal 
rheumatism  is  not  a  serious  complication,  but  a  purulent  spiovitis  is  apt 
to  prove  fatal.  Xephritis  adds  to  the  gravity  of  the  prognosis  in  pro- 
portion to  the  extent  and  severity  of  the  inflammation  of  the  kidney. 
If  the  nephritis  develops  gradually,  with  a  moderate  amount  of  albu- 
min in  the  urine  and  little  hematuria,  without  much  decrease  in  the 
amount  of  urine,  if  there  he  an  absence  of  accumulation  of  fluid  in  the 
serous  cavities  and  of  ursemic  symptoms,  the  prognosis  is  good.  If  the 
nephritis  come  on  suddenly  with  very  scanty,  bloody  urine,  the  case  is 
to  be  regarded  as  very  unfavorable.  Death  from  nephritis  usually 
results  from  ursemia  or  dropsical  accumulations  in  or  around  important 
organs,  and  when  signs  indicating  the  presence  of  these  conditions  are 
noted  a  very  guarded  prognosis  should  be  given,  though  it  must  be 
borne  in  mind  that  children  seem  to  bear  uraemia  better  than  adults. 
The  involvement  of  the  ear  is  serious,  not  only  with  reference  to  the 
special  sense  of  the  organ,  but  from  the  influence  which  it  may  exert  on 
the  patient's  chances  of  recovery.  The  shock  of  an  acute  suppurative 
otitis,  added  to  the  already  serious  impairment  of  the  vital  forces,  mav 
be  an  important  factor  in  determining  a  fatal  issue.  The  fact  has 
Vol.  I.— 39 


610  SCARLET  FEVEB. 

already  been  mentioned  that  serious  intracranial  mischief  may  result 
from  suppurative  otitis  media.  Whether  or  not  affections  of  the  eye 
add  to  the  gravity  of  the  prognosis  will  depend  on  the  nature  of  the 
eye  complication,  A  simple  conjunctivitis  would  not  be  regarded  as  of 
serious  import,  while  a  panophthalmitis  would  increase  the  gravity  of 
the  case.  In  general,  it  may  be  said  that  any  complication  renders  the 
prognosis  unfavorable  in  proportion  to  the  importance  of  the  organ 
involved  and  the  severity  of  the  involvement. 

Treatment. — It  is  convenient  to  consider  the  treatment  of  scarla- 
tina under  three  heads — prophylaxis,  hygiene,  and  therapeutics. 

Prophylaxh. — By  far  the  most  important  part  of  the  treatment  of 
scarlet  fever  in  our  present  state  of  knowledge  consists  in  prophylaxis. 
From  this  standpoint  treatment  aims  at  the  prevention  of  scarlatina 
and  the  limitation  of  its  spread,  as  far  as  may  be,  when  it  has  occurred. 
Thus  far,  there  is  no  remedy  known  which  has  the  power  of  destroying 
the  susceptibility  to  the  disease.  Prevention  must  therefore,  for  the 
present,  interest  itself  in  closing  as  far  as  possible  those  avenues  by 
which  the  poison  is  brought  into  contact  with  susceptible  persons.  This 
will  include,  in  the  first  place,  a  careful  supervision  on  the  part  of 
health  boards  of  the  health  of  all  individuals  who  are  brought  into 
close  contact  with  their  fellows.  There  can  be  no  doubt  that  scarlet 
fever  is  often  acquired  by  school  children  from  mild  cases  of  scarlatina 
which  have  occurred  in  the  school  and  passed  unnoticed  or  have  been 
regarded  as  some  simple  rash.  Furthermore,  children  often  are  allowed 
to  return  to  school  too  soon  after  an  attack  of  scarlatina  and  without  a 
proper  disinfection  of  their  clothing,  books,  etc. 

The  progress  of  preventive  medicine  in  its  relation  to  scarlatina 
would  no  doubt  be  much  furthered  were  thoroughly  equipped  hospitals 
established  in  all  cities  where  those  affected  could  be  at  once  isolated 
and  properly  cared  for.  Where  cases  are  treated  at  their  homes  it  may 
be  said  that,  as  a  rule,  complete  isolation  is  impossible. 

So  many  facts  point  to  the  possibility  of  carrying  the  scarlatinal 
poison  in  milk  that  special  attention  should  be  directed  to  the  milk 
supply  of  all  communities.  Xot  only  should  no  dairyman  in  whose 
family  a  case  of  scarlet  fever  exists  be  allowed  to  distribute  milk  until 
thorough  disinfection  has  been  carried  out,  but  all  herds  of  milch  cows 
should  be  inspected  from  time  to  time,  and  those  with  vesicular  erup- 
tions of  the  udder  or  desquamating  patches  upon  the  body  should  be 
isolated  and  their  milk  not  used. 

When  a  case  of  scarlatina  occurs  in  a  family,  it  is  of  the  highest 
importance  for  the  sake  of  the  unaffected  to  isolate  the  case  at  once. 
The  apartment  chosen  as  the  sick  chamber  should  be  at  the  top  of  the 
house,  and  the  well  children  should  be  kept  in  the  lower  story,  as  by 
this  means  all  communication  between  the  sick  and  the  well  is  as  far  as 
possible  interrupted.  From  the  sick  chamber  should  be  removed  all 
objects  except  such  as  are  needed  in  the  proper  nursing  of  the  case. 
Thus  all  pictures,  carpets,  hangings,  curtains,  upholstered  furniture, 
and  bric-a-brac  should  be  banished.  Xo  one  should  have  access  to  the 
room  save  the  physician  and  nurse.  Over  the  door  of  the  chamber 
should  be  hung  a  sheet  kept  wet  with  a  5  per  cent,  solution  of  carbolic 
acid.     It   is   of  the  highest  importance  to  see  that  no   object  of  any 


TREATMENT.  611 

cle^(•l•iptiun  is  alluuoil  to  leave  the  room  until  it  lias  been  thorouf^hly 
(lisiiiteeied.  Any  food  remaining  from  the  meals  of  the  patient  or  nurse 
should  1)1'  either  destroyed  in  the  room  or  immersed  for  some  hours  in  a 
bucket  tilled  with  a  10  per  cent,  solution  of  earbolie  acid  before  being 
earried  out.  The  urine  and  fteees  of  the  patient  are  to  be  placed  for 
some  time  in  a  similar  solution  before  they  are  removed.  For  the  pur- 
pose of  cleansing-  the  throat  and  nose  of  the  patient  soft  rags  are  to  be 
recommended,  which  should  then  be  burnt  in  the  fireplace  in  the  room. 
When  the  clothing  of  the  })atient  is  i-hanged,  before  that  which  is  re- 
moved is  put  in  the  laundry  it  should  be  boiled  for  an  hour  in  a  5  per 
cent,  solution  of  carbolic  acid  or  a  1  :  1000  solution  of  bichloride  of 
mercury.  The  nurse  should  wear  a  washable  dress,  and  before  going 
into  the  presence  of  those  susceptible  should  carefully  cleanse  her  person 
in  the  same  manner  soon  to  be  recommended  for  physicians,  and  change 
to  a  fresh  dress.  It  is  not  a  good  plan  to  allow  a  cat  or  a  dog  to  remain 
in  the  chamber  for  the  amusement  of  the  sick  child,  as  it  has  been 
shown  that  in  some  cases  scarlet  fever  has  been  carried  by  such  animals 
to  those  who  are  well.  The  physician,  wdio  has  necessarily  to  mingle 
with  susceptible  persons  after  leaving  a  scarlet  fever  case,  should  neg- 
lect no  precaution  to  avoid  carrying  the  infection.  It  is  an  excellent 
plan  to  wear  a  light  rubber  coat  during  the  visit.  This  can  be  M'iped 
off  with  a  sponge  dipped  in  an  antiseptic  solution  after  leaving  the  sick 
room,  and  thus  the  clothing  is  prevented  from  conveying  the  infection. 
The  hair  could  be  in  a  manner  prevented  from  absorbing  the  virus  by 
wearing  during  the  visit  a  silk  or  rubber  cap,  which  should  be  removed 
on  leaving  the  room.  On  arriving  at  his  home  the  physician  should 
adopt  the  further  precaution  of  removing  the  suit  which  he  has  worn 
during  the  call ;  this  clothing  should  be  hung  in  a  well  ventilated  room 
in  the  sunlight  for  a  few  days  before  it  is  again  worn.  Before  calling 
on  another  patient  the  hands  and  face  should  be  washed,  using  some 
good  antiseptic  soap,  such  as  Eichhoff's  menthol-eucah-ptol  soap. 

During  the  whole  course  of  the  disease  a  dish  of  water  into  which 
carbolic  acid  or  eucalyptus  oil  has  been  placed  should  be  kept  boiling- 
over  a  lamp.  This  may  have  some  influence  in  limiting  the  diffusion 
of  the  scarlatinal  virus. 

The  patient  should  remain  in  the  sick  room  till  desquamation  is 
entirely  completed.  The  chamber  and  all  that  it  contains  must  then 
be  carefully  disinfected.  All  articles  which  can  be  spared  should  be 
destroyed  by  burning.  Objects  which  cannot  be  spared  can  be  disinfected 
in  several  ways.  For  such  as  will  not  be  injured  by  the  process  the 
best  method  of  sterilization  is  by  steam  under  pressure.  This  method 
is  especially  suitable  for  bedding  and  clothing.  For  its  application 
somewhat  elaborate  apparatus  is  required,  which  will  generally  luuit 
the  use  of  this  process  to  those  municipalities  which  have  provided 
proper  disinfecting  stations.  In  lieu  of  steam  all  articles,  as  far  as 
possible,  should  be  boiled  for  an  hour  in  the  carbolic  or  mercuric  solu- 
tion mentioned  above.  For  objects  which  cannot  be  thus  sterilized  some 
one  of  the  gaseous  disinfectants  must  be  used.  Perhaps  one  that  is  as 
good  as  any  other,  while  at  the  same  time  it  is  easy  of  application,  is  the 
liberation  in  the  room  of  sidphurous  acid  vapors.  In  order  to  be  most 
effective  steam  should  be  liberated  in  the  room  at  the  same  time  that 


612  SCARLET  FEVER. 

sulphur  is  burnt,  since  sulphurous  acid  is  most  active  in  the  presence  of 
moisture.  At  least  3  pounds  of  sulphur  for  every  1000  cubic  feet  of 
room  space  must  be  burnt.  The  sulphur  candles  now  obtainable  in  all 
drug  stores  are  convenient,  or  the  sulphur  may  be  finely  broken  and 
mixed  with  alcohol  to  secure  its  thorough  combustion.  It  is  burnt  in 
an  iron  pan  placed  upon  bricks  in  a  tub  of  water  to  prevent  danger 
from  fire.  Previous  to  liberating  the  gas  all  cracks  around  windows 
and  doors  should  be  stopped  with  paper  and  the  room  rendered  as  tight 
as  possible.  The  gas  should  be  left  in  the  room  for  a  day  at  least. 
The  paper  upon  the  walls  of  the  chamber  should  be  removed  and  fresh 
paper  applied,  or,  where  paper  is  not  used,  the  walls  should  be  wiped 
down  with  bichloride  solution  and  then  freshly  lime-washed.  The  floor 
should  be  scrubbed  with  soap  and  water  and  then  freely  washed  with 
bichloride  solution.  All  the  furniture  in  the  room  must  be  washed  with 
the  solution,  and  it  is  an  excellent  precaution  to  have  it  revarnished. 
All  books  and  toys  which  have  been  used  by  the  patient  should  be 
destroyed  by  burning,  as  such  articles  are  very  difficult  to   disinfect. 

It  may  seem  that  all  these  precautions  are  difficult  to  carry  out,  and 
many  have  urged  against  them  that  even  when  they  are  carefully 
observed  scarlatina  may  be  contracted  by  other  members  of  the  family. 
Statistics,  however,  show  that  with  thorough  enforcement  of  these 
measures  the  disease  is  less  apt  to  be  conveyed,  and  it  is  manifestly  the 
duty  of  the  physician  to  enforce  anything  that  offers  a  reasonable  hope 
of  checking  the  spread  of  so  formidable  a  malady  as  scarlatina. 

Hygiene. — The  hygienic  surroundings  of  the  patient  must  be  made 
as  good  as  possible.  The  sick  room  should  be  a  large  chamber  with 
abundant  means  for  ensuring  thorough  ventilation.  Usually  this  can 
best  be  accomplished  by  having  an  open  fire  burning  in  the  grate. 
There  should  be  maintained  an  even  temperature  of  70°  or  75°  F. 
The  linen  of  the  patient  and  of  the  bed  should  be  kept  fresh  and  clean. 
The  bedclothing  must  be  warm  but  light. 

It  is  wise  to  endeavor  to  keep  the  skin  in  good  condition,  as  we  often 
have  to  depend  upon  its  activity  to  accomplish  the  work  of  a  damaged 
kidney.  To  this  end  a  full  warm  bath  should  be  given  each  evening, 
and  if  the  fever  is  high  this  will  be  still  more  necessary.  After  the 
bath  the  surface  should  be  anointed  with  a  bland  fatty  substance  which 
has  an  antiseptic  property.  This  gives  ease  to  the  swollen,  tender  skin, 
often  reduces  the  temperature,  and  is  supposed  by  many  to  prevent  the 
volatilization  of  the  scarlatinal  poison.  A  good  formula  for  such  an 
ointment  is — 

I^.  Acicli  carbolici,  Tlliv  ; 

Olei  eucalypti,  lUxx ; 

Vaselini,  3vj ; 

Unguenti  aquse  rosse,  3ij. — M. 

The  careful  antiseptic  treatment  of  the  throat  forms  an  important 
part  of  the  hygienic  management,  but  it  will  be  considered  later  on. 

Jamieson  believes  that  desquamation  can  be  accelerated,  while  at  the 
same  time  the  scales  are  rendered  less  infectious,  by  a  daily  bath  with 
EichhoflP's  resorcin-salicylic  soap.     The  lather  from  this  soap  is  to  be 


TRKATMEyr.  613 

well  rul>l)('»l  ill  with  a  piece  of  flannel,  and  then  the  surface  washed  with 
warm  water.  In  the  case  of  the  palms  and  soles  the  soap  siioid'l  he 
used  several  times  a  day.  Ivieh  use  ol'  this  soap  npon  the  l)ody  should 
be  followed  with  inunction  of  the  ointment  rec(»nunended  above. 

The  length  of  time  which  must  be  .spent  in  the  sick  room  is  a  ques- 
tion concernini!:  which  there  is  a  variety  of  ojiinion.  The  only  safe  rule 
is  that  the  patient  must  remain  isolated  till  desquamation  is  entirely 
completed.  In  the  opinion  (»f  the  writer  it  is  the  wisest  plan  to  con- 
fine the  jnitient  strictly  to  bed  till  des([uamation  is  finished.  Reference 
has  already  been  made  to  the  injurious  effects  of  exposure  of  the  sur- 
face to  varvinty  degrees  of  temperature,  and  of  the  erect  posture.  Both 
of  these  evil  influences  are  best  avoided  by  a  sufficientlv  long  stay  in 
bed. 

The  diet  of  the  person  suffering  from  scarlet  fever  should  be  light, 
but  nutritious.  ^lilk  forjus  the  ideal  food  in  a  large  proportion  of  the 
cases.  Where  it  is  not  readily  taken  in  its  simple  form,  s«jme  one  of 
its  preparations  may  be  substituted,  as,  for  instance,  koumyss,  kefyr,  or 
peptonized  milk.  Often  the  addition  of  lime  water  renders  the  milk 
more  digestil)le.  In  older  patients  the  diet  may  occasionally  be  varied 
by  allowing  a  soft-boiled  i^g^,  or  oysters  raw  or  stewed  with  crackers  or 
toast.  The  patient  ought  to  be  fed  at  frequent  intervals,  and  only 
small  amounts  given  at  a  time,  as  very  often  the  digestive  processes  are 
so  impaired  as  to  render  the  proper  preparation  and  assimilation  of  any 
but  small  quantities  of  food  impossible.  Under  such  circumstances 
systematic  stufBng  of  the  patient  can  be  only  injurious,  as  a  large  amount 
of  material  is  introduced  which  will  not  be  taken  up  by  the  tissues,  but 
must  be  removed  from  the  body  partly  by  the  kidneys,  which  are 
already  incapable  of  their  normal  amount  of  work.  In  some  cases  the 
stomach  is  so  irritable  that  it  cannot  be  made  to  retain  food ;  when  this 
is  the  case  rectal  alimentation  must  be  used,  though  this  form  of  feeding 
is  not  so  well  borne  by  children  as  by  adults.  Water  both  in  its  ordi- 
nary form  and  carbonated  alkaline  waters  should  be  allowed  as  freely 
as  the  patient  desires. 

Therapeutics. — From  time  to  time  many  remedies  have  been  vaunted 
as  specifics  in  the  treatment  of  scarlatina.  It  is  hardly  necessary  to 
refer  to  belladonna,  which  has  enjoyed  a  reputation  with  some,  appar- 
ently for  no  better  reason  than  the  fallacious  one  that  because  it  can 
produce  a  rash  like  scarlet  fever  it  can  also  prevent  or  cure  the  disease. 
Illingworth  claims  that  biniodide  of  mercury  is  a  specific,  and  Duke 
says  it  arrests  fever  and  prevents  desquamation.  Shakhovsky  lauds 
salicylic  acid  as  being  capable  of  preventing  all  complications  and  of 
arresting  them  when  present.  A  wide  experience  with  any  or  all  of 
these  remedies  will  probably  convince  the  practitioner  that  their  appar- 
ent specific  action  depends  more  on  the  mildness  of  the  epidemic  than 
the  curative  nature  of  the  drug. 

The  milder  forms  of  the  disease  demand  little  in  the  way  of  internal 
medication.  The  diet  and  hygiene  should  be  arranged  in  accordance 
with  the  principles  already  set  forth.  The  author  has  for  many  years 
made  it  a  rule  to  administer  to  nearly  all  cases  of  scarlatina  iodide  of 
potassium  and  bichloride  of  mercury.  It  has  seemed  to  him  that  these 
drugs  at  least  modify  the  severity  of  the  symptoms  and  complications. 


614  SCARLET  FEVER. 

For  a  child  three  years  of  age  the  iodide  of  potassium  may  be  given  in 
the  following  prescription  : 

]^ .  Potassii  iodidi,  gr.  xlviii ; 

Syrupi  limonis,  5j  ; 

Aquam,  ad  giij. — M. 

Sig.  A  teaspoonful  three  times  a  day  in  water. 

The  bichloride  is  most  elegantly  administered  in  the  form  of  Van 
Swieten's  liquid.  To  a  child  of  three  a  third  of  a  teaspoonful  should 
be  given  in  water  three  times  a  day. 

It  has  been  the  custom  for  a  long  time  to  administer  in  scarlet  fever 
tincture  of  the  chloride  of  iron.  For  this  drug  it  is  claimed  that  it  is 
of  use  in  counteracting  the  acute  ansemia  which  often  exists,  that  the 
chlorine  it  contains  has  a  valuable  antiseptic  action,  and  that  the  local 
eifect  upon  the  throat  as  the  medicine  is  swallowed  is  beneficial.  The 
iron  is  often  combined  with  chlorate  of  potash,  as  in  this  prescription  : 

I^.  Potassii  chloratis,  3j  ; 

Tincturse  ferri  chloridi,  Siss  ; 

Syrupi,  q.  s.  ad  §ij. — M. 

Sig.  Half  teaspoonful  every  three  hours  for  a  child  three  years  old. 

Wilson  of  Philadelphia  has  recommended  the  administration  of 
chloral  throughout  the  whole  course  of  the  disease.  He  claims  that  by 
this  means  the  nervous  symptoms  are  controlled  and  the  condition  of 
the  patient  is  rendered  more  comfortable.  The  drug  is  to  be  given  in 
small  doses  at  repeated  intervals,  and  any  deep  narcotism  is  to  be 
avoided,  but  the  patient  is  to  be  kept  in  such  a  condition  that  though 
easily  aroused  he  soon  falls  asleep  again.  Wilson  recommends  the  fol- 
lowing manner  of  administration  : 

]^.  Chloralis,  gr.  xxx  ; 

Syrupi  lactucarii  (Aubergier), 
Aquse,  da.  gj. — M. 

Sig.  Teaspoonful  as  often  as  necessary  for  a  child  of  three. 

The  condition  of  the  bowels  should  receive  attention.  When  consti- 
pation exists  a  mild  aperient  or  an  enema  should  be  given.  The  im- 
portance of  preventing  constipation  would  assume  much  importance 
could  we  accept  Mahomed's  opinion  as  to  the  frequent  causal  relation 
of  this  condition  to  nephritis. 

No  part  of  the  treatment  of  scarlatina  is  more  important  than  the 
local  treatment  of  the  throat  and  nose.  By  proper  care  of  these  regions 
not  only  may  the  severe  throat  complications  often  be  prevented,  but 
ear  trouble  can  usually  be  averted.^  An  ice  bag  applied  over  the  neck 
tends  to  subdue  the  faucial  inflammation  and  at  the  same  time  often 
lowers  the  temperature.  Swallowing  of  small  bits  of  ice  at  frequent 
intervals  exerts  a  beneficial  influence,  as  is  often  evinced  by  the  lessened 
pain  on  deglutition.  Some  antiseptic  wash  should  be  used  in  the  nose 
'  Spencer,  oral  communication. 


TRKATMEXr.  (jlo 

;iii(l  tliroat  as  oIUmi  as  possible  It  not  iiiiVc(|ii('iitlv  happens  that  then; 
is  siicli  turiicsc'oiu'c  aiul  suclliiiji;  of  the  iiiirrior  (iirhiiiatcd  Ixxly  as  to 
hinder  the  free  access  of  the  antise})tic  to  the  })osterior  narcs.  This  can 
usually  be  overcome  bv  applying-  to  the  turl)inate(l  body  with  a  (-(jtton 
swab  a  4  per  cent,  solution  of  cocaine.  In  older  children  ami  adults 
the  antiseptic  solution  iiiay  be  a[)plie(l  by  a  spray  apparatus  or  nasal 
douche,  but  in  young-  children  it  is  often  necessary  to  use  a  dro})ping 
tube  for  this  purpose.  A  great  number  of  antiseptic  fluids  have  been 
suggested,  but  perhaps  none  is  better  than  a  2  or  3  per  cent,  solution  of 
boric  acid.  Six  to  ten  drachms  of  this,  warmed  to  the  temperature  of 
the  body,  should  be  used  in  the  nasal  cavities  two  or  three  times  a  day. 
\Mien  a  s])ray  apparatus  can  be  used  the  throat  should  also  l)e  sprayed 
with  the  same  solution.  If  the  throat  symptoms  are  mild,  this  alone 
suffices,  but  when  the  inflammation  is  intense  great  good  is  derived 
from  the  thorough  application  with  the  cotton  holder  of  a  10  per  cent, 
alcoholic  solution  of  salicylic  acid.  This  should  be  used  once  or  tAvice 
a  day.  After  the  use  of  all  these  applications  it  is  well  t(j  api)ly  Ijoth 
to  the  nose  and  throat  an  antiseptic  oil.  This  can  be  used  in  a  spray, 
or  a  few  drops  may  be  introduced  into  the  nose,  whence  they  will  run 
back  int(j  the  throat.     A  good  formula  for  such  an  oil  is — 

^.  Camphora?, 

Menthol,  aa.  gr.  iij  ; 

Albolene,  5J. — M. 

In  the  case  of  individuals  who  can  gargle  it  is  of  advantage  to  use 
an  antiseptic  solution  for  this  purpose  at  frequent  intervals.  According 
to  Yeo,  one  of  the  best  preparations  to  be  thus  used  is  chlorine  water 
made  in  the  following  way  :  Into  a  sixteen-ounce  flask  put  eight  grains 
of  chlorate  of  potash.  Upon  this  pour  one  drachm  of  hydrochloric  acid. 
AYhen  the  green  vapor  has  filled  the  bottle  pour  in  water  little  by  little, 
corking  and  shaking  after  each  addition,  till  the  bottle  is  fiill.  This  not 
only  makes  an  excellent  local  application,  but  by  many  is  prized  as  an 
internal  remedy,  a  teaspoonful  or  two  being  swallowed  every  two  hours. 
Another  jirescription  AA'hich  is  frequently  used  by  the  writer  as  a  gargle 
and  also  as  a  spray  is — 

Ki.  Acidi  carbolici,  3ss  ; 

Glycerini,  3v ; 

Sol.  pot.  chloratis  sat.,  q.  s.  ad  Iv. — M. 

Sig.  Dilute  at  time  of  use  -with  equal  parts  of  warm  water. 

The  treatment  outlined  above  is  sufficient  for  the  ordinary  cases  of 
scarlet  fever.  Since  any  additional  treatment  will  depend  on  the  sever- 
ity of  the  particular  symptoms  presented  by  each  case,  it  will  facilitate 
matters  to  discuss  the  treatment  of  some  of  the  more  important  symp- 
toms which  are  likely  to  arise. 

One  of  the  chief  symptoms  which  the  physician  is  called  u]3on  to 
combat  is  fever.  As  long  as  the  temperature  remains  below  103°  F., 
it  does  not  constitute  a  dangerous  condition  unless  it  be  unduly  pro- 
longed. 


gr. 

XX ; 

3SS 

} 

gr. 
ad  s}y 

.— M 

gr. 

viij  ; 

gr. 

XX  ; 

3iij 
ad  §iv 

.— M 

616  SCARLET  FEVER. 

For  the  reduction  of  temperature  the  use  of  drugs  is  not,  as  a  rule, 
to  be  so  highly  recommended  as  the  abstraction  of  heat  by  means  of  the 
application  to  the  body  of  cold.  Quinine  is  a  drug  which  has  some 
antipyretic  action,  and  used  in  reasonable  doses  it  also  acts  as  a  tonic. 
One  half  to  three  grains,  according  to  age,  given  every  two  hours,  may 
be  considered  as  expressing  the  limits  of  the  usual  dose  for  children. 
Quinine,  according  to  Yeo,  if  given  dissolved  in  the  chlorine  water  men- 
tioned above,  will  have  a  more  decided  eifect  in  lowering  temperature 
than  if  given  in  powder  or  capsules.  It  seems  also  to  exert  a  more 
decided  action  when  given  in  an  effervescing  mixture.  The  formula  for 
the  alkaline  portion  of  the  mixture  is — 

Vy.  Sodii  bicarbonatis, 
Potassii  bicarbonatis, 
Potassii  chloratis, 
Aquam, 

The  formula  for  the  acid  part  is  as  follows 

II .  Quininse  sulphatis, 
Acidi  citrici, 
Syrupi  limonis, 
Aquam, 

From  a  dessertspoonful  to  a  tablespoonful  of  each  portion  of  this  pres- 
cription is  mixed  together  at  the  time  of  administration. 

The  drugs  which  have  the  greatest  potency  in  reducing  temperature 
are  the  coal-tar  derivatives.  The  best  known  of  these  are  antipyrine, 
phenacetin,  and  acetanilid.  It  may  be  said  that  all  of  these  prepara- 
tions are  dangerous  on  account  of  their  depressing  effect,  and  if  given 
should  be  used  with  caution,  especially  in  a  disease  like  scarlet  fever, 
where  the  vital  powers  are  already  below  par.  Phenacetin  is  the  safest 
of  these  drugs,  and  it  has  the  advantage  that  its  sedative  effects  are 
quite  marked.  If  administered,  it  is  best  given  in  small  doses  at  fre- 
quent intervals,  for  the  effect  desired  can  be  thus  more  exactly  obtained 
than  if  large  doses  are  exhibited. 

By  far  the  best  and  safest  manner  of  controlling  the  temperature  is 
by  direct  abstraction  of  heat  from  the  body.  There  are  a  number  of 
methods  by  which  this  can  be  accomplished.  A  simple  means  is  to 
apply  bags  of  ice  to  portions  of  the  body  where  a  considerable  volume 
of  blood  is  flowing  close  beneath  the  surface,  as  over  the  neck  and 
wrists.  In  this  way  a  marked  reduction  of  temperature  can  often  be 
effected.  A  more  prompt  effect  is  produced  by  sponging  the  whole  body 
with  cool  water  or  equal  parts  of  water  and  alcohol.  To  be  of  avail  the 
sponging  must  be  repeated  at  frequent  intervals.  The  cold  pack  is  an 
efticient  method  of  reducing  fever,  but  one  that  it  is  often  impossible 
to  use  on  account  of  the  prejudices  of  the  parents  or  friends  of  the 
patient.  In  practice  the  cold  pack  is  thus  applied  :  A  blanket  is  spread 
upon  a  cot ;  over  this  a  sheet  wrung  out  of  water  at  a  temperature  of 
70°  F.  is  placed.  The  patient  is  envelojjed,  with  the  exception  of  his 
head,  in  the  sheet,  and  the  blanket  is  wrapped  over  all.     When  a  suf- 


TIIKATMKST.  017 

ficieiit  rediic'tioii  of  tempcratiirc  has  hcen  secured,  the  patient  is  re- 
moved tV(»m  the  pack  and  wrajjped  in  a  drv,  warm  l>lanket.  The  most 
powerful  as  well  as  the  most  certain  method  of  rapidly  lowerino;  the 
temperature  is  the  lull  cool  bath.  A  l)athtuh  hnye  enough  to  admit  <»f 
the  patient's  lyinir  at  len<ith  is  filled  with  suflicicut  wat<'r  at  a  teni])era- 
ture  of  about  100^  F.  to  cover  the  body.  After  the  patient  is  placed 
in  the  tub  the  bath  is  gradually  cooled,  i)y  the  addition  of  cold  water, 
to  a  temperature  of  8(J°  or  7o°  F.  A\'hile  the  patient  is  in  the  bath  the 
effect  may  be  still  further  increased  by  applying  to  the  head  an  ice  cap. 
The  length  of  time  that  the  bath  is  continued  will  vary  with  the  effect 
produced,  but  it  is  a  good  rule  to  remove  the  patient  before  the  tem- 
perature reaches  the  normal,  as  not  uncommonly  it  continues  to  fall  for 
some  time  after  leaving  the  bath.  AVhile  the  bath  is  being  administered 
a  careful  watch  should  be  maintained  upon  the  patient,  and  any  cyanosis 
or  lividity,  or  weakness  or  irregularity'  of  the  pulse,  or  complaint  of 
chilliness,  should  be  the  signal  for  the  cessation  of  the  bath.  A  warm 
blanket  sh(»uld  be  ready  to  receive  the  patient,  and  after  his  surface  has 
been  rapidly  dried  he  should  be  tucked  snugly  in  bed.  If  prostration 
follows,  as  occasionally  will  happen,  alcoholic  stimulants  must  be 
administered. 

The  treatment  of  the  unpleasant  or  dangerous  symptoms  on  the  part 
of  the  nervous  system  will  var^'  according  to  their  character,  (xreat 
restlessness  and  active  delirium  are  usually  l)est  controlled  by  the  bro- 
mides of  soda  or  potash.  Sometimes  a  combination  of  bromides  with 
chloral  is  very  efficient.  It  is  well,  especially  in  cases  where  there  is 
marked  rapidity  of  the  pulse,  to  add  to  the  mixture  digitalis,  as  in  this 
prescription  : 

R .  Cliloralis,  gr.xlviij  ; 

Potassii  bromidi,  3j  ; 

Tincturse  digitalis,  Tllxvj  ; 

S}Tupi  pruni  Virginianse,  3t  ; 

Aquam,  ad  ^ij. — M. 
Sig. — One  half  to  one  teaspoonful  every  two  hoiu's  for  a  child  three 
years  old. 

Convulsions  in  the  early  stages  of  the  disease  can  usually  be  con- 
trolled by  the  same  drugs,  but  it  will  often  be  necessary  to  administer 
them  per  rectum.  In  addition,  it  is  frequently  of  the  greatest  benefit  to 
immerse  the  whole  body  in  a  warm  bath.  At  a  later  period  of  scarlet 
fever  convulsions  generally  depend  on  the  presence  of  some  comjjlica- 
tion,  and  the  treatment  will  be  largely  that  of  the  complication.  When 
the  nervous  manifestations  are  accompanied  by  high  fever  a  reduction 
of  the  temperature  will  usually  produce  an  amelioration  of  these  symp- 
toms. In  cases  where  a  low  form  of  delirium  exists  or  the  patient  is 
in  a  semi-comatose  condition,  with  rapid,  weak  pulse,  as  occurs  in  the 
malignant  forms  of  scarlatina,  thorough  and  systematic  stimulation  will 
from  the  first  be  necessary-.  As  stimulants  the  alcoholic  preparations, 
such  as  brandy  or  whiskey  or  sherry*  wine,  rank  first.  The  amount  of 
alcohol  which  can  be  given  varies  with  the  age  of  the  patient  and  his 
susceptibility  to  the  remedy.     It  is  often  of  importance    to  add   full 


618  SCARLET  FEVER. 

doses  of  digitalis  to  the  alcohol.     Thus  for  a  child  of  three  years  one 
may  order — 

^,.  Tincturae  digitalis,  tVLxlj 

Spiritus  frumenti,  iiij. — M. 

Sig.  Teaspoonful  every  two  hours. 

It  is  well  to  give  this  in  milk,  as  we  can  thus  stimulate  and  nourish  at 
the  same  time.  Carbonate  of  ammonia  may  also  be  used  as  a  stimu- 
lant, or  equal  parts  of  spiritus  setheris  compositus  and  spiritus  ammo- 
nise  aromaticus  with  camphor  Avater  may  be  administered,  or  in  urgent 
cases  camphor  dissolved  in  olive  oil  may  be  given  hypodermically.  In 
the  opinion  of  the  writer  these  measures  are  not  so  reliable  nor  of  such 
universal  application  as  the  whiskey  and  digitalis  mixture  recommended. 
Occasionally  diarrhoea  and  vomiting  are  so  persistent  as  •  to  require 
special  treatment.  Vomiting  may  usually  be  stopped  by  the  applica- 
tion over  the  stomach  of  a  mustard  or  spice  poultice,  while  small  bits 
of  ice  are  swallowed  at  frequent  intervals.  When  this  does  not  suffice 
the  administration  of  champagne  in  very  small,  frequently  repeated 
doses  will  often  prove  of  benefit.  It  may  be  necessary  in  severe  cases 
to  resort  to  some  of  the  numerous  stomachic  sedatives.  A  useful  pre- 
scription is — 

^.  Cocainse  hydrochloratis,  S^^- i  > 

Acidi  carbolici,  TTLv ; 

Aquse  laurocerasi,  3v ; 

Aquam,  ad  gij. — M. 
Sig.  Teaspoonful  every  hour. 

For  diarrhoea  quite  often  the  application  of  cold  compresses  over  the 
belly  will  suffice.  Internally  such  a  powder  as  the  following  may  be 
administered  : 

^.  Bismuthi  subcarbonatis,  3ss  ; 

Pulveris  ipecacuanhse  compositi,  gr.  v. — M. 

Fiant  pulvereSj^JSTo.  x. 
Sig.  One  every  two  hours  for  a  child  three  years  old. 

To  treat  appropriately  the  complications  and  sequelse  of  scarlet  fever 
will  often  demand  all  the  skill  of  even  the  most  accomplished  physi- 
cian. Here  only  the  treatment  of  the  more  important  and  most  common 
of  these  conditions  can  be  considered. 

The  treatment  of  the  throat  iniiammation  as  it  is  seen  in  the  ordi- 
nary cases  of  scarlatina  has  been  sufficiently  dealt  Avith,  and  it  only 
remains  to  make  some  suggestions  as  to  the  treatment  of  the  severer 
forms  of  angina.  In  cases  where  there  is  a  false  membrane  or  slough 
the  throat  should  be  first  cleansed  by  means  of  a  spray  of  peroxide  of 
hydrogen,  and  then  one  of  the  antiseptic  solutions  recommended  above 
should  be  used.  There  are  many  Avho  make  use  of  a  1  :  500  or  1  :  1000 
solution  of  bichloride  of  mercury  applied  to  the  throat  on  a  cotton  swab 
after  the  pharynx  has  been  cleansed  with  the  peroxide.     When  there  is 


TREATMENT.  (519 

cellulitis  of  the  neck  an  ice  haf>:  should  he  constantly  applied.  As  soon 
as  it  can  be  determined  that  pus  has  tonned  an  opening  must  be  made 
under  antiseptic  precautions,  and  thorough  draina<i;e  for  the  abscess  pro- 
vided. The  treatment  of  dij)htheria  complicatinir,  scarlatina  does  not 
dilfer  from  the  treatment  of  the  malady  wiicn  occurring  alone.  Today 
it  seems  that  Bchrinti's  "  heil-serum  "  is  in  a  fair  way  to  banish  the 
multitudinous  drugs  which  have  been  used  in  the  treatment  of  this  com- 
plication. In  all  the  forms  of  severe  throat  complications  early  and 
systematic  stimulation  is  of  the  utmost  importance.  It  sometimes  hap- 
pens that  on  account  of  the  ])ain  of  swallowing  there  is  difficulty  in 
persuading  the  patient  to  take  a  sufficient  quantity  of  nourishment. 
Under  such  circumstances  cold,  liquid  food  is  most  suitable,  l)ut  it  may 
be  necessary  to  give  nourishment  per  rectum. 

If  careful  and  systematic  cleansing  and  disinfection  of  the  nose  and 
throat  is  practised,  the  number  of  cases  in  which  middle-ear  inflam- 
mation arises  will  be  comparatively  small,  but  the  physician  should 
always  be  on  the  alert  for  the  first  evidence  of  this  important  com- 
plication. As  a  rule,  the  patient  complains  of  pain  in  the  ear,  but 
if  the  mental  faculties  are  blunted  or  if  the  patient  is  a  very  young 
child,  such  notice  of  otitis  may  not  be  given.  It  is  therefore  a  wise 
plan  for  the  physician  during  the  height  of  the  disease  daily  to  inspect 
the  ear  with  head  mirror  and  speculum.  In  the  early  stages  of  the  ear 
trouble  the  pain  is  usually  due  to  closure  of  the  Eustachian  tube,  and 
inflation  by  Politzer's  method  may  affi^rd  great  relief.  In  addition  to 
this,  chloroform  vapor  may  be  applied  to  the  ear  by  placing  in  a  good 
sized  wine-glass,  previously  warmed  by  immersion  in  hot  water,  a  few 
drops  of  chloroform  on  a  piece  of  cotton  ;  the  glass  is  then  pressed 
closely  over  the  ear.  Another  application  which  at  this  time  often 
gives  relief  is  a  small  bag  filled  with  salt  or  bran  well  heated  and 
placed  on  the  ear.  A  leech  placed  behind  the  ear  will  often  prove  of 
great  benefit.  When  inflammatory  secretions  have  accumulated  in  the 
ear  in  sufficient  quantity,  severe  pain  is  caused  by  the  tension  thus  pro- 
duced. This  condition  can  be  relieved  only  by  spontaneous  rupture  of 
the  drumhead  or  by  surgical  art.  When  the  drumhead  is  found  red- 
dened, tense,  and  bulging,  an  opening  in  it  should  be  made.  By  this 
means  an  escape  of  the  imprisoned  fluids  with  cessation  of  pain  is 
secured,  and  damage  to  the  delicate  structures  of  the  ear  as  well  as  the 
tedious  recovery  which  follows  a  spontaneous  rupture  is  avoided.  The 
opening  should  be  made  at  the  most  prominent  portion  of  the  mem- 
brana  tympani  with  a  cataract  needle,  special  care  being  used  not  to 
thrust  the  needle  deeper  than  is  necessary  to  perforate  the  membrane, 
thus  avoiding  injury  to  the  chorda  t^inpani  or  other  important  struc- 
ture. If  suppuration  of  the  ear  with  perforation  of  the  drumhead  has 
occurred,  the  external  auditory  canal  should  be  gently  syringed  twice  a 
day  with  an  antiseptic  solution,  such  as  a  2  per  cent,  boric  acid  or  a 
1 :  5000  mercuric  bichloride  solution.  The  orifice  of  the  meatus  should 
be  kept  closed  with  an  absorlient  cotton  plug.  For  an  account  of  the 
treatment  of  other  serious  ear  complications  the  reader  must  be  referred 
to  special  treatises  on  diseases  of  the  ear. 

In  those  cases  of  scarlatina  in  which  conjunctivitis  occurs  the  eye 
must   receive  special   attention.     The  room  in  which  the  patient  lies 


620  SCARLET  FEVER. 

should  be  shielded  from  too  great  a  glare  of  light.  By  anointing  with 
vaseline  or  unguentum  aquse  rosse  agglutination  of  the  eyelids  is  pre- 
vented, and  thus  the  comfort  of  the  patient  is  increased.  Several 
times  a  day  cloths  wet  in  the  following  solution  should  be  placed  over 
the  eyes  for  ten  or  fifteen  minutes  at  a  time  : 

]^.  Acidi  borici,  .5ss  ; 

Tincturse  opii  deodoratse,  3iv ; 

Aquam,  ad  siv. — M. 

When  keratitis  is  present,  cloths  wrung  out  of  boric  acid  solution  as 
hot  as  can  be  comfortably  borne  should  be  kept  on  the  eyes.  When 
sloughing  of  the  cornea  results,  panophthalmitis  with  loss  of  the  eye 
follows.  Paralysis  of  the  muscles  of  the  eye  following  scarlet  fever 
requires  such  treatment  as  is  applicable  under  similar  circumstances  in 
other  regions  of  the  body. 

Bronchitis  and  catarrhal  pneumonia  complicating  scarlet  fever  de- 
mand the  same  treatment  which  would  be  appropriate  under  other 
circumstances — stimulating  and  supportive  measures,  proper  protection 
of  the  chest,  and  hydrotherapy. 

Attention  has  been  called  to  the  frequency  with  which  pleuritis 
arising  during  scarlet  fever  is  purulent.  This  suggests  a  prompt  use  of 
the  aspirator  in  pleural  effusions,  and  especially  as  the  physical  signs  of 
fluid  in  the  chest  in  young  children  are  often  equivocal.  If  pus  is 
found,  provision  must  be  made  for  draining  the  chest.  In  children 
repeated  aspiration  is  more  apt  to  succeed  than  is  the  same  procedure  in 
adults,  but  even  in  children  this  method  cannot  be  relied  upon,  and  if 
the  condition  of  the  patient  will  permit  it  is  better  to  open  the  chest, 
resecting  a  rib  if  necessary.  A  drainage  tube  must  be  introduced  of 
such  a  size  and  in  such  a  position  as  to  secure  thorough  drainage.  In 
every  case  of  empyema  careful  stimulation  and  nutrition  is  of  the 
highest  importance. 

Pericarditis  and  endocarditis  require  the  use  of  digitalis  to  slow  and 
strengthen  the  pulse.  In  the  earlier  stages  of  both  aflPections  an  ice  bag 
should  be  kept  over  the  heart.  If  fluid  accumulate  about  the  heart  in 
sufficient  quantity  to  impede  its  action,  it  must  be  removed  by  aspira- 
tion. In  pericarditis  the  outlook  is  especially  unfavorable,  since  the 
condition  of  the  patient  does  not  offer  encouragement  for  undertaking 
those  serious  surgical  procedures  which  are  necessary  for  draining  the 
pericardium  of  a  purulent  accumulation. 

Scarlatinal  rheumatism  is  usually  so  mild  as  not  to  need  any  special 
treatment,  or  at  most  the  application  of  an  anodyne  liniment,  such  as 
the  chloroform  liniment,  with  a  layer  of  cotton  wool  held  in  place  by 
a  firmly  adjusted  bandage.  In  severe  cases  the  salicylate  of  soda  and 
an  opiate  may  be  necessary.  When  a  suppurative  synovitis  occurs  the 
condition  demands  surgical  interference,  which  is  often  rendered  of  no 
avail  by  the  pysemic  condition  of  the  patient. 

The  proper  treatment  of  scarlatinal  nephritis  demands  the  most 
careful  consideration.  Attention  has  been  called  to  the  prophylactic 
treatment  of  this  complication.  If  this  part  of  the  treatment  is  prop- 
erly carried  out,  the  cases  of  dangerous  nephritis  will  be  comparatively 


TUi:.\rMi:sT.  621 

rare.  The  danger  tu  lite  in  luphiili.-?  arises  chiefly  from  two  causes — 
the  faihire  of  the  elimination  of  waste  products  fnjni  the  body  by  the 
kidney,  antl  the  accumuhition  in  tlie  cavities  of  the  b(Kly  of  serous  fluids. 
To  prevent  both  of  these  eontiniiencies  it  is  necessary  to  bring  into 
active  play  tiie  accessory  emunctorics  of  the  Ixtdy,  the  skin  and  intes- 
tinal canal,  as  well  as  to  encourage  as  thorough  functi(jning  of  the 
kidneys  as  may  be  possible.  AVheu  the  urine  is  only  slightly  decreased 
in  volume  with  a  fairly  normal  amount  of  solids  in  solution,  a  rather 
warm  temperature  of  the  sick  chamber,  clothing  of  the  patient  in 
flannel,  a  fluid  diet,  and  regulation  of  the  bowels  will  be  all  the  treat- 
ment re(piired.  If  under  these  measures  the  condition  does  not  im- 
prove, but,  on  the  other  hand,  the  urine  grows  scantier  or  less  solids  are 
eliminated,  the  full  activity  of  the  skin  should  be  called  to  the  assist- 
ance of  the  kidneys.  The  activity  of  the  skin  may  be  stimulated  by 
hot  water,  hot  air,  or  steam,  or  by  the  administration  of  drugs.  Very 
often  the  most  convenient  way  of  provoking  diaphoresis  will  be  the  hot 
bath.  The  patient  is  immersed  in  water  at  a  temperature  of  90°  F., 
and  the  heat  of  the  water  is  gradually  raised  to  105°  or  even  110°  F. 
The  duration  of  the  bath  should  be  from  fifteen  to  twenty  minutes.  At 
the  close  of  the  bath  the  patient  should  be  rapidly  removed  to  a  warmed 
bed  and  covered  M'ith  several  blankets.  If  perspiration  follows,  the 
bath  has  been  of  use,  and  may  be  repeated  two  or  three  times  a  day 
according  to  the  urgency  of  the  case.  If  no  perspiration  follows,  one 
of  the  other  methods  of  promoting  diaphoresis  must  be  tried.  For 
instance,  after  the  patient  has  been  removed  from  the  hot  bath  the 
effect  may  be  kept  up  by  surrounding  his  body  with  bottles  filled  with 
hot  water.  At  times  a  steam  or  hot  air  bath  succeeds  "where  the  ordi- 
nary hot  bath  has  failed,  A  steam  bath  may  be  administered  by 
placing  over  the  patient  blankets  elevated  slightly  above  the  body  by  a 
frame,  so  as  to  form  a  sort  of  canopy  ;  the  ends  and  edges  of  the  blankets 
are  tucked  carefully  around  the  patient,  only  his  head  being  left  out,  so 
that  when  the  steam  is  introduced  under  the  blankets  it  will  not  escape. 
By  means  of  a  rubber  tube  steam  is  conveyed  from  a  suitable  generator, 
such  as  a  croup-kettle,  and  passed  under  the  blankets,  where  it  sur- 
rounds the  body  in  a  hot  vapor  bath.  The  same  thing  may  be  accom- 
plished by  placing  around  the  patient  hot  bricks  wrapped  in  wet  cloths 
and  covering  snugly  with  blankets.  The  hot  air  bath  can  be  given  by 
causing  the  patient  to  sit  on  a  chair  with  a  blanket  fastened  around  the 
neck  and  coming  down  to  the  floor  all  around  ;  under  the  chair  a  small 
quantity  of  alcohol  is  burned  upon  a  plate.  If  the  condition  of  the 
patient  does  not  permit  his  sitting  up,  a  hot  air  bath  may  be  conve- 
niently given  by  placing  around  him  while  in  bed  several  Japanese 
stoves  and  covering  with  blankets.  The  effect  of  any  one  of  these 
methods  may  be  still  further  increased  by  administering  at  the  conclu- 
sion of  the  bath  a  hot  drink,  such  as  a  hot  toddy. 

Quite  a  number  of  drugs  have  more  or  less  reputation  as  diaphoret- 
ics. The  acetates  of  potassium  and  ammonium,  Dover's  powder,  citrate 
and  bitartrate  of  potassium,  and  sweet  spirits  of  nitre  have  all  been 
advocated  for  this  purpose,  but  there  is  no  other  drug  which  exerts  so 
noticeable  an  effect  in  this  direction  as  jaborandi.  Jaborandi  may  be 
used  as  an  adjuvant  to  heat,  a  dose  of  the  muriate  of  pilocarpine  l)eing 


622  SCARLET  FEVER. 

given  hypodermically  at  the  bath,  or  it  may  be  given  alone  and  at  reg- 
ular intervals  to  keep  up  a  constant  mild  diaphoresis.  In  using  jabo- 
randi  or  its  alkaloid  every  precaution  to  prevent  depression  must  be 
used,  and  the  physician  should  be  always  prepared  to  resort  promptly 
to  stimulation  in  case  such  an  untoward  effect  occurs.  For  a  child  of 
three  one-fortieth  to  one-twentieth  of  a  grain  of  j)ilocarpine  may  be 
administered  every  six  hours.  The  effect  of  the  drug  is,  however,  much 
more  marked  when  given  hypodermically ;  in  this  way  a  child  three 
years  old  should  receive  one-thirtieth  of  a  grain,  which  may  be  repeated 
according  to  the  necessities  of  the  case. 

AVhen  ursemia  threatens  or  oedema  is  increasing  at  an  alarming  rate 
the  physician  will  appreciate  the  importance  of  invoking  the  elimina- 
tive  action  of  the  bowels.  Some  cathartic  must  be  chosen  which  will 
promptly  produce  copious  watery  evacuations  with  as  little  depression 
as  possible.  Calomel  is  recommended,  because  it  not  only  acts  as  a 
cathartic,  but  has  also  a  diuretic  action.  It  should  be  given  in  one 
fairly  large  dose — for  a  three-year  old  child,  two  grains.  In  the  course 
of  three  or  four  hours  the  calomel  should  be  followed  by  the  adminis- 
tration of  sulphate  of  magnesium.  This  is  best  given  in  saturated  solu- 
tion, small  doses  being  taken  at  frequent  intervals.  For  a  child  half  a 
teaspoonful  undiluted  may  be  given  CA^ery  half  hour  until  the  desired 
effect  is  produced.  Another  preparation  which  has  justly  acquired  a 
good  reputation  is  the  compound  jalap  powder.  To  a  child  of  three, 
one  to  five  grains  can  be  given,  and  this  dose  should  be  repeated  once  a 
day  or  as  often  as  may  be  necessary.  When  the  symptoms  are  very 
urgent  one  of  the  more  powerful  cathartics  may  be  required,  such  as 
podophyllin,  elaterium,  or  croton  oil,  but  these  drugs  are  dangerous 
and  should  be  used  only  when  milder  measures  have  failed. 

The  use  of  remedies  to  stimulate  the  action  of  the  kidneys  must  be 
limited  to  those  which  are  non-irritating  diuretics.  It  is  frequently  of 
benefit  to  apply  over  the  region  of  the  kidneys  hot  poultices.  With 
the  poultices  are  sometimes  incorporated  drugs  for  absorption  by  the 
skin ;  thus  a  poultice  of  digitalis  leaves  is  recommended.  The  two 
drugs  which  are  most  apj)ropriate  for  administration  as  diuretics  are  the 
acetate  of  potassium  and  digitalis.  The  latter  causes  diuresis  by  increas- 
ing the  force  of  the  heart's  action,  and  this  often  affords  an  additional 
indication  for  its  exhibition,  as  not  uncommonly  the  heart  is  much 
weakened  by  the  scarlatinal  poison.  It  has  been  taught  that  the  infu- 
sion of  digitalis  is  a  more  efficient  diuretic  than  the  tincture  ;  the  infusion 
is,  however,  not  a  preparation  which  will  keep,  and  it  should  be  made 
up  each  time  it  is  prescribed  from  perfectly  fresh  digitalis  leaves,  so 
that  unless  the  physician  can  rely  implicitly  upon  his  druggist  the  tinc- 
ture will  be  found  the  more  useful  of  the  two.  The  acetate  of  potash 
and  digitalis  are  usually  given  together  : 

^.  Potassii  acetatis,  Sij  ; 

Infusi  digitalis,  liss ; 

Aquam,  ad  iiij. — M. 

Sig.  Teaspoonful  every  three  hours  for  a  child  three  years  old. 

In  the  opinion  of  the  writer  the  drugs  which  produce  diuresis  by 


TREATMENT.  623 

diret't  stiinulation  of  tho  scHTctin^-  structures  of  the  kiducy  arc  not 
a])proj)natc  for  the  trcatinent  of  severe  acute  iuHaniination  of  tliat  orj^an, 
such  as  is  tlie  nephritis  of  scarhitina. 

When  dropsy  of  a  serous  cavity  occurs  to  so  i;'reat  an  extent  that 
life  is  threatened  the  fluid  should  be  withdrawn  by  aspiration.  It  is 
then  often  possible  to  prevent  the  reaccuniulation  by  keeping  up  as 
thorouiihly  as  possible  diuresis,  catharsis,  and  dia[)horesis.  In  less 
severe  cases  tliese  means  alone  may  suifice  to  remove  the  dropsical  accu- 
mulation, but  whenever  there  is  any  interference  witli  important  vital 
functions  on  account  of  the  amount  of  the  fluid,  valuable  time  should 
not  be  wasted  before  employing  our  most  certain  means  of  relief. 

Urremic  convulsions  demand  a  thorough  and  prompt  use  of  all  those 
depurative  measures  recommended  above.  In  addition  we  must  try  to 
control  the  convulsions  by  the  exhibition  of  the  bromides  and  chloral. 
To  a  child  of  three,  five  grains  of  bromide  of  potash  may  be  given 
everv  ten  minutes  until  the  convulsion  ceases,  and  then  at  longer  inter- 
vals to  sustain  the  effect.  Chloral  is  a  still  more  powerful  agent.  In 
some  cases  of  convulsions  it  is  impossible  to  get  the  patient  to  swallow. 
It  is  then  necessary  to  resort  to  rectal  medication.  For  a  child  three 
years  old  five  grains  of  chloral  dissolved  in  an  ounce  of  water  should 
be  introduced  into  the  rectum  with  a  small  syringe,  and  retained  by 
pressing  a  cloth  firmly  over  the  anus.  As  an  adjuvant  the  body  should 
be  immersed  in  warm  water.  When  these  means  fail  to  control  the 
convulsions,  chloroform  should  be  given  by  inhalation,  though  in  cases 
of  such  severity  the  result  will  hardly  be  favorable. 

During  convalescence  from  nephritis  the  patient  should  be  kept  in 
bed  clothed  in  flannel,  and  not  allowed  to  get  up  till  the  urine  has  been 
for  some  days  entirely  normal.  After  getting  out  of  bed  a  careful  daily 
examination  of  the  urine  must  be  made,  and  upon  the  reappearance  of 
albumin  the  patient  must  be  again  put  to  bed.  The  diet  is  to  be  light 
but  nutritious,  and  suitable  to  the  age  of  the  patient.  The  administra- 
tion of  an  iron  tonic  is  frequently  demanded  by  the  anaemia  which  often 
follows  the  nephritis.  Basham's  mixture  is  very  suitable,  and  with  it 
small  doses  of  digitalis  may  be  prescribed. 

The  treatment  of  some  of  the  sequelae  of  scarlet  fever  has  been 
necessarily  considered  in  speaking  of  the  treatment  of  the  complications. 
Mention  will  now  be  made  of  the  remedial  measures  which  should  be 
used  in  some  of  the  more  important  sequelae  to  which  reference  has  not 
been  made  above.  The  chronic  enlargement  of  the  tonsils  which  not 
infrequently  follows  in  the  wake  of  scarlatina  should  be  carefully 
treated,  as  this  condition  constantly  exposes  the  sufferer  to  all  forms  of 
infectious  angina.  Often  the  tonsils  may  be  reduced  to  a  normal  size 
by  repeated  cauterizations  with  nitrate  of  silver  or  the  galvano-cautery. 
If  these  measures  fail,  it  is  best  to  remove  the  organs  by  surgical 
procedure. 

When  tubercular  infection  of  the  lungs  or  other  organs  results  from 
scarlatina,  those  remedies  are  indicated  which  are  of  avail  in  tubercu- 
losis under  other  circumstances.  A  change  to  an  appropriate  climate 
must  be  advised,  cod-liver  oil  and  creasote  prescribed,  and  surgical 
interference  urged  where  it  is  indicated,  as  in  tuberculosis  of  the  bones 
and  lymph  ganglia. 


624  SCARLET  FEVER. 

For  the  paralysis  of  the  muscles  which  sometimes  follows  scarlatina 
strychnine  by  the  mouth  or  hypodermically,  passive  movements,  mas- 
sage, and  electricity  are  the  methods  of  treatment  at  our  disposal. 

The  valvular  lesions  of  the  heart  which  result  from  scarlet  fever 
require  the  ordinary  treatment  of  chronic  valvular  heart  disease,  a  care- 
ful regulation  of  the  life  and  habits  of  the  patient,  and  the  administra- 
tion of  the  well  known  heart  tonics  when  necessary. 

Attention  has  been  called  to  the  peculiar  anaemia  which  sometimes 
persists  without  apparent  reason  after  scarlet  fever.  This  condition 
demands  a  nutritious  diet  and  residence  in  the  country,  where  pure  air 
and  plenty  of  sunshine  can  be  obtained.  In  addition,  one  of  the 
stronger  ferruginous  tonics  should  be  prescribed : 

I^.  Tincturse  ferri  citro-chloridi,  3ij  ; 

Glycerini,  Siij ; 

Aquse  cinnamomi,  §iij. — M. 

Sig.  Teaspoonful  an  hour  after  meals  for  a  child  of  three. 

It  is  not  possible  nor  is  it  necessary  to  consider  the  treatment  of 
all  the  sequelae  which  may  follow  scarlatina.  In  general  it  may  be  said 
that  they  demand  the  same  treatment  that  would  be  appropriate  if  they 
occurred  independently,  the  physician  always  bearing  in  mind  that  the 
sequel  is  aifecting  a  person  whose  vital  forces  are  impaired  by  the  poison 
of  scarlatina. 


RUBEOLA-MEASLES. 

By  J.  P.  CROZER  GRIFFITH,  M.  D. 


Deftxitiox. — An  acute,  infectious,  eruptive  fever,  beginnino-  with 
marked  catarrhal  <yiaptoms  and  later  developing  a  characteristic  nuiculo- 
papular  rash. 

Synonyms. — The  disease  is  called  Rougeole  by  the  French  and 
Maseru  by  the  Germans.  The  Italian  name,  Jlorbilli,  later  became  the 
most  popular  until  recent  years,  but  "  rubeola  "  has  now  largely  sup- 
planted it,  at  least  in  English.  Morbilli  is  not  to  be  preferred,  since  it 
has  no  significance  as  applied  to  this  disease ;  rubeola  is  much  better,  in- 
asmuch it  is  at  least  suggestive  of  the  color  .of  the  eruption. 

Etiology. — Measles,  if  not  the  most  frecpient,  is  one  of  the  most 
frequent  diseases  of  childhood.  Climate  and  geographical  distribution 
seem  to  have  no  influence  whatever  upon  it,  and  it  develops  equally 
well  wherever  the  infectious  principle  has  access  to  the  inhabitants.  It 
has  a  decided  tendency  to  prevail  in  epidemics,  which  come  at  intervals 
of  two  or  three  years.  In  large  cities,  however,  cases  occur  nearly 
every  year,  although  even  in  them  the  epidemic  influence  is  very  dis- 
tinct, and  in  some  years  the  disease  will  be  far  more  prevalent  than  in 
others.  It  often  happens,  too,  that  its  severit}'  in  some  years  is  very 
much  greater. 

The  influence  of  age  is  not  so  great  as  would  at  first  appear.  Al- 
though principally  a  disease  of  childhood,  its  greater  rarity  in  adults 
depends  solely  on  the  fact  that  most  individuals  have  suffered  from  it 
before  reaching  adult  life.  There  is  no  reason  to  believe  that  any 
degree  of  immunity  is  conferred  by  advancing  years.  Numerous  well 
known  and  often  cpioted  instances  prove  the  susceptibility  of  adults  to 
it.  Perhaps  best  known  of  these  is  the  history  of  the  disease  in  the 
Faroe  Islands,  in  which  persons  of  all  ages  suffered  with  ecpial  severity. 
In  addition  may  be  mentioned  the  prevalence  of  measles  among  the 
soldiers  in  the  American  Civil  War  and  in  the  Franco-Prussian  AVar. 

On  the  other  hand,  infants  under  six  months  are  comparatively  rarely 
attacked,  and  this  does  not  seem  to  be  explicable  entirely  on  the  ground 
that  they  are  less  exposed  to  infection.  That  it  may  sometimes  occur 
is  shown,  for  instance,  by  the  experience  of  Embden,  who  observed  24 
cases  in  children  less  than  six  months  old  in  an  epidemic  at  Heidel- 
berg. Thomas  collected  the  reports  of  6  cases  in  which  children  had 
been  born  with  the  disease,  and  other  instances  have  since  been  observed 
(F.  B.  Richards,  Philpott).  Statistics  show  that  the  greatest  number 
of  cases  seem  to  develop  in  children  from  three  to  eight  years  old. 

Sex  cannot  be  said  to  possess  any  special  influence,  and  statistics 
show  no  certain  differences  between  the  susceptibility  of  males  and 
females. 

Vol.  I.— 40  625 


626  RUBEOLA— MEASLES. 

Season  has  a  positive  power  as  an  etiological  factor,  the  disease  being 
decidedly  more  common  in  the  winter  and  spring  months.  This  may 
depend  upon  the  greater  degree  to  which  children  are  housed  at  this 
time,  and  the  increased  exposure  to  infection  through  meeting  in 
schools.  The  diminished  degree  of  resistance  which  the  state  of  the 
health  often  offers  at  this  time  may  also  have  some  influence.  The 
statistics  of  Hirsch  show  that  3390  of  the  epidemics  which  he  records 
occurred  in  the  cooler  weather  and  only  191  in  warm  w^eather. 

The  only  real  cause  of  measles  is  infection.  The  infectious  principle 
is  certainly  a  very  active  one,  for,  as  stated,  nearly  all  those  exposed 
contract  the  disease.  Very  short  exposure  is  all  that  is  ordinarily  re- 
quired. The  virulence  of  the  infectious  principle  is  so  great  that  if  the 
disease  breaks  out  in  a  school  or  other  institution  for  children,  it  is 
usually  impossible  to  stop  its  spread.  The  poison  is  certainly  very  dif- 
fusible, and  is  probably  oftenest  carried  by  the  surrounding  air  and 
deposited  u])on  the  respiratory  mucous  membrane  of  those  about  to  be 
attacked.  It  may  be  desiccated  nasal  or  bronchial  mucus  which  con- 
tains the  poison  thus  transmitted,  for  inoculation  experiments  with  nasal 
mucus  applied  to  the  mucous  membrane  of  children  appear  to  have  been 
successful  (Mayr).  Other  experiments  of  a  similar  nature  have  indi- 
cated that  the  tears  and  saliva  contain  the  infectious  principle.  On  the 
other  hand,  although  it  has  been  commonly  supposed  that  the  desqua- 
mating skin  was  decidedly  infectious,  inoculation  experiments  do  not 
indicate  that  this  is  the  case  (Guinon).  There  is  an  element  of  doubt 
about  some  of  the  inoculation  experiments  reported,  but  the  investiga- 
tions with  the  blood  are  quite  convincing,  since  nearly  all  observers 
agree  that  the  disease  can  be  produced  by  inoculating  with  it. 

It  is  possible  for  the  infection  to  be  carried  by  the  clothing  of  the 
sick  or  by  a  third  person  from  the  sick  to  the  well,  and  numerous 
instances  have  beeii  reported  in  which  this  has  occurred.  This  method 
of  transmission  is,  however,  certainly  uncommon,  and  it  is  very  unusual 
for  a  phvsician  to  carry  the  disease  from  house  to  house.  The  vitality 
of  the  infectious  principle  is  comparatively  brief,  for  infected  clothing 
soon  ceases  to  be  dangerous.  Home  found  that  clothes  saturated  with 
the  blood  taken  from  cases  of  measles  lost  their  infecting  power  in  ten 
days,  although  in  these  the  poison  was  probably  present  in  its  most 
virulent  state. 

Measles  is  infectious  at  all  periods  of  the  attack.  The  power  of 
infection  probably  exists  during  incubation,  and  is  certainly  very  active 
during  the  prodromal  stage.  It  persists  during  the  stage  of  eruption 
and  is  least  strong  in  the  desquamative  stage. 

Pathology. — Analogy  to  other  infectious  diseases  whose  cause 
has  been  found  to  be  a  pathogenic  microbe  would  certainly  indicate 
that  some  such  organism  is  present  in  measles  also.  Observations 
have,  however,  as  yet  led  to  no  positive  conclusions.  The  earlier  in- 
vestigations have  ceased  to  possess  much  value  in  the  light  of  recent 
bacteriological  methods.  There  is  no  proof  that  the  various  bodies 
which  were  discovered  in  the  blood,  sputum,  or  breath  by  different 
observers  had  any  real  connection  with  the  disease.  Among  later 
studies  those  of  Canon  and  Pielicke  are  interesting.  These  observers 
discovered  a  bacillus  in  the  blood  and  nasal  mucus  of  14  morbillous 


SYMPTOMS.  G27 

pationts.  Tlioy  sueoocdod  ton  limited  extent  in  making  cultures  of  them 
in  bouillon,  8ub.se([uent  invest i<;'ations  by  Laveran  and  by  Josia.s  have 
not  confirmed  their  results.  Doehle  reports  tlie  presence  of*  a  fiagellated 
parasite  which  infests  the  red  corpuscles  and  the  ])lasma.  Other  writers, 
among  whom  are  C\>rnil  and  I^abes,  have  described  micro-organisms 
found  in  the  lungs  of  patients  dead  of  pneumonia  after  measles,  but  it 
<loes  not  appear  that  these  were  in  any  way  the  cause  of  the  measles 
itself.  So,  too,  M6ry  and  Boulloclie  found  the  pneumococcus  and  a 
.streptococcus  in  unusual  numbers  in  the  saliva  in  cases  of  measles,  and 
believe  that  this  accounts  for  the  tendency  to  respiratory  complications. 
It  is  clear  that  the  nature  of  the  cause  of  measles  needs  further  study. 

There  are  no  pathological  lesions  characteristic  of  measles.  There 
exists  some  cellular  infiltration  of  the  skin  around  the  vessels  of  the 
cutis,  the  sebaceous,  hair,  and  sudoriparous  follicles,  in  the  superficial 
layer  of  the  papillae,  and  in  the  Malpighian  layer.  There  is  a  catarrhal 
inflammation  of  the  larynx  with  swelling  and  redness  and  cellular 
infiltration,  and  sometimes  ulceration  also.  The  lining  of  the  trachea 
and  brt)nehi  exhibits  inflammation  of  varying  intensity.  The  different 
types  of  pneumonia  described  as  attending  measles  have  no  anatomical 
features  distinguishing  them  from  broncho-pneumonia  produced  in  other 
w'ays.  The  mucous  membrane  of  the  alimentary  tract  and  of  the  eyes 
is  subject  to  the  swelling  and  small-celled  infiltration  of  catarrhal 
inflammation.     Sometimes  Peyer's  patches  are  much  swollen. 

Symptoms. — Stage  of  Incubation. — The  length  of  time  between  the 
entrance  of  the  germs  into  the  system  and  the  appearance  of  characteristic 
symptoms  is  a  period  not  subject  to  much  variation,  although  there  seem 
to  be  occasional  exceptions  to  this.  The  duration  has  been  determined 
by  direct  inoculation  experiments  performed  by  Home,  Mayr,  and  others. 
There  have  been  besides  numerous  instances  in  clinical  experience  in 
which  the  duration  of  incubation  could  be  accurately  determined ;  but 
the  most  valuable  published  reports  are  those  of  Panum  upon  measles 
in  the  Faroe  Islands.  The  majority  of  observations  agree  in  fixing  the 
incubation  at  ten  to  twelve  days  until  the  first  appearance  of  symptoms  ; 
most  of  the  variations  from  this  which  have  been  reported  depending 
upon  the  difficulties  in  determining  just  when  infection  has  occurred. 

There  are,  as  a  rule,  no  symptoms  to  be  observed  during  the  period 
of  incubation.  Rarely  there  is  slight  fever,  headache,  malaise,  or  loss 
of  appetite  for  some  days  before  actual  evidences  of  the  disease  begin, 
but  in  the  majority  of  cases  these  symptoms  cannot  with  certainty  be 
attributed  to  the  action  of  the  germs  upon  the  system. 

Stage  of  Invasion. — In  typical  cases  the  prodromal  symptoms  last 
three  days,  and  are  quite  characteristic,  the  eruption  appearing  upon 
the  fourth  day.  The  child  is  irritable,  fretful,  feels  tired,  is  indis- 
posed to  play,  and  is  often  chilly.  There  is  often  a  very  decided  and 
almost  characteristic  drowsiness.  The  most  important  symptoms  are 
the  fever  and  the  catarrh  of  the  respiratory  apparatus.  The  conjunc- 
tivae, particularly  of  the  eyelids,  are  red  and  swollen,  the  sclerotics  are 
injected,  there  are  lachrymation  and  photophobia.  There  are  running  from 
the  nose,  obstruction  to  respiration  through  it,  sneezing,  and  sometimes 
nosebleed.  The  voice  is  hoarse  and  a  hard,  dry,  and  often  distressing 
cough  is  present.     Auscultation  shoAvs  but  a  few  dry  rales,  or  none  at 


628  RUBEOLA— MEASLES. 

all,  in  spite  of  the  severity  of  the  cough.  All  the  catarrhal  symptoms 
are  well  marked  by  the  second  day,  and  they  increase  in  severity 
throughout  the  prodromal  stage. 

The  fever  of  the  stage  of  invasion  is  rather  irregular.  Generally 
there  is  some  elevation  of  temperature  from  the  first  day  of  the  disease,^ 
and  this  may  be  very  considerable.  Afterward  it  runs  a  variable 
course.  Perhaps  in  most  cases  it  goes  steadily  upward,  with  a  morning 
remission,  but  in  others  there  occurs  a  very  decided  remission,  or  even 
intermission,  of  both  morning  and  evening  temperature,  usually  on  the 
second,  third,  or  fourth  day,  followed  by  another  rise.  This  curve  has 
been  described  by  some  writers  as  that  characteristic  of  measles,  but  it 
cannot  properly  be  called  so. 

Among  other  symptoms  of  the  invasion  those  of  the  alimentary  tract 
are  important.  The  tongue  is  coated,  but  exhibits  nothing  characteristic. 
The  tonsils  are  slightly  swollen,  and  the  mucous  membrane  covering 
them,  the  pharynx,  and  the  fauces  is  red.  By  the  second  or  third  day 
of  the  prodromal  symptoms  spots  which  have  been  called  the  "  enan- 
thema  "  appear,  especially  on  the  uvula  and  soft  palate,  but  often  extend- 
ing over  the  lining  of  the  cheeks,  the  hard  palate,  and  even  the  lips 
and  the  gums.  They  have  also  been  found  on  the  mucous  membrane 
of  the  larynx  and  on  that  of  the  eyes,  and  have  even  been  seen  at 
autopsies  in  the  small  intestine  (Steiner).  The  spots  are  deep  red  in 
color  and  of  the  size  of  a  pinhead  to  that  of  a  split  pea.  They  last 
several  days,  or  may  disappear  before  the  eruption  on  the  skin  shows 
itself.  They  are,  indeed,  entirely  analogous  to  the  latter,  and  are  really 
of  the  same  nature. 

There  are  loss  of  appetite,  thirst,  often  slight  sore  throat,  and  some- 
times vomiting.  The  bowels  may  be  either  constipated  or  loose.  Some- 
times there  is  irritability  of  the  bladder  with  frequent  desire  to  pass 
urine.  Occasionally  there  is  delirium  in  this  stage,  and,  rarely,  convul- 
sions. Enlargement  of  the  lymphatic  glands  in  different  parts  of  the 
body  is  a  not  infrequent  symptom.  In  an  earlier  publication^  the 
writer  called  attention  to  the  fact  that  examination  would  almost  always 
show  an  enlargement  of  the  superficial  cervical  glands  in  cases  of 
measles,  and  that  this  enlargement  could  not  therefore  be  relied  upon  as 
a  diagnostic  symptom  of  rubella. 

Stage  of  Eruption. — The  rash  generally  first  becomes  visible  during 
the  night,  and  is  found  when  the  child  wakes  upon  the  morning  of  the 
fourth  day.  Close  observation  will  show,  some  hours  before  the  macules 
actually  develop,  a  not  easily  described  alteration  in  the  apjiearance  of 
the  skm  of  the  face — an  indistinct  redness,  or  as  though  there  were  an 
indefinite  roughness  or  mottling  situated  beneath  the  surface.  I  have 
frequently  had  nurses  call  my  attention  to  this,  and  predict,  with  cor- 
rectness, that  the  typical  rash  would  be  present  by  the  next  day.  The 
rash  first  appears  upon  the  forehead,  cheeks,  temples,  about  the  ears  and 
the  mouth.  Just  what  part  of  the  face  is  first  attacked  is  variously 
stated.  It  probably  differs  in  different  cases.  The  eruption  consists 
of  pale  red  macules,  at  first  not  perceptibly  elevated,  round,  oval,  or 
irregular  in  shape,  and  of  pinhead  to  pea  size  and  separated  from  each 
other  by  healthy  skin.  The  number  of  these  rapidly  increases,  and  their 
^  Univ.  Med.  Magazine,  June,  1893. 


SYMPTOMS.  629 

color  i;onenilly  throws  more  intense  until  they  become  deep  red,  often 
slightly  tinged  with  purple.  They  also  become  distinctly  elevated  to 
the  finger  if  not  to  the  eye,  although  careful  examination  usually  shows 
that  the  elevation  is  visible  as  well.  Not  infrequently,  especially  in 
very  mild  cases,  tiie  eruption  preserves  its  pale  red  color.  By  the 
.second  dav  of  its  a])])earance  it  has  sj)read  over  the  whole  Ixxly,  perhaps 
with  the  exception  of  the  legs  and  forearms,  which  may  not  show  it  until 
the  third  day,  and  it  is  yet  more  abundant  in  the  situations  where  first 
seen.  In  certain  regions,  especially  on  the  face,  inner  surfaces  of  the 
thighs,  and  the  back,  or  wherever  there  is  much  hyperemia,  the  spots 
become  confluent  in  large  areas.  Still,  however,  the  appearance  is  cha- 
racteristic, for  the  skin  is  somewhat  infiltrated  and  unequally  rough,  and 
the  color  is  not  evenly  intense,  as  it  would  be  in  scarlatina.  Besides  this 
tendency  to  confluence  there  is  seen  all  over  the  body  a  peculiar  and  very 
characteristic  disposition  of  the  individual  papules  to  group  themselves 
into  irregular,  short,  straight,  or  oftener  curved  lines,  constituting  the 
well  known  "  crescentic  "  eruption  of  measles. 

The  individual  spots  reach  their  fullest  development  in  about  twenty- 
four  hours  and  then  begin  to  fade.  When  first  seen  pressure  with  the  finger 
causes  them  to  lose  their  color  momentarily,  but  later  this  is  not  the 
case  and  a  faint  yellowish  tinge  remains.  The  eruption  as  a  Avhole  is 
most  intense  on  the  second  or  third  day.  Then  it  begins  to  grow  paler, 
beginning  in  the  regions  where  it  first  appeared,  and  assumes  a  some- 
what brownish  and  finally  a  yellowish  color.  All  trace  of  the  spots 
generally  has  disappeared  in  four  to  five  days  from  their  first  develop- 
ment. 

By  the  second  day  of  the  eruption  the  face  presents  a  decided  puf- 
finess,  which,  with  the  inflammation  of  the  eyes,  gives  a  heavy  and 
stupid  expression  that  is  very  characteristic  of  the  disease.  The  tem- 
perature still  ascends  as  the  eruption  develops,  or,  if  it  has  previously 
fallen,  goes  up  again  and  continues  to  increase  for  the  first  two  days, 
with  the  morning  elevation  slightly  lower  than  the  evening  one.  It 
attains  its  height  when  the  eruption  is  at  its  maximum.  On  about  the 
third  day  of  the  rash  it  begins  to  fall  rapidly  to  normal,  although  some- 
times the  descent  is  more  gradual  and  the  normal  is  not  attained  for 
four  or  five  days  after  the  fall  begins.  Crisis  is,  however,  the  rule. 
The  persistence  of  the  catarrhal  symptoms  probably  has  much  to  do 
with  the  existence  of  the  fall  by  lysis. 

The  pulse  is  increased  in  proportion  to  the  temperature,  and  the 
respiration  likewise,  unless  influenced  by  respiratory  complications. 

The  catarrhal  symptoms  of  the  initial  stage  persist  or  even  increase 
in  severity  during  the  first  part  of  the  stage  of  eruption.  Coryza  and 
photophobia  are  often  very  severe ;  the  cough  may  be  distressing  and 
often  croupy,  and  the  voice  hoarse  and  even  whispered.  As  the  disease 
advances  examination  of  the  chest  reveals  numerous  mucous  rales  of 
different  sorts.  The  discharge  from  the  nose  is  thin  and  acrid  and 
irritates  the  lip  over  which  it  runs ;  later  it  becomes  purulent.  Nose- 
bleed is  not  uncommon.  The  secretion  of  the  bronchi  is  tenacious,  and 
only  grows  purulent  as  the  severity  of  the  attack  decreases.  In  most 
cases  there  is  no  expectoration,  owing  to  the  early  age  of  the  patient. 

Most  of  the  catarrhal  symptoms  grow  less  with  the  fading  of  the 


630  RUBEOLA— MEASLES. 

eruption,  but  the  cough  and  hoarseness  often  tend  to  persist  a  little 
longer. 

The  tongue  is  moist  and  coated  with  a  white  fur  in  nearly  all  in- 
stances. In  some  severe  cases,  however,  although  uncomplicated,  it  may 
be  dry  or  even  denuded  of  epithelium,  as  in  scarlet  fever.  The  throat 
is  often  sore,  and  the  pharynx,  tonsils,  and  palate  are  hyperjemic.  Ap- 
petite is  diminished  or  gone,  but  thirst  is  greatly  increased  and  is  often 
most  intense.  Vomiting  sometimes  occurs,  but  is  not  frequent.  On 
the  other  hand,  diarrhoea  is  a  very  common  symptom  ;  it  may  develop 
at  any  time  during  the  eruptive  stage  and  may  be  severe. 

The  urine  is  reduced  in  amount,  is  high  colored,  and  is  voided 
frequently.  It  occasionally  contains  albumin  during  the  height  of 
the  fever.  Acetonuria  has  been  reported  by  several  observers,  and 
propeptonuria  by  Loeb.  The  diazo  reaction  is  particularly  well  marked 
in  measles.     I  have  found  it  present  in  every  case  examined. 

Enlargement  of  the  lymphatic  glands  of  the  body  is  of  common 
occurrence,  especially  of  those  of  the  neck. 

A  tendency  to  drowsiness  often  persists  during  the  height  of  the  dis- 
ease.    Slight  delirium,  especially  at  night,  is  very  common. 

Stage  of  Desquamation. — This  may  be  said  to  begin  with  the  disap- 
pearance of  the  eruption,  although  the  scaling  itself  may  not  take  place 
until  a  day  or  two  later — on  the  average  the  tenth  or  eleventh  day  of 
the  disease.  The  desquamation  consists  of  very  small  branny  scales  or 
dust,  entirely  different  from  the  peeling  or  stripping  which  occurs  in 
scarlatina.  In  severe  cases  it  may  be  quite  extensive,  but  as  a  rule 
it  is  most  marked  on  the  face  and  is  slight,  and  very  often  cannot  be 
detected  at  all  or  only  if  carefully  looked  for.  It  lasts  but  a  few 
days. 

Anomalous  Forms. — Measles  is  subject  to  a  great  number  of  varia- 
tions either  in  certain  particulars  or  in  the  course  of  the  disease  as  a 
whole.  Some  children  are  scarcely  sick  at  all,  but  the  majority  are 
not  fit  to  be  out  of  bed.  Occasionally  the  duration  of  incubation  seems 
to  vary  from  the  normal,  and  may  be  either  longer  or  shorter  than  the 
figures  given.  The  stage  of  invasion  may  be  much  prolonged  (sixteen 
days,  Barthez),  but  it  is  oftener  either  abnormally  short  or  marked  by 
so  few  symptoms  that  it  is  overlooked.  I  have  seen  house  epidemics  in 
which  the  invasion  was  so  little  marked  in  all  the  cases  that  the  diag- 
nosis of  the  disease  was  at  first  rendered  obscure.  In  the  fully  devel- 
oped disease  we  may  have  several  different  varieties.  The  mild  form 
exhibits  a  very  short  course  with  well  developed  or  poorly  developed 
eruption  and  very  mild  symptoms.  The  patient  is  not  confined  to  bed 
and  may  have  scarcely  appreciable  fever  {rubeola  afebrilis).  In  the 
abortive  form  the  stage  of  invasion  may  have  been  well  developed  and 
all  its  symptoms  pronounced,  as  were  those  of  the  eruption  stage  at 
the  outset,  but  the  eruption  .and  its  attending  symptoms  disappear 
with  remarkable  rapidity.  A  variety  without  eruption,  rubeola  sine 
eruptione,  has  often  been  described.  This  can  be  recognized  only  when 
it  occurs  in  school  or  house  epidemics,  exhibits  all  the  symptoms  of  the 
disease  except  the  rash,  and  confers  a  future  immunity  against  it.  Simi- 
larly, a  rubeola  sine  catarrho  has  been  described,  in  which  the  eruption 
is  present,  but  Avithout  catarrhal  symptoms  either  attending  it  or  pre- 


ANOMALOI\^'  VOllMS.  G31 

ceding  it  during  the  period  of"  invasion.  Tiicrc  is  not  much  doubt  that 
the  great  majority  of  sucii  described  eases  were  in  fact  instances  of 
rubella  or  of  sonic  affection  of  the  skin  not  of  the  nature  of  measles. 
It  could  only  be  in  house  epidemics  where  it  was  certain  that  rubella 
was  absent,  or  in  cases  in  which  rubella  had  previously  occurred,  that 
the  diagnosis  could  be  made.  On  the  other  hand,  with  tlu;  capability 
which  measles  has  to  vary  there  is  not  much  (piestion  but  that  this  f<»rm 
is  sometimes  seen. 

Grave  or  malignant  forms  of  measles  may  show  themsehes  in  vari- 
ous ways.  One  of  the  best  known  is  hemorrhagic  measles,  or  "black 
measles"  as  it  has  often  been  called  by  earlier  writers.  It  is  now  a 
rare  disease.  It  occurs  only  in  debilitated  subjects  living  under  imper- 
fect hygienic  conditions,  as  in  prisons,  camps,  asylums,  and  the  like. 
The  eruption  never  develops  well  and  soon  becomes  pale.  Hemorrhages 
of  different  size  now  take  place  into  the  spots  and  elsewhere  under  the 
skin,  as  well  as  from  the  urethra,  vagina,  nose,  intestine,  and  other 
raucous  membranes,  and  even  into  the  muscles  and  from  serous  mem- 
branes. There  is  profound  adynamia,  delirium,  and  stupor.  The 
disease  is  very  fatal  and  its  course  very  rapid,  although  recovery  may 
occur.  In  another  severe  variety,  which  may  be  called  the  ataxic  or 
typhoid  form,  the  poison  appears  to  have  produced  great  depression  of 
the  system.  There  are  high  fever,  rapid,  weak  pulse,  feeble  circulation, 
dry  tongue,  rapid  breathing,  great  prostration,  restlessness  with  subsul- 
tus,  low  delirium  and  often  convulsions,  and  finally  coma.  In  this  form, 
as  in  the  last,  the  rash  is  poorly  developed,  or,  if  well  out  at  the  first, 
rapidly  disappears  with  the  onset  of  the  grave  symptoms. 

Rubeola  occurring  during  the  course  of  other  affections  may  run 
a  very  abnormal  course.  The  invasion  may  be  unnoticed,  the  eruption 
poorly  developed,  and  the  symptoms  severe.  So,  too,  when  some  inter- 
current disease  appears  during  an  attack  of  measles  the  rash  may  rapidly 
recede. 

There  are  numerous  minor  variations  seen  in  measles  depending 
ujjon  characteristics  of  the  eruption.  Sometimes  a  rash  appears,  es- 
pecially about  the  head,  almost  at  the  beginning  of  the  invasion,  and 
resembles  that  of  measles  except  that  it  is  pale.  It  may  remain 
unchanged  or  perhaps  grow  paler  still,  and  then  be  replaced  at  the 
proper  time  by  the  regular  eruption.  Such  cases  are  apt  to  lead  the 
physician  to  believ'e  at  first  that  the  case  is  one  of  rubella  or  that  he  has 
to  do  with  a  mild  instance  of  measles.  Sometimes  the  rash  develops 
upon  the  face  after  appearing  first  upon  the  trunk,  or  it  may  become 
visible  only  on  certain  parts  of  the  body.  The  recession  of  the  rash 
has  already  been  referred  to.  It  may  take  place  early  in  the  attack  in 
some  severe  or  complicated  cases.  The  reappearance  of  the  rash  is  then 
a  favorable  sign.  An  ecchyniotic  eruption  is  of  common  occurrence.  It 
is  seen  in  those  cases  in  which  the  rash  has  been  very  well  developed.  It 
is  due  to  extravasation  of  blood  into  the  spots  or  to  the  decomposition  of 
red  blood  corpuscles  which  have  exuded  from  the  vessels.  The  deep  blu- 
ish purple  spots  thus  produced,  which  do  not  disappear  on  pressure,  and 
which  occur  in  greatest  numbers  on  the  extremities,  remain  long  after 
the  patient  has  recovered  in  all  other  respects.  Traces  of  them  may  be 
seen  for  as  much  as  a  week  or  two.     This  form  of  eruption  has  nothing 


632  RUBEOLA— MEASLES. 

whatever  in  common  with  hemorrhagic  or  purpuric  measles,  and  is  not 
attended  by  especially   severe   symptoms. 

Complications  and  Sequels. — The  most  important  complica- 
tions are  those  connected  with  the  respiratory  apparatus.  Spasmodic 
croup  sometimes  occurs.  Ulceration  of  the  larynx,  possibly  with 
oedema  of  the  glottis,  is  an  unusual  complication.  Diphtheritic  laryn- 
gitis sometimes  develops.  Chronic  coryza  may  remain  as  a  sequel. 
Severe  exhausting  epistaxis  may  occur.  Bronchitis  in  moderate  degree 
is  a  symptom  of  the  aiFection,  but  not  seldom  it  becomes  so  severe  that  it 
deserves  consideration  more  than  the  measles  does,  and  is  then  to  be 
regarded  as  a  serious  complication.  Still  oftener  it  is  a  sequel,  and  con- 
tinues after  other  symptoms  have  disappeared,  being  the  cause  of  the 
persistence  of  more  or  less  fever  for  a  considerable  time.  In  infants  it 
may  prove  fatal,  principally  by  inducing  atelectasis. 

Broncho-pneumonia  is  a  frequent  and  very  dangerous  complication 
in  infancy  and  early  childhood.  It  may  develop  at  any  time  during  the 
attack,  but  oftenest  as  the  eruption  is  fading,  or  as  a  sequel  after  a  week 
or  two,  and  only  infrequently  during  the  invasion.  It  is  recognized  by 
the  failure  of  the  fever  to  disappear  at  the  proper  time  or  its  reappear- 
ance if  the  temperature  has  already  fallen,  and  by  the  increase  in  the 
severity  of  the  cough,  the  rapidity  of  the  respiration,  and  the  develop- 
ment of  other  characteristic  symptoms  of  pneumonia  in  children.  Often 
the  condition  is  really  a  tubercular  broncho-pneumonia.  Croupous  pneu- 
monia is  also  a  complication  or  sequel  of  measles,  but  is  of  much  less 
unfavorable  prognosis  and  is  less  common  than  the  catarrhal  form. 
Pleurisy  is  of  rare  occurrence.  Phthisis  pulmonum  is  a  very  frequent 
sequel. 

Complications  situated  in  the  intestinal  tract  are  often  present.  The 
drying  and  peeling  of  the  tongue  seen  in  severe  cases  have  already  been 
mentioned.  Catarrhal,  aphthous,  and  ulcerous  stomatitis  may  occur, 
the  latter  oftenest  as  a  sequel,  especially  in  debilitated  and  cachectic 
subjects.  Xonia  is  an  occasional  sequel  oftener  produced  by  measles 
than  by  any  other  disease.  The  occurrence  of  measles  predisposes  to 
the  development  of  faucial  diphtheria,  which  is  not  uncommon  as  a  com- 
plication or  sequel.  Occasional  vomiting  and  frequent  diarrhoea  have 
already  been  referred  to  as  symptoms  of  measles.  The  diarrhoea  may 
become  a  serious  complication  dej)ending  on  entero-colitis ;  this  occurs 
especially  in  debilitated  subjects  or  during  the  heat  of  summer.  Some- 
times the  disease  is  dysenteric  or  choleriform  ;  not  rarely  a  chronic 
diarrhoea  persists  as  a  sequel. 

Endocarditis  and  pericarditis  are  rare.  A  suppurative  pericarditis 
has  been  reported  by  several  observers. 

Nervous  affections  are  unusual.  The  occurrence  of  convulsions, 
delirium,  and  the  like  has  already  been  noted.  Convulsions  during 
the  course  of  the  attack  are  often  an  indication  of  the  onset  of  some 
complication.  Tubercular  meningitis  is  a  sequel.  Paralyses  of  various 
forms  may  follow  measles.  Allyn  has  collected  over  4*0  cases  of  this 
nature.  ]NIaniacal  seizures,  tetanus,  and  strabismus  have  been  reported 
in  rare  instances. 

Chronic  conjunctivitis,  iritis,  blepharitis,  keratitis,  and  other  affec- 
tions of  the  eye  are  prone  to  develop,  especially  as  sequels.     Catarrhal 


RELAPSE  AND  RECURnENCE.  633 

or  piiriilcMit  otitis  iiiodia  not  nircly  a('('oiii|)anics  or  folloAvs  nioasles, 
iiltlioiigh  k'ss  ol'teii  than  it  does  scarlatina.  Disease  of  tlic  labyrinth  has 
been  reported. 

The  oeeurrenee  of  alhiniiinuria  as  a  sym])tom  has  been  mentioned. 
A  true  acute  nc])hritis  I'oliowinii-  the  attack  has  been  observed,  but  is 
certainly  very  exceptional.  Ulcerous  vulvitis  is  an  uncommon,  and 
noma  pudendi  is  a  rare  sequel,  but  measles  distinctly  predis[)oses  to  their 
development.  Very  rarely  ganjirene  has  been  observed  on  other  parts 
of  the  body.  Other  affections  of  the  skin  sometimes  complicate  or  fol- 
low the  disease.  Miliaria  and  sndamina  sometimes  appear  when  the 
<^ruption  is  at  its  height.  Im])etigo  or  abscesses  are  occasional  sequels. 
Herpes  zoster  has  been  seen  Avith  measles.  Vesicles  or  bullae  sometimes 
iiccompany  the  rash.  Subcutaneous  emphysema  has  rarely  been  reported. 
Tuberculosis  of  the  bronchial  or  mesenteric  glands  may  be  a  sequel. 
Dropsy,  necrosis,  progressive  emaciation,  and  other  and  various  condi- 
tions have  occasionally  been  reported. 

Measles  may  complicate  or  be  complicated  by  any  other  acute  or 
chronic  disease.  The  influence  which  other  diseases  sometimes  have 
upon  its  course  has  been  referred  to  in  discussing  the  variations  in  the 
symptoms.  On  the  other  hand,  measles  occurring  in  the  course  of 
pneumonia,  bronchitis,  or  tuberculosis  aggravates  greatly  the  severity  of 
the  previous  affection.  It  seems  to  render  some  disorders  less  severe  or 
■even  to  cause  them  to  disappear.  Thus  Barthez  and  Rilliet  have  seen 
-chorea,  incontinence  of  urine,  and  epilejjsy  cease  after  the  occurrence 
■of  measles.  Eczema  and  some  other  skin  affections  may  disappear 
when  measles  is  present,  and,  although  liable  to  come  back  when  the 
■disease  is  over,  they  may  stay  away  permanently. 

Measles  may  be  combined  with  various  infectious  diseases,  and  cases 
have  been  reported  in  which  it  has  occurred  with  variola,  varicella,  vac- 
cinia, scarlatina,  typhoid  fever,  rubella,  and  mumps.  As  above  stated, 
it  not  infrequently  is  complicated  by  diphtheria.  The  frequency  of  the 
<;ombination  of  whooping  cough  and  measles  or  the  following  of  one  by 
the  other  has  long  been  well  known.  The  association  renders  the  prog- 
nosis of  either  decidedly  worse.  Just  what  the  etiological  relation  is,  or 
whether  there  is  indeed  any,  is  not  certain. 

Relapse  and  Recurrence. — Rarely  a  relapse  may  occur.  This 
takes  place  either  during  the  attack  or  during  convalescence,  in  the 
■course  of  the  second,  or  possibly  even  the  fourth,  week.  Sometimes 
all  the  original  symptoms  are  reproduced  in  a  characteristic  state.  In 
■other  instances  the  second  eruption  may  be  very  pale,  and  last  not 
more  than  twenty-four  hours,  while  the  catarrhal  symptoms  and  fever 
are  absent  or  very  slight.  Relapses  are  certainly  much  rarer  than 
reported  cases  would  seem  to  indicate.  A  large  number  of  the  sup- 
posed instances  are  probably  errors  in  diagnosis,  but  this  does  not  apply 
to  all  of  them. 

One  attack  of  measles  almost  certainly  protects  from  subsequent 
ones.  There  is  not  much  doubt  that  most  of  the  children  who  are 
stated  to  have  had  two  attacks  of  measles  suffered  from  some  other 
affection  upon  one  of  the  occasions.  At  the  same  time  two  distinct  and 
genuine  attacks  may  sometimes  occur,  and  instances  of  this  have  been 
reported  by  well  known  and  careful  observers.     Duchesne  has  recently 


6  34  B  VBEOLA— MEASLES. 

published  an  instance  of  three  well  marked  attacks  occurring  within  two 
years. 

Diagnosis. — The  diagnosis  of  measles,  taken  as  a  whole,  rests  upon 
the  long  prodromal  stage  with  its  attending  fever  and  catarrh,  and  upon 
the  presence  later  of  a  characteristic  eruption.  In  the  initial  stage  it  is 
impossible  at  first  to  do  more  than  suspect  the  development  of  measles. 
The  degree  of  fever  which  accompanies  the  catarrhal  symptoms  seems 
often  to  be  too  great  for  an  ordinary  cold.  It  is,  however,  what  might 
be  expected  in  a  case  of  influenza,  and  from  this  disease  the  initial  stage 
of  measles  can  sometimes  hardly  be  distinguished.  So,  too,  a  severe 
bronchitis  will  produce  high  fever,  but  is  more  apt  in  young  children  to 
be  attended  by  numerous  rales  in  the  chest.  The  discovery  of  the 
enanthema  on  the  mucous  membrane  of  the  throat  and  mouth  renders 
the  diagnosis  certain.  When  the  eruption  appears  the  diagnosis  is 
generally  easy,  and  yet  even  now  difficulties  sometimes  arise  in  cases 
which  are  not  quite  typical. 

Rubella  is  the  disease  which  most  resembles  rubeola.  It  is  to  be  dis- 
tinguished by  the  shorter  and  much  less  severe  initial  stage,  the  paler,, 
more  fugacious,  and  more  multiform  character  of  the  eruption,  which 
does  not  tend  to  arrange  itself  in  crescentic  forms,  and  the  less  intensity 
of  the  symptoms  attending  the  eruptive  stage.  (See  table  of  diagnostic 
symptoms  in  article  on  Rubella.)  In  sporadic  cases,  however,  the  diag- 
nosis between  the  two  diseases  often  cannot  be  made. 

Scarlatina  can  never  be  confounded  with  measles  in  typical  cases.  In 
the  initial  stage  of  the  latter  affection  the  sore  throat,  if  present  with 
the  fever,  might  suggest  scarlet  fever.  There  is  not  the  rapid  onset 
with  unusually  rapid  pulse,  the  absence  of  catarrhal  symptoms,  and  the 
great  tendency  to  vomiting  which  characterize  scarlet  fever.  In 
anomalous  cases  of  scarlet  fever  the  eruption  is  sometimes  patchy  and 
resembles  measles  decidedly  ;  while,  on  the  other  hand,  measles  may  be- 
come very  confluent  and  may  at  first  sight  look  like  scarlet  fever.  Such 
confusion  is  more  theoretical  than  real,  for  the  character  of  the  other 
symptoms  will  rarely  leave  any  difficulty  in  diagnosis.  In  the  stage  of 
desquamation  the  differences  are  very  distinct,  for  the  scales  of  scarla- 
tina are  in  flakes,  while  those  of  measles  are  dustlike  or  branny. 

Typhus  fever  has  an  eruption  which  is  strikingly  like  that  of  measles,, 
especially  when  the  rash  of  the  latter  becomes  ecchymotic.  There  is, 
however,  an  absence  of  coryza  and  of  conjunctivitis,  while  the  presence 
of  mental  torpor,  the  slight  development  of  the  rash  on  the  face,  and 
the  persistence  of  fever  for  so  long  a  time  help  to  distinguish  typhus  fever. 

Typhoid  fever  sometimes  has  such  numbers  of  spots  that  it  bears  a 
superficial  resemblance  to  a  poorly  developed  eruption  of  measles.  The 
diseases  are  distinct  in  every  other  particular. 

Variola  can  only  resemble  that  form  of  measles  in  which  the  erup- 
tion is  unusually  papular,  isolated,  and  hard,  and  then  the  resemblance 
is  of  brief  duration  only.  It  is  close  enough,  however,  to  have  caused 
serious  blunders.  The  rash  is  harder  and  more  shotlike  than  that  of 
measles  ever  is,  the  papules  become  vesicles  by  the  third  day  or  ear- 
lier, and  the  temperature  curve  is  characteristic.  In  the  period  of 
invasion,  too,  smallpox  exhibits  intense  headache,  pain  in  the  back,, 
vomiting,  and  an  absence  of  catarrhal  symptoms. 


rROGNOSrS—TREA  TMENT.  635 

Varicella  i^  distingiiislu'd  bv  tlif  rapid  (Ic'velopiiient  of  vesicles, 
as  well  as  by  the  absence  of  catarrhal  symptoms. 

There  are  various  eriij)tions,  not  symptoms  of  the  infectious  fevers, 
which  may  resemble  that  of  measles.  Prominent  amontr  these  are  some 
of  the  medicamentous  rashes,  not:U)ly  those  sometimes  j)r()duced  by  an- 
tipyrine,  co})aiba,  quinine,  chloral,  etc.  As  a  rule,  the  fever  and  the 
catarrhal  symptoms  are  absent,  but  sometimes,  especially  in  the  copaiba 
and  antipvrine  eruptions,  both  may  be  present  and  the  similarity  to 
measles  may  be  strikino-.  The  eruption  is  not,  however,  purely  that  of 
measles,  but  is  more  or  less  multiform.  There  is  the  al)sence,  too,  of 
an  initial  stage.  In  infants  the  presence  of  catarrh,  combined  with  some 
of  the  erythematous  rashes  to  which  children  of  this  age  are  lial)le,  may 
simulate  mild  measles  closely.  In  adults  forms  of  erythema  may 
resemble  measles,  but  usually  not  closely,  and  the  multiform  nature 
with  the  absence  of  characteristic  initial  and  attendant  symptoms  serves 
to  distinguish  them. 

Prognosis. — The  prognosis  of  measles  is  usually  excellent,  but 
varies  with  the  epidemic  and  Avith  the  individual,  and  is  especially 
influenced  by  the  presence  or  absence  of  complications.  An  average 
mortality  would  be  3  per  cent,,  but  there  have  been  series  of  cases 
with  a  mortality  of  over  30  per  cent.  (36.7  per  cent,  in  the  siege  of 
Paris ;  Colin).  The  younger  the  patient  the  graver  the  prognosis. 
This  applies  particularly  to  children,  for  adults  are  often  very  severely 
attacked.  This  has  been  exemplified,  for  instance,  in  the  American 
Civil  War,  the  Brazilio-Paraguayan  War,  the  Franco-Prussian  War, 
and  among  savage  nations.  In  such  cases,  however,  we  have  another 
important  element  influencing  the  prognosis — namely,  the  effect  of 
exposure,  want,  crowding,  and  other  elements  of  imperfect  hygiene, 
combined  with  lack  of  nursing  and  often  with  the  existence  of  pre- 
viously debilitated  health.  Such  conditions,  too,  account  for  the  high 
rate  of  mortality  often  seen  in  foundling  asylums  and  in  homes,  hos- 
pitals, and  other  institutions  for  children.  It  is  not  only  that  the  hy- 
giene is  not  always  perfect,  but  that  the  previous  debilitated  condition 
of  children  of  this  class,  which  existed  before  they  entered  the  institu- 
tions, has  rendered  them  less  able  to  resist  the  effect  of  the  disease. 

The  combination  with  measles  of  any  other  previously  existing  dis- 
ease, such  as  scarlatina,  tuberculosis,  bronchitis,  whooping  cough,  dys- 
pepsia, rachitis,  atrophy,  etc.,  renders  the  prognosis  much  more  unfavor- 
able. In  fact,  the  development  of  any  complication  adds  greatly  to  the 
gravity  of  the  affection,  for  it  is  to  the  complications  that  the  mortality 
is  almost  entirely  due.  Broncho-pneumonia  is  probably  the  complica- 
tion which  kills  the  most  children,  but  atelectasis,  croupous  pneumonia, 
and  diarrhoea  carry  off"  a  great  many  cases. 

Unfortunately,  even  after  the  patient  has  apparently  recovered 
entirely  the  danger  is  not  over,  for  the  sequels  of  the  disease,  notably 
tuberculosis  in  some  of  its  forms,  weaken  the  constitution  and  may  at 
last  prove  fatal. 

Treatment. — Prophylaxis. — The  fact  that  measles  is  contagious 
before  any  symptoms  appear  renders  prophylaxis  almost  impossible. 
Once  the  disease  has  broken  out  in  a  family  or  institution,  it  is  seldom 
that  its  spread  can  be  controlled.     Nevertheless,  the  effort  should  always 


636  RUBEOLA— MEASLES. 

be  made.  An  affected  child  should  be  isolated  immediately  after  the 
first  suspicious  symptom  has  been  noticed.  The  room  should  be  at  the 
top  of  the  house,  away  from  other  susceptible  inmates  of  the  household, 
Unneeded  furniture  and  hangings  are  better  taken  away.  All  soiled  bed 
and  body  linen  should  be  disinfected.  There  should  be  as  little  com- 
munication as  possible  with  other  parts  of  the  house,  and  the  attendants 
upon  the  sick  would  do  well  to  confine  themselves  to  the  room,  only 
leaving  it  when  going  out  of  the  house  for  rest  and  recreation.  In  fine, 
the  ordinary  means  of  disinfection  and  isolation  used  in  nursing  infec- 
tious diseases  should  be  followed,  although  there  is  not  as  great  danger 
of  carrying  the  disease  as  exists  in  the  case  of  scarlatina  and  some  other 
disorders.  Although  it  is  not  certain  that  the  scales  of  the  desquama- 
tion possess  any  infectious  power,  it  is  best  to  give  the  patient  a  hot 
disinfecting  bath  after  about  the  twelfth  day  of  the  disease.  Quaran- 
tine should  last  for  at  least  two  weeks  from  the  onset,  and  three  weeks 
is  a  much  safer  period.  After  the  room  is  vacated  ordinary  airing  and 
cleaning  are  all  that  is  needed,  since  the  measles  germ  is  short  lived. 
Still  more  careful  disinfection,  as  by  burning  sulphur  and  washing  the 
walls  with  disinfectant  solutions,  can  be  used  if  desired,  and  after 
malignant  cases  it  is  best  to  do  this.  Other  children  of  the  family 
should  not  go  to  school  until  after  fourteen  days  from  the  time  the 
sick  child  was  isolated — not  so  much  to  avoid  the  carrying  of  the  germs 
in  their  clothing,  since  this  is  not  likely  to  occur,  as  because  they  may 
themselves  be  going  through  the  incubative  process  and  be  soon  able  to 
transmit  the  disease  to  others.  If  one  can  be  sure  that  the  disease  has 
not  already  been  contracted,  it  is  well  to  remove  children  entirely  from 
the  locality  where  measles  is  prevailing.  This  is  especially  true  if  they 
are  debilitated  from  any  cause. 

Treatment  of  the  Attack. — In  mild  cases  very  little  treatment  is 
required,  and  in  any  event  it  must  be  purely  symptomatic.  As  soon  as 
symj^toms  appear  the  patient  should  be  confined  to  one  room,  as  stated, 
and,  better  still,  to  bed.  The  temperature  of  the  room  should  be  equable, 
at  68°  to  70°  F.,  and  there  should  be  no  draughts.  At  the  same  time  it 
is  absolutely  necessary  that  there  should  be  abundance  of  fresh  air,  pre- 
viously warmed  if  possible.  The  child  should  be  covered  only  as  warmly 
as  is  comfortable  to  it.  Far  too  often  the  bed  is  heaped  with  too  much 
clothing.  About  the  close  of  the  third  day  a  warm  bath  may  be  given, 
as  it  tends  to  relieve  the  fever,  to  quiet  the  nervous  system,  and  to  aid 
a  satisfactory  development  of  the  rash.  At  all  times  water  must  be 
used  in  a  manner  to  ensure  cleanliness.  There  is  no  need  of  shunning 
water  in  the  w^ay  that  is  sometimes  done.  Ablution,  if  performed 
properly,  never  need  do  harm.  The  same  remark  applies  to  the  chang- 
ing of  the  bedclothes  and  the  garments  of  the  child,  which  popular 
prejudice  causes  to  be  too  much  neglected. 

Liquid  or  semi-liquid  diet  is  to  be  recommended,  but  it  is  not 
necessary  in  the  case  of  older  children  with  undisturbed  digestion  to  use 
an  absolute  milk  diet.  In  cases  of  gastric  irritability  predigested  or  other 
special  food  may  be  needed.  Water  may  be  given  freely  in  any  reason- 
able quantity  to  assuage  the  severe  thirst.  Infants  must  be  given  water 
without  fail,  to  prevent  their  overloading  their  stomachs  with  milk. 
Cool,  slightly  acid  drinks  may  be  given  to  older  patients,  or  alkaline  or 


TREATMENT.  637 

carboiuitcd  waters  ;  or,  in  casc^  the  sk'iii  is  dry  and  the  kidneys  not  uct- 
ino-  tVeely,  hot  drinks.  In  order  to  iclicvc  tiic  [)hotoj)liol)ia  it  is  neces- 
sary to  keep  the  room  (hirkcni'd  or  the  patient's  eyes  turned  away  from 
the  li*2,ht  and  shiekU'd  l)y  a  screen. 

With  regard  to  medicinal  treatment,  very  little  is  required  in  or- 
dinary eases.  The  eoug-h  is  often  distressing  and  demands  sedative 
mixtures.  Small,  frecpiently  repeated  doses  of  a  combination  of  opium 
and  ipecacuanha,  Avith  sweet  spirits  of  nitre  or  citrate  of  potash  on 
account  of  the  fever,  answer  the  pur])ose  very  \vell.  As  the  disease 
advances  and  the  cough  grows  looser  expectorants  may  be  substituted. 
Some  bromide  salt,  combined  with  other  drugs,  is  also  an  excellent 
remedy  for  cough.  Fever  ordinarily  needs  no  special  treatment,  even 
when  it  reaches  as  high  as  104°  F.,  provided  this  elevation  occurs  at  the 
height  of  the  eruption,  is  not  continuous,  and  is  unattended  by  threaten- 
ing symptoms.  The  effect  of  the  fever  rather  than  its  degree  consti- 
tutes the  indication  for  treatment.  In  ordinary  cases  the  use  of  nitre 
or  citrate  of  potash,  as  mentioned  above,  is  sufficient.  When,  however, 
this  does  not  succeed,  and  the  fever  is  accompanied  by  tossing,  delirium, 
gritting  of  the  teeth,  twitching  of  the  muscles,  or,  on  the  other  hand, 
by  stupor  and  unconsciousness,  more  active  measures  are  needed.  A 
warm  bath  is  often  very  efficacious.  Still  more  powerful  is  the  action 
of  the  cold  bath  and  of  antipyretic  drugs.  The  cold  bath  constitutes 
a  rigorous  treatment  for  children,  yet  the  experience  of  Fodor,  Dieulafoy, 
and  others  shows  that  it  is  often  well  borne  and  very  effectual  in  malig- 
nant cases  with  hyperpyrexia. 

We  are,  however,  fortunate  in  possessing  in  drugs  of  the  antipyretic 
class  a  very  valuable  means  in  ordinary  cases  of  attaining  the  end 
desired  in  a  less  disagreeable  way.  It  is,  after  all,  upon  the  threatening 
nervous  symptoms  that  we  wish  to  act  in  most  cases.  I  have  elsewhere 
published  ^  some  cases  illustrative  of  the  powerful  and  favorable  action 
which  drugs  of  this  class  exert  upon  nervous  symptoms.  Delirium 
may  be  stopped  and  impending  convulsions  aborted  by  small  doses  of 
antipyrine,  phenacetin,  benzanilid,  and  similar  remedies,  sufficient  in 
amount  to  produce  slight  reduction  of  temperature,  but  not  sufficient  to 
cause  any  excessive  fall  with  coldness  of  skin  or  profuse  perspiration. 
Such  an  effect  is  not  needed  and  is  not  desirable.  Nervous  symptoms 
may  also  be  favorably  influenced  by  the  bromides  in  full  doses. 

It  is  important  to  attend  to  the  condition  of  the  bowels.  Constipa- 
tion is  sometimes  present  and  must  be  relieved.  This  must  be  done 
carefully  in  view  of  the  tendency  patients  with  measles  have  to  the 
development  of  diarrhoea.  Enemata  are  to  be  preferred,  and,  if  they 
are  not  sufficient,  mild  laxatives,  such  as  castor  oil,  calomel  in  small 
dose,  or  rhubarb,  may  be  given.  Should  there  be  slight  diarrhoea, 
medication  is  hardly  needed.  If  more  severe  diarrhoea  exists,  bis- 
muth with  or  without  opium  may  be  required. 

Vomiting  does  not  often  call  for  treatment.  Allowing  the  stomach 
to  rest  for  a  time  is  often  the  best  of  measures,  and  after  this  attending 
carefully  to  the  character  of  the  food.  If  this  does  not  avail,  some  of 
the  various  remedies  commonly  used  to  control  it  may  be  employed. 

The  irritation  of  the  eyes  is  best  treated  by  diminishing  the  amount 

^  Transac.  Amer.  Foddiat.  Soc,  vol.  v. 


638  BUBEOLA— MEASLES. 

of  light  in  the  room.  A  boric-acid  eye  lotion  used  frequently  is  often 
a  relief.  The  application  of  a  little  vaseline  to  the  edges  of  the  lids  will 
prevent  their  adhering  during  sleep.  The  spraying  of  the  nose  with 
weak  tepid  alkaline  solutions  is  grateful. 

Failure  of  the  strength  in  bad  cases  of  measles  is  to  be  combated  by 
the  use  of  stimulants,  sinapisms,  hot  mustard  foot  baths  and  general  hot 
mustard  baths,  with  digitalis,  quinine,  and  other  tonic  remedies.  The 
recession  of  the  rash  may  be  treated  by  warm  baths,  although  it  is  to 
be  borne  in  mind  that  this  symptom  probably  indicates  the  development 
of  some  complication  which  most  be  sought  for  and  appropriately 
treated.  In  general,  complications  must  receive  the  treatment  proper 
for  them,  and  cannot  be  considered  here. 

As  the  patient  is  convalescing  the  diet  can  be  increased,  but  confine- 
ment to  bed,  except  in  very  mild  cases,  should  continue  for  at  least  ten 
days  from  the  onset  of  the  disease,  and  the  confinement  to  the  room  for 
tTwo  weeks.  This  is  with  reference  solely  to  the  patient  and  without 
regard  to  the  question  of  quarantine.  The  first  outing  should  be  made 
in  good  weather,  and  the  patient  must  be  well  clothed,  for  the  mucous 
membranes  are  left  in  a  sensitive  state  after  the  attack.  Tonic  treat- 
ment, including  cod-liver  oil,  is  often  needed  during  convalescence,  and 
a  change  of  air  is  very  desirable  if  the  full  degree  of  health  does  not 
promptly  return. 


RUBELLA. 

By  J.  P.  CROZER  GRIFFITH,  M.  D. 


Synonyms. — The  disease  has  been  known  by  many  names,  of  which 
**  rubella "  seems  to  be  the  only  one  free  from  objection.  The  term 
"rubeola"  is  applied  to  it  by  German  writers,  but,  us  it  is  commonly 
used  to  designate  measles  by  English  physicians,  it  is  better  to  restrict 
it  to  the  latter  disease.  Rotheln  is  also  a  German  name  for  it,  unsuit- 
able because  it  is  a  foreign  word  and  one  especially  difficult  of 
pronunciation  for  the  English  tongue.  "  Roseola "  is  a  generic  term 
carelessly  applied  to  rashes  of  many  kinds,  and  even  with  the  prefix 
"  epidemic  ''  it  is  not  entirely  free  from  objections.  "  Rubella,"  has  the 
double  advantage  that  it  causes  no  confusion,  since  it  has  been  employed 
in  no  doubtful  sense,  and  that  it  is  a  diminutive  of  '"  rubeola,"  and  thus 
indicates  the  relationship  of  the  disease  to  measles  (rubeola)  a  relation- 
ship akin  to  that  of  varicella  and  variola. 

Definition. — An  infectious  febrible  disease  exhibiting  a  charac- 
teristic maculo-papular  rash,  sore  throat,  and  mild  catarrhal  symptoms, 
and  running  a  definite  limited  course. 

Etiology'. — Age  is  an  important  predisposing  cause.  The  great 
majority  of  cases  occur  during  childhood,  especially  between  the  ages 
of  five  and  fifteen  years.  The  disease  very  rarely  attacks  infants, 
yet  instances  do  occur,  and  a  case  is  reported  in  which  it  developed  a 
few  days  after  birth,  and  in  which  it  would  seem  that  the  infectious 
principle  had  been  transmitted  from  the  mother  to  the  foetus  (Scholl). 
Adults  are  not  infrequently  attacked,  yet  certainly  seem  to  possess  a  less 
marked  disposition  to  contract  it.  A  case  in  a  woman  of  seventy-three 
years  was  observed  by  Seitz. 

Sex  appears  to  be  without  etiological  influence. 

The  affection  occurs  especially  in  epidemics,  which  are  oftenest  seen 
in  winter  or  spring.  It  is  not  yet  certain  whether  the  malady  is  a 
cyclic  one,  as  Thomas  thought  probable,  coming  in  epidemics  at  intervals 
of  some  years,  but  it  would  seem  that  this  is  very  likely  the  case. 
Infection  is  the  only  directly  exciting  cause.  The  degree  of  infectious- 
ness has  been  a  matter  of  dispute,  some  observers  believing  it  to  be  but 
slight,  while  others  claim  that  the  disease  is  even  more  infectious  than 
measles.  My  own  experience  is  entirely  in  accord  with  those  who  hold 
that  its  infectiousness  is  great.  The  infectious  principle  is  probably  trans- 
mitted by  the  breath  and  by  exhalations  from  the  skin,  but  it  seems 
probable  that  it  can  also  be  carried  by  infected  clothing.  The  stage  at 
which  the  disease  is  most  infectious  is  not  definitely  known,  and  opinions 
differ  regarding  it.  It  is  certainly  infectious  very  early  in  the  attack, 
even  during  incubation,  and  probably  continues  so  during  desquamation 
and  longer. 

6.S9 


640  RUBELLA. 

Pathology. — The  exact  position  of  rubella  among  the  infectious 
diseases  was  long  a  matter  of  dispute,  and  some  writers  have  even 
claimed  that  it  did  not  belong  at  all  to  this  class  of  disorders.  At 
first  it  was  looked  upon  as  a  form  either  of  measles  or  of  scarlatina  or 
as  a  hybrid  of  the  two,  but  gradually  its  existence  as  an  independent 
infectious  disorder  has  been  recognized,  until  at  the  present  time  the 
great  majority  of  observers  have  no  doubt  about  the  matter.  Statistics 
unquestionably  show  that  rubella  is  an  infectious  fever  and  not  a  mere 
eruption  of  the  skin ;  that  it  appears  in  epidemics  which  hold  no 
relation  whatever  to  epidemics  of  measles  or  of  scarlatina ;  that  it 
attacks  indiscriminately  and  with  equal  severity  those  who  have  suJB'ered 
from  either  or  both  of  these  two  aifections,  and  that  its  previous  occur- 
rence does  not  prevent  either  of  them  from  developing ;  that  it  occurs 
but  once  in  an  individual,  and  never  communicates  anything  but  rubella 
to  others ;  and,  finally,  that  its  symptoms  and  course  diifer  from  those  of 
either  scarlatina  or  measles.  These  points  are  quite  sufficient  to  establish 
it  as  an  independent  infectious  disease.  Analogy  suggests  that  some 
microbe  is  the  causal  agent  in  producing  it,  but  the  earlier  observations 
which  recorded  the  presence  of  a  micrococcus  in  the  blood  were  not 
attended  by  culture  and  inoculation  experiments,  and  have  not  been  con- 
firmed by  later  investigations.  The  real  nature  of  the  infectious 
principle  is  therefore  still  unknown.  Post-mortem  examinations  are 
only  to  be  had  on  cases  dying  of  complications,  and  reveal  nothing 
bearing  upon  the  disease  itself. 

Symptoms. — Incuhation. — The  stage  of  incubation  appears  to  vary 
considerably.  This  variability  constitutes  one  of  the  characteristics  of 
the  disease  as  contrasted  with  the  more  fixed  period  of  measles.  In 
cases  in  which  I  have  been  able  to  determine  accurately  the  period  of 
incubation  it  has  varied  from  five  to  eleven  days.  As  an  average 
estimate  based  upon  the  experience  of  many  observers  it  may  be  stated 
to  extend  from  one  to  three  weeks.  There  are  usually  no  symptoms 
complained  of  during  this  time.  I  have  occasionally  observed  very 
decided  enlargement  of  the  superficial  cervical  glands.  Squire  states 
that  some  complaint  of  the  throat  is  occasionally  made  and  that  epi- 
staxis  and  enlargement  of  the  post-cervical  glands  may  be  noted. 

Invasion. — The  symptoms  of  this  stage  are  generally  either  absent 
or  so  slight  that  they  are  overlooked  entirely.  When  present  they  con- 
sist of  slight  malaise,  slight  cough,  suffusion  of  the  eyes  and  coryza, 
frequently  some  sore  throat,  very  commonly  enlargement  of  the  superficial 
cervical  glands,  occasionally  nausea,  hoarseness,  pains  in  the  limbs,  drowsi- 
ness, and  oedema  of  the  face,  and  an  elevation  of  temperature  of  1°  or  2°  F. 
These  prodromes  last  but  a  few  hours,  or  at  the  longest  not  more  than  a 
day.  I  have  but  once  seen  them  last  as  long  as  forty-eight  hours.  A 
number  of  observers,  however,  have  observed  them  continue  three  or 
even  four  days,  and  sometimes  be  severe,  but  such  cases  cannot  be  looked 
upon  as  other  than  anomalous. 

Rarely  unusual  prodromal  symptoms  show  themselves.  Among 
those  reported  are  vomiting,  convulsions,  delirium,  hemorrhages  from 
the  eyes  and  ears,  epistaxis,  dizziness,  fainting,  crouplike  attacks, 
intense  headache,  rigors,  urticaria,  erythema,  or  some  unclassified  pro- 
dromal rash. 


SYMPTOMS.  641 

Eruption. — Vcrv  often  the  child  on  waking  in  the  niornint^  is  found 
to  be  extensively  covered  by  the  characteristic  rash.  When,  however, 
the  progress  of  the  eruption  can  he  watched  tVoni  its  ineipiciuey,  it  will 
generally  i)e  found  to  develop  iirst  on  the  face,  and  to  spread  with  great 
rai)ldity  downward  over  the  rest  of  the  body,  covering  it  in  a  few  liours 
or  a  day.  This  is  the  opinion  of  the  great  majority  of  writers,  alth(»ugh 
a  few  would  locate  its  Iirst  appearance  on  the  breast  and  anus  or  the 
truid<.  In  a  ty])ical  ease  the;  eruption  consists  of  small,  irregtdarly 
shaped  spots  of  from  pinhead  to  split  pea  size,  very  slightly  elevated 
and  of  a  pale  rose  tint.  The  spots  are  not  grouped  as  in  measles.  They 
are  widely  distributed,  elosely  placed,  discrete  for  the  most  part,  but 
showing  a  tendency  to  become  confluent  in  large  areas  in  certain  regions, 
particularly  the  face,  nates,  and  flexor  surfaces  of  the  thighs.  On  the 
trunk  the  spots  are  paler,  or  are  brownish  red,  very  small  and  thickly 
placed.  This  is  the  ap])earance  of  the  eruption  as  seen  in  a  typical  case. 
One  of  the  gr(?atest  characteristics  of  the  rash,  however,  is  its  tendency 
to  vary  in  different  epidemics  and  in  different  cases  in  the  same  epidemic. 
This  accounts,  to  a  large  extent,  for  much  of  the  confusion  regarding  the 
disease,  and  for  the  differences  in  the  descriptions  which  have  been  given. 
Some  observers  report  the  rash  as  macular  only,  and  others  as  slightly 
elevated.  Some  describe  it  as  purpler  and  darker  than  measles,  while 
most  recognize  it  as  paler.  Vesicles  have  occasionally  been  seen  ;  petechias 
and  a  purpuric  eruption  have  been  rarely  reported  ;  a  marbled  appear- 
ance of  the  skin  is  mentioned;  and  a  sensation  as  of  shot  beneath  the  skin, 
which  I  have  observed  in  one  case,  was  also  found  once  by  Clausen, 
There,  are  however,  two  very  marked  types  of  variations  of  the  eruption 
to  which  I  have  endeavored,  in  a  former  article,'  to  call  especial  atten- 
tion under  the  names  of  rubella  searlatiniforme  and  7'ubella  morhilliforme. 
In  the  first  the  spots  are  for  the  most  part  nearly  or  fully  as  large  as 
those  of  measles,  have  the  same  dark  red  color,  and  are  slightly  ele- 
vated and  more  or  less  grouped.  Cases  of  this  sort  cannot  be  distin- 
guished from  measles.  In  the  second  type  the  rash  is  confluent  in  large 
patches  or  almost  universally  and  is  not  elevated,  and  resembles  scarla- 
tina very  closely.  Sometimes  careful  examination  in  these  cases  shows 
a  few  slightly  elevated  papulo-macules  in  the  general  redness ;  these  are 
most  apt  to  be  noticed  on  the  brows,  wrists,  and  fingers.  Even  the  most 
careful  examination  may  fail  at  first  satisfactorily  to  distinguish  these 
cases  from  scarlatina.  All  gradations  may  be  found  from  the  normal 
eruption  toward  either  of  these  two  types.  The  more  papular  the  rash 
the  greater  is  the  tendency  to  the  grouping  of  measles,  and  the  more 
distinctly  macular  the  greater  the  disposition  to  confluence.  Filatow 
has  gone  so  far  as  to  describe  a  rubeoloid  and  a  scarlatinoid  form,  which 
he  claims  are  entirely  distinct  affections.  There  seems,  however,  not 
the  slightest  doubt  that  they  are  really  the  same  disease,  as  they  are 
produced  by  the  same  infection.  Many  observers  have  called  atten- 
tion to  the  likeness  of  cases  of  rubella  sometimes  to  measles  and  some- 
times to  scarlet  fever.  In  many  instances  the  rash  has  been  scarla- 
tiniform  on  one  part  of  the  body  and  rubeoloid  on  another.  Ladell 
reports  three  such  cases,  two  of  wdiich  developed  scarlatina  six  months 
later,  and  the  other  measles,  thus  negativing  any  possible  theory  that  a 

1  Medical  Record,  July  2  and  9,  1887. 
Vol.  1.— 41 


642  RUBELLA. 

combination  of  the  two  diseases  had  existed.  It  is,  too,  of  very  fre- 
quent occurrence  for  the  rash  to  be  papular  upon  the  first  day,  but  to  be 
distinctly  confluent,  not  elevated,  and  like  scarlatina  upon  the  second 
day. 

The  duration  of  the  eruption  upon  any  one  part  of  the  body  is  sub- 
ject to  some  variation.  In  many  cases  it  is  often  at  its  height  on  the 
face,  neck,  and  trunk  before  it  appears  at  all  on  the  extremities,  and  then 
has  nearly  disappeared  from  these  regions  in  twelve  to  twenty-four 
hours  by  the  time  it  is  at  its  height  on  the  arms  and  legs.  The  duration 
of  the  full  blown  rash  on  any  one  part  is  thus  from  a  few  hours  to 
half  a  day.  In  these  cases  the  rash  spreads  over  the  body  like  a  wave, 
fading  from  one  place  while  it  appears  in  another.  This  method  of 
spreading  has  been  considered  diagnostic  by  a  number  of  clinicians,  but 
in  certainly  just  as  many  cases  the  persistence  of  the  rash  is  greater. 
In  such  cases  it  will  be  found  after  twenty -four  hours  still  fully  devel- 
oped on  the  face,  while  it  has  extended  to  the  rest  of  the  body ;  so  that 
the  acme  of  the  rash  may  be  said  to  have  been  attained  everywhere  by 
the  second  day.  The  fading  then  takes  place  from  all  parts  at  once  or 
from  the  face  first,  or  first  from  those  parts  which  had  been  least  affected. 
The  total  duration  of  the  rash  is,  of  course,  subject  to  considerable  vari- 
ation, depending  upon  the  intensity  of  its  development.  The  average 
may  be  said  to  be  three  or  four  days,  although  it  often  lasts  a  very  much 
shorter  time,  and  may  be  visible  even  longer. 

Tlie  Eruptive  Stage. — AVith  the  appearance  of  the  rash  develop  the 
attendant  symptoms  of  the  disease  if  they  have  not  been  present  before. 
They  consist  chiefly  of  a  combination  of  slight  sore  throat  with  a  mild 
catarrhal  condition  of  the  eyes  and  of  the  respiratory  apparatus.  The 
disagreement  between  writers  regarding  the  intensity  of  the  symptoms 
indicates  beyond  doubt  the  difference  which  exists  between  various  epi- 
demics of  the  disease.  Certainly  as  a  rule  the  catarrhal  symptoms  are 
either  absent  entirely  or  are  very  mild  as  compared  with  measles,  con- 
sisting only  of  slight  suffusion  of  the  eyes  with  coryza  and  a  loose 
bronchial  cough. 

Sore  throat  is  a  very  characteristic  symptom  nearly  always  present, 
yet  also  nearly  always  slight.  Frequently  it  is  not  complained  of  at  all, 
and  is  only  detected  on  examination.  Oftenest  there  is  only  a  redden- 
ing of  the  pharynx,  and  particularly  of  the  anterior  pillars,  but  some- 
times the  tonsils  are  much  swollen  and  deglutition  is  difficult.  In  not  a 
large  number  of  cases  an  eruption  of  punctate  brownish  red  or  yellowish 
red  spots  are  visible  over  the  uvula,  soft  palate,  and  lining  of  the  cheeks. 
Hoarseness  is  sometimes  observed,  but  is  not  a  common  symptom. 

The  anginose  and  catarrhal  symptoms  may  disappear  entirely  after 
twentv-four  hours,  and  while  the  rash  is  still  well  out,  but  as  a  rule  they 
diminish  with  the  eruption.  Not  seldom,  however,  the  cough  and  the 
congestion  of  the  throat  persists  for  some  time  longer,  and  an  increase  of 
the  catarrhal  symptoms  at  the  time  of  the  fading  of  the  rash  has  been 
reported  hy  Squire. 

The  temperature  of  the  disease  is  variable.  As  a  rule,  fever  is  ab- 
sent or  slight,  but  in  some  cases,  and  particularly  in  some  epidemics,  it 
may  reach  103°  F.,  or  even  more.  It  is  at  its  height  on  the  first  or 
second    day  of   the    eruption    and   diminishes   as   the  rash  fades,  but 


'      COMPLICATIOXS  AND  SEQUELJE.  640 

sometimes  it  falls  al)niptly  t(i  tlio  iiormiil  on  the  second  day,  Avhile  the 
rash  is  still  hriuht.  Indct'il,  the  tenipcratiire  may  fall  snddenly  or  slowly 
at  any  time  during  the  attaek.  Generally  the  severity  of  the  fever  and 
of  the  catarrhal  sym[)toms  is  in  proportion  to  the  intensity  of  the  erup- 
tion, yet  this  is  by  no  means  an  infallil)le  rule.  There  may  be  a  wide- 
si)read  rrnption  with  an  entire  absenee  of  fever  or  with  slight  catarrhal 
symptoms,  and  the  converse  of  this  may  l)e  equally  true.  S<J,  too,  the 
acme  of  the  rasii  and  the  fullest  development  of  the  fever  or  catarrh 
are  not  necessarily  coincident. 

The  rate  of  the  pulse  and  of  the  respiration  is  increased  in  propor- 
tion to  the  degree  of  fever. 

The  tongue  is  clean  or  covered  with  a  thin  yellowish  coating.  This 
is  the  condition  as  recognized  almost  with  unanimity  by  writers.  It 
may  be  considered  a  diagnostic  point  that  the  tongue  never  assumes  the 
peeled  or  straNvberry  appearance  characteristic  of  scarlet  fever.  A  few 
writers  descrii)e  the  tongue  as  similar  to  that  of  scarlet  fever,  but  cases 
presenting  this  appearance  cannot  but  be  considered  as  altogether  anoma- 
lous, if,  indeed,  some  of  them  were  actually  instances  of  rubella. 

Enlargement  of  the  superficial  cervical  and  posterior  auricular  glands 
has  long  been  considered  one  of  the  diagnostic  evidences  of  rubella. 
It  is  one  of  the  earliest  symptoms  to  appear,  being  present  in  some 
cases  even  during  incubation,  and  often  continuing  after  the  rash  has 
disappeared.  I  have,  however,  called  attention  previously  to  the  fact  that 
this  glandular  enlargement  is  not  so  diagnostic  as  is  often  supposed.'  A 
similar  enlargement,  although  usually  not  so  great,  is  very  often  seen  in 
measles.  It  is,  indeed,  very  probable  that  many  children,  with  their 
natural  tendency  to  this  condition,  have  these  glands  enlarged  independ- 
ently of  the  infectious  disease.  Enlargement  of  glands  elsewhere  in 
the  body  occasionally  occurs. 

OEdema  of  the  face  is  sometimes  seen,  although  not  so  often  as  in 
measles.  An  odor  has  been  said  to  attend  the  eruption,  but  this  does 
not  seem  to  be  corroborated  bv  general  observation.  Itching  of  the 
skin  is  generally  absent,  bttt  occasionally  is  present  with  the  eruption, 
and  a  general  roughness  of  the  skin  is  sometimes  observed. 

Xausea  and  vomiting  are  usually  considered  to  be  of  very  rare  occur- 
rence. In  some  of  the  severest  cases  they  may  be  present  early  in  the 
attack,  or  even  be  more  prolonged,  but  they  cannot  be  viewed  as  at  all 
characteristic.  The  bow^els  are  regular  or  slightly  constipated.  The 
urine,  as  a  rule,  contains  no  sugar  or  albumin.  In  exceptional  cases 
there  may  be  a  febrile  albuminuria,  but  this  is  rather  anomalous. 

Desquamation. — As  the  eruption  fades,  spots  of  a  faint  brownish  or 
yellowish  color  often  are  left  and  last  two  or  three  days.  A  slight 
branny  desquamation  may  or  may  not  take  place.  Some  observers 
have  never  seen  it,  and  few  describe  it  as  more  than  slight  and  always 
furfuraceous.  In  this  respect  it  is  entirely  different  from  the  scaling 
or  peeling  of  scarlatina.  The  desquamation  is  generally  completed  in 
from  one  to  three  days,  but  occasionally  lasts  a  longer  time. 

CoMPLiCATioxs  AND  Sequel.i:. — The  usual  slight  import  of  rubella 
makes  complications  and  sequel*  uncommon.  Those  most  often  seen 
are  affections  of  the  respiratory  apparatus.    Pneumonia  and  severe  bron- 

*  University  Medical  Magazine,  June,  1892. 


644 


RUBELLA. 


chitis  may  occur.  Pleurisy  has  been  reported,  as  has  croup.  Most 
observers  have  found  intestinal  catarrh  quite  unusual.  This  is  in  sharp 
contradistinction  to  measles.  It  is  only  in  anomalous  cases  that  diar- 
rhoea is  seen.  Stomatitis  has  been  occasionally  witnessed  as  a  compli- 
cation, as  have  temporary  painful  enlargement  of  the  thyroid  gland, 
urticaria,  convulsions,  delirium,  and  rheumatism.  Erysipelas,  earache, 
otorrhoea,  and  diphtheria  have  been  described  as  sequelae.  Among  other 
complications  and  sequelae  Avhich  have  been  referred  to  by  writers,  but 
which  are  certainly  to  be  considered  as  purely  accidental  as  they  are 
rare,  are  varicella,  typhoid  fever,  phlyctenular  keratitis,  abscesses  in 
different  parts  of  the  body,  blepharitis,  mumps,  tubercular  meningitis, 
numbness  and  loss  of  power  in  the  arms  and  legs,  oedema  of  the  legs, 
miliaria,  pemphigus,  etc. 

Relapse  axd  Recurrence. — Relapse  is  certainly  of  the  greatest 
rarity,  and  the  possibility  of  its  occurrence  is  not  even  referred  to  by 
the  majority  of  writers.  Cuomo  saw  it  in  all  of  the  90  anomalous  cases 
of  rubella  reported  by  him,  and  Kingsley  has  witnessed  it  frequently, 
but  with  these  exceptions  the  reported  cases  are  rare.  It  would  seem 
to  be  most  apt  to  develop  from  a  week  to  three  weeks  after  the  begin- 
ning of  the  first  attack.  Recurrence  is  very  rare,  one  attack  almost 
certainly  protecting  from  subsequent  ones. 

Diagnosis. — The  distinguishing  of  the  disease  from  measles  has 
been  discussed  more  fully  under  that  heading.  The  most  important 
diagnostic  points  are  the  absence  or  slight  importance  of  the  prodromes, 
their  short  duration,  the  absence  or  slight  degree  of  the  catarrhal 
svmptoms  of  the  attack,  the  slight  fever  or  its  irregularity,  the  presence 
of  more  or  less  sore  throat ;  the  greater  enlargement  of  the  glands  of 
the  neck  and  behind  the  ears,  and  the  peculiar  characteristics  of  the 
eruption.  Nevertheless,  although  the  average  case  can  be  recognized 
without  difficulty,  occasions  arise,  as  has  been  stated,  in  sporadic  cases 
where  a  diagnosis  is  entirely  impossible. 

The  following  table  exhibits  some  of  the  most  important  differential 
symptoms  between  rubeola,  rubella,  and  scarlatina  : 

Differential  Diagnosis  of  Rubeola,  Rubella,  and  Scarlatina. 


Rubeola. 


Fourteen  days. 


Usually  last  three  days. 


Severe  catarrhal  symp- 
toms of  nose  and  eyes ; 
considerable  cough. 

Slight  sore  throat  not  un- 
common. 

Vomiting  occasionally  oc- 
curs. 

Decided  fever,  often  with  a 
characteristic  tempera- 
ture curve. 


Rubella. 
Incubatiox. 
Very    variable ;     one 
three  weeks. 

Prodromal  Symptoms. 

Absent  or  seldom  last 
longer  than  twelve  to 
twenty-four  hours. 

Catarrhal  symptoms,  if 
present,  usually  slight. 

Sore  throat  often  attends. 

Vomiting  very  rare. 

Fever  absent  or  slight. 


Scarlatina. 


to     One  to  seven  days. 


Last  twenty-four  hours  or 
less. 


Marked  sore  throat. 

Vomiting  a  frequent  symp- 
tom. 

High  fever,  rapid  pulse, 
marked  nervous  symp- 
toms. 


PROGNOSIS— TREA  TMENT. 


645 


Rubeola. 


First  on  the  face. 

Spreads  gradually ;  niaxi- 
mum  all  over  body  by 
the  second  or  third  day. 


Lasts  an  average  of  four 
days. 

Color  deeji  red ;  often 
purplish. 

Papular ;  arranged  in  ir- 
regular or  crescentic 
groupings. 


Rubella. 
Eruption. 
First  on  the  face. 

Spreads  very  rapidly ; 
either  fading  from  one 
part  before  in  full  bloom 
on  another,  or  with  uni- 
versal maximum  in 
twenty-four  hours. 

Lasts  three  to  four  days  or 
less. 

Color  usually  pale  rose 
red. 

More  or  less  elevated; 
spots  smaller  than  in 
measles;  discrete  or  con- 
fluent, seldom  arranged 
in  groupings. 


Scarlatina. 


First  on  the  neck  and 
chest. 

Spreads  slowly ;  maxi- 
mum reached  by  the 
fourth  day. 


Lasts  six  to  seven  days  or 
longer,  sometimes  much 
less. 

Color  intense  red ;  dusky 
or  livid  in  some  cases. 

Minute  red  points,  con- 
fluent in  large  patches 
or  universally. 


Symptoms  of  Stage  of  Eruption. 


Severe  catarrhal  symptoms 
persist  and  increase;  se- 
vere bronchitis  common. 

Throat  sometimes  sore. 

Superficial  cervical  and 
other  glands  often  en- 
larged. 

Tongue  coated,  in  bad 
cases  dry  and  brown. 

Temperature  102°-104°  F.; 
ascends  slowly ;  maxi- 
mum with  that  of  erup- 
tion. 


Pulse  in  proportion  to  fe- 
ver. 

Diarrhoea  common  during 
eruption. 

Albuminuria  not  very 
common. 


Branny. 


Slight  catarrhal  symptoms 
persist  or  may  appear. 

Slight  sore  throat  nearly 
always  present. 

Superficial  cervical  and 
posterior  auricular 
glands  nearly  always  en- 
larged. 

Tongue  clean  or  slightly 
coated ;  never  strawberry 
or  peeled. 

Temperature  variable ;  sel- 
dom over  101°  F ;  no 
constant  connection  of 
maxima  of  temperature 
and  of  eruption ;  often 
normal  by  second  day. 

Pulse  in  proportion  to  fe- 
ver. 

Diarrhoea  rare. 

Albuminuria  very  rare. 

Desquamation. 
Absent ;  or  slight,  branny. 


Corvza  in  bad  cases. 


Sore  throat  a  very  marked 
and  constant  feature. 

Glands  below  the  jaw  often 
much  enlarged. 


Strawberry  tongue. 


Temperature  usually  104° 
-105°  F.  from  outset  for 
three  to  four  days. 


Pulse  very  rapid. 


Albuminuria     very     fre- 
quent. 

In  flakes  or  rolls. 


Prognosis. — In  nearly  all  cases  the  prognosis  is  entirely  good.  In 
some  severe  local  epidemics  deaths  have  taken  place.  These  have 
usually  been  the  result  of  complications,  but  in  some  instances  they  seem 
to  have  resulted  from  the  depressing  effects  of  the  disease  itself. 

Treatment. — Prophylaxis. — It  is  exceedingly  difficult  to  limit  the 
spread  of  the  disease,  owing  to  its  great  contagiousness  and  to  the  fact 
that  this  exists  before  any  very  distinct  evidences  of  illness  are  present. 
Any  child  attacked  ought  to  be  separated  from  the  other  members  of  the 
familv,  since  we  can  never  know  that  we  may  not  be  about  to  encounter 
the  disease  in  a  severe  form. 


646  RUBELLA. 

After  recovery  such  means  of  disinfection  are  required  as  have  been 
advised  for  measles.  The  duration  of  the  infectiousness  is  difficult  to 
determine.  Quarantine  should  certainly  last  three  weeks  from  the  onset 
of  the  symptoms. 

Treatment  of  the  Attack. — But  little  treatment  ordinarily  is  required, 
and  what  is  needed  is  entirely  symptomatic.  The  patient  should  be 
confined  to  bed  and  guarded  carefully  against  cold,  in  view  of  the  pos- 
sible danger  of  respiratory  complications.  Darkening  of  the  room  is 
not  so  often  needed  as  in  measles,  but  may  be  necessary,  and  should 
certainly  be  carried  out  if  there  is  any  weakness  of  the  eyes.  A  light 
diet  is  advisable.  A  febrifuge  or  perhaps  an  expectorant  or  sedative 
cough  mixture  may  be  needed  if  there  is  much  cough.  Antipyrine  or 
other  drugs  of  this  class  will  rarely  be  required  to  reduce  temperature. 
All  severe  symptoms  or  complications  are  to  be  treated  as  they  arise. 


DIPHTHERIA. 

By  WILLIAM  HALLOCK  PAKK,  M.  IX 


Dii'HTHERiA  is  an  acute  infectious  disease  caused  by  a  specific 
niicro-oriianisni.  This  niiero-organisni  usually  develops  upon  the  nui- 
cous  menibmnes,  especially  those  of  the  upper  respiratory  tract,  but  also 
occasionally  upon  other  wounded  surfaces. 

The  disease  is  chai-acterized  locally  by  a  grayish  exudate  or  pseudo- 
membrane  formed  chiefly  of  fibrin,  broken-down  epithelium,  and  leuco- 
cytes. The  development  of  the  membrane  is  accompanied  by  swelling 
and  hyperjeinia  of  the  adjacent  tissues,  and  by  more  or  less  severe  fever, 
prostration,  and  other  constitutional  disturbances. 

Both  the  local  lesions  and  general  disturbances  are  caused  Ijy  the 
poisonous  action  of  the  absorbed  toxins  produced  by  the  diphtheria 
bacilli  and  the  associated  bacteria.  As  it  is  impossible  to  ol)tain  a  correct 
knowledge  of  the  etiology,  diagnosis,  or  treatment  of  diphtheria  without 
a  thorough  understanding  of  its  bacteriology,  this  portion  of  the  subject 
M'ill  be  very  thoroughly  considered.  Even  those  physicians  who  never 
expect  to  conduct  any  bacteriological  investigations  themselves  need  to 
inform  themselves  fully  concerning  the  facts  already  established  in  order 
that  they  may  form  correct  opinions  as  to  the  value  of  bacteriological 
examinations  in  suspected  diphtheria,  and  the  worth  and  limitations  of 
the  use  of  antitoxin  in  the  prevention  and  treatment  of  the  disease. 

Successive  Investigations  showing  the  Specific  Causal  Re- 
lation OF  THE  Diphtheria  Bacillus  of  Klebs  and  Lopfler 
TO  Diphtheria. 

In  the  year  1883  bacilli  which  were  very  peculiar  and  striking  in 
appearance  were  shown  by  Klebs  to  be  of  constant  occurrence  in  the 
pseudo-membranes  from  the  throats  of  those  dying  of  true  ejndemic 
diphtheria.  One  year  later,  Loffler  published  the  results  of  a  very 
thorough  and  extensive  series  of  investigations  on  this  subject.  He 
found  the  bacillus  described  by  Klebs  in  most,  but  not  all,  cases  of 
throat  inflammations  which  had  been  diagnosticated  as  diphtheria.  He 
separated  the.se  bacilli  from  the  other  bacteria  present  and  obtained  them 
in  pure  culture.  When  he  inoculated  these  bacilli  upon  the  abraded 
raucous  membrane  of  susce]>til)le  animals,  pseudo-membranes  were  })ro- 
duced,  and  frequently  death  followed.  If  a  certain  amount  of  a  bouillon 
culture  was  injected  subcutaneously  into  guinea-pigs,  death  was  caused 
with  characteri.stic  lesions.  Loffler's  failure  to  find  the  bacilli  in  every 
case  examined  is  now  ex])lained  by  the  fact  that  certain  varieties  of 
pseudo-membranous   inflammation    not  due  to  the   diphtheria    bacillus, 


648  DIPHTHERIA. 

such  as  occur  especially  in  scarlet  fever,  were  then  wrongly  considered 
to  be  true  diphtheria. 

In  1887  further  studies  by  Loffler  added  to  the  proof  of  the  depend- 
ence of  diphtheria  on  the  diphtheria  bacilli.  In  1888,  D'Espine  found 
the  bacilli  in  14  cases  of  characteristic  diphtheria,  and  proved  them  to 
be  absent  in  24  cases  of  mild  sore  throats  which,  clinically,  were  believed 
not  to  be  cases  of  diphtheria.  In  the  same  year  the  first  portion  of  the 
results  of  the  very  important  investigations  of  Roux  and  Yersin  was 
published,  and  the  dependence  of  the  disease  on  the  diphtheria  bacilli 
may  be  considered  to  have  been  established.  Roux  and  Yersin  found 
the  diphtheria  bacilli  were  present  in  all  characteristic  cases,  and  that 
these  bacilli  possessed  the  cultural  and  pathogenic  qualities  of  those 
described  by  L5ffler.  They  found,  too,  when  the  bacilli  were  inoculated 
upon  the  healthy  mucous  membrane  of  the  trachea  of  the  rabbit,  no 
inflammation  followed ;  but  if  the  inoculation  was  made  on  the  abraded 
membrane,  phenomena  occurred  which  strikingly  resembled  those  present 
in  membranous  laryngitis  in  man — i.  e.  congestion  of  the  mucous  mem- 
brane, followed  by  the  formation  of  a  pseudo-membrane,  oedematous 
swelling  of  the  tissues  and  of  the  glands  of  the  neck,  dyspnoea,  stridulous 
breathing,  and  asphyxia.  Injection  of  cultures  beneath  the  skin  of 
rabbits  and  guinea-pigs  in  sufficient  quantity  caused  their  death  in  from 
thirty-six  hours  to  five  days,  the  period  varying  in  ratio  to  the  suscepti- 
bility of  the  animal  and  the  number  and  virulence  of  the  bacteria  intro- 
duced. The  same  result  followed  the  injections  of  filtered  cultures, 
showing  that  the  products  formed  by  the  growth  of  the  bacilli  were,  by 
themselves,  capable  of  causing  the  general  lesions. 

Roux  and  Yersin  were  also  able  to  produce  in  animals  characteristic 
diphtheria  paralysis.  They  produced  this  in  many  cases  where  the  in- 
oculated animals  did  not  succumb  to  a  too  rapid  intoxication.  Paralysis 
commenced  in  a  pigeon  three  weeks  after  the  inoculation  of  the  pharynx 
and  after  all  membrane  had  disappeared  and  the  animal  seemed  to  have 
completely  recovered.  In  rabbits  the  paralysis  usually  commenced  in 
the  posterior  extremities,  and  then  gradually  extended  to  the  whole  body, 
causing  death  by  paralysis  of  the  heart  or  respiration.  In  rare  instances 
the  muscles  of  the  neck  or  of  the  larynx  were  first  paralyzed,  and  thus 
characteristic  symptoms  were  caused.  The  authors  conclude:  "The 
occurrence  of  these  paralyses,  following  the  introduction  of  the  bacilli 
of  Klebs  and  L5ffler,  completes  the  resemblance  of  the  ex])erimental 
disease  to  the  natural  malady,  and  establishes  with  certainty  the  specific 
rule  of  this  bacillus." 

Finally,  the  microscopic  changes  in  the  internal  organs  of  animals 
dying  of  experimental  diphtheria  produced  by  the  bacilli  have  been 
shown  by  Welch  and  Flexner,  and  by  Babes  and  others,  to  be  essentially 
the  same  as  those  produced  by  diphtheria  in  man,  and  thus  a  still  further 
proof  is  afforded  of  the  specific  role  of  this  bacillus. 

The  results  of  the  various  observations  detailed  above  have  since  been 
confirmed  by  a  great  number  of  combined  clinical  and  bacteriological 
investigations,  so  that  all  who  have  studied  the  bacteriology  of  diphtheria 
would  now  agree  with  the  following  statement  made  by  Welch'  in  an 
address  on  diphtheria  :  "All  the  conditions  have  been  fulfilled  for  dipli- 

1  Welch,  Medical  News,  May  16,  1891. 


PLATE    X. 


6.  Colonies  of  pseudo-diphtheria  bacilli,  X  160 


c.  Coloaies  of  diphtheria  bacilli,  x  '2.-UJ. 


Ml!       I    V 


L.^mi:    '^^ 


Z^ 


theria  bacilli,  X  1000.    /.  Pseudo-diphtl 


e.  Diphtheria  bacilli,  X  1000.    /.  Pseudo-diphtheria  bacilli.  ,'  1000.    g.  Streptococci,  v  1000. 


I    4 


/t.  Streptococci,  X  1000. 


I.  Streptococci,  X  1000. 


Diphtheria  Bacilli  and  Streptococci, 


THE  Diruriir.iiiA  iiacillcs.  649 

theria  wliioli  aiv  lu't'cssarv  to  tlic  most  riiiid  jn-oof  oi'  tlio  ilependeiice  of 
an  intc'ctivc  disease  upon  a  given  iniero-oriranism — \i/..  the  eonstant 
preseni-e  <»t"  this  oriianism  in  the  lesions  of  the  disease,  the  isolation  of 
the  oro-anisni  in  pnre  enlture,  tiie  reprodnetion  of  the  disease  hy  inoeula- 
tions  of  pure  cultures,  and  similar  distribution  of  the  ortranism  in  the 
experimental  and  in  the  natural  disease.  In  view  of  these  facts  we  must 
agree  with  Prudden  that  we  are  now  justified  in  saying  that  the  name 
dij)htheria,  or  at  least  primary  diphtheria,  should  he  applied,  and  exclu- 
sivelv  applied,  to  that  acute  infectious  disease  usually  associated  with 
pseudo-memhranous  alfection  of  the  mucous  membrane  which  is  primarily 
caused  by  the  bacillus  called  the  bacillus  diphtherite  of  Lofiler." 

Characteristics  of  the  Loffler  Bacillus. — Groirth  on  Blood 
^cruiii. — If  we  examine  the  growth  of  the  diphtheria  bacillus  in  pure 
culture  on  blood  serum,  we  will  lind  at  the  end  of  ten  to  twelve  hours 
little  colonies  of  bacilli  which  appear  as  pearl-gray  or  whitish-gray 
slii»-htlv  raised  points.  The  colonies  when  separated  from  each  other 
mav  increase  in  forty-eight  hours,  so  that  the  diameter  may  be  one  fourth 
of  an  inch.  The  borders  are  usually  somewhat  uneven.  Those  colonies, 
lying  together,  fuse  into  one  mass,  especially  if  the  serum  is  rather  moist. 
Durmg  the  first  twelve  hours  the  colonies  of  the  diphtheria  bacilli  al)0ut 
equal  in  size  those  of  the  streptococci  ;  but  after  this  time  the  diphtheria 
colonies  become  larger  than  those  of  the  streptococci,  nearly  equalling 
those  of  the  staphylococci.  The  diphtheria  bacilli  in  their  growth  never 
liquefy  the  blood  serum. 

When  cover-glass  preparations  made  from  the  blood  serum  tubes  are 
examined,  the  diphtheria  bacilli  are  found  to  possess  the  following  cha- 
racteristics (Plate  X.,  f/,  e) : 

The  diameter  of  the  bacilli  varies  from  0.3  to  0.8  u,  and  the  length 
from  1.5  to  6.5  tjt.  They  occur  singly  and  in  pairs,  and  very  infre- 
quently in  chains  of  three  or  four.  The  rods  are  straight  or  slightly 
curved,  and  usually  are  not  uniformly  cylindrical  throughout  their  entire 
length,  but  are  swollen  at  the  ends  or  pointed  at  the  ends  and  swollen  in 
the  middle  portion.  Even  from  the  same  culture  different  bacilli  differ 
greatly  in  their  size  and  shape.  The  two  bacilli  of  a  pair  may  lie  with 
their  long  diameter  in  the  same  axis  or  at  an  obtuse  or  an  acute  angle. 
The  bacilli  possess  no  spores,  but  have  in  them  highly  refractile  bodies. 
They  stain  readily  with  the  ordinary  aniline  dyes  and  retain  their  color 
after  staining  bv  Gram's  method.  AVith  an  alkaline  solution  of  methyl 
blue,  the  bacilli,  from  blood  serum  especially,  and  from  other  media  less 
constantly,  stain  in  an  irregular  and  extremely  characteristic  way. 
The  bacilli  do  not  stain  uniformly.  Certain  oval  bodies  situated  in 
the  ends  or  in  the  central  portions  stain  much  more  intensely  than  the 
rest  of  the  bacillus.  Sometimes  these  highly  stained  bodies  are  thicker 
than  the  rest  of  the  bacillus  ;  again,  they  are  thinner  and  surrounded  by 
a  more  slightly  stained  portion.  The  bacilli  seem  to  stain  in  this  pecu- 
liar way  at  a  certain  period  in  their  gro^^'th,  so  that  only  a  portion  of  the 
organisms  taken  from  a  culture  at  any  one  time  will  show  the  characteristic 
staining.  In  old  cultures  it  is  often  difficult  to  stain  the  bacilli,  and  the 
staining,  when  it  does  occur,  is  frequently  not  at  all  characteristic. 

Groirth  on  1  per  cent.  Alkaline  Glycerin  Agar,  and  Method  of  Ob- 
taining Pure  Cultures. — It  is  frequently  desired  to  obtain  the  diphtheria 


650  DIPHTHERIA. 

bacillus  in  pure  culture.  This  is  most  readily  accomplished  by  removing 
with  a  platinum  needle  a  portion  of  the  mixed  growth  of  bacteria  in  a 
serum  tube,  and  lightly  streaking  it  over  the  surface  of  the  nutrient  agar 
contained  in  a  Petri  dish. 

Though  the  growth  of  the  diphtheria  bacilli  upon  agar  is  less  certain 
and  luxuriant  than  upon  serum,  the  appearance  of  the  colonies  when  ex- 
amined under  the  microscope  is  more  characteristic. 

If  the  diphtheria  colonies  develop  deep  in  the  substance  of  the  agar, 
they  are  usually  round  or  oval,  and,  as  a  rule,  present  no  extensions,  but 
if  near  the  surface  from  one  or  both  sides  they  spread  out  an  apron-like 
extension  which  exceeds  in  surface  area  the  rest  of  the  colony.  When 
the  colonies  develop  entirely  on  the  surface,  they  are  more  or  less  coarsely 
granular,  are  nearly  translucent,  and  usually  have  a  darker  centre.  The 
edges  are  sometimes  very  jagged,  and  frequently  shade  off  into  a  delicate 
lace-like  fringe ;  at  other  times  the  margins  are  more  even  and  the 
colonies  are  nearly  circular.  With  a  high  power  lens  the  edges  show 
sprouting  bacilli  (Plate  X.,  c).  The  colonies  are  gray  or  grayish  white 
by  reflected  light,  and  pure  gray  with  olive  tint  by  transmitted  light. 

The  growth  of  the  diphtheria  bacillus  upon  agar  presents  certain 
peculiarities  which  are  of  the  utmost  practical  importance.  While  the 
bacilli  from  the  majority  of  cases  grow  rather  feebly,  some  grow  luxuri- 
antly. If  a  large  number  of  the  bacilli  from  a  recent  culture  are  im- 
planted upon  a  properly  prepared  agar  plate,  a  certain  and  fairly  vigorous 
growth  will  always  take  place.  If,  however,  the  agar  is  inoculated  with 
the  exudate  of  a  throat  which  contaius  but  few  Loflfler  bacilli,  or  from  a 
serum  tube  containing  also  a  growth  of  other  bacteria,  no  growth  what- 
ever of  the  bacilli  may  occur,  while  the  tubes  of  coagulated  blood  serum 
inoculated  with  the  same  material  contain  them  abundantly.  Again, 
agar  prepared  from  broth  made  from  different  specimens  of  beef,  or  to 
which  different  peptones  have  been  added,  varies  somewhat  as  to  its 
suitability  for  the  growth  of  the  bacilli.  Because  of  the  uncertainty 
of  obtaining  a  growth  by  the  inoculation  of  agar  with  a  few  bacilli 
or  with  bacilli  of  diminished  vigor,  agar  is  a  far  less  reliable  medium 
than  blood  serum  for  use  in  cultures  made  for  diagnostic  purposes,  and 
is,  therefore,  not  to  be  recommended.  All  agar  should  be  tested  by 
means  of  a  pure  culture  of  the  diphtheria  bacillus  before  being  used 
experimentally. 

The  agar  is  prepared  by  adding  1  per  cent,  of  agar  to  the  required 
quantity  of  broth.  The  broth  is  prepared  in  the  same  way  as  that  used 
in  the  blood  serum  mixture,  except  that  it  contains  no  glucose.  The 
agar  must  be  thoroughly  dissolved  in  the  broth,  and  to  accomplish  this 
in  an  ordinary  Arnold  sterilizer  it  is  necessary  to  boil  the  mixture  for 
from  three  to  six  hours.  Sufficient  alkali  must  be  added  to  make  the 
agar  slightly  but  distinctly  alkaline.  Many  advise  that  before  final 
sterilization  5  per  cent,  glycerin  be  added.  The  bouillon  agar  sterilized 
on  three  successive  days  may  be  kept  for  many  months  in  litre  flasks. 

Growth  in  Broth. — All  the  varieties  of  the  Loffler  bacillus  experi- 
mented with  have  grown  in  slightly  alkaline  broth  with  or  without 
the  addition  of  1  per  cent,  glucose.  The  characteristic  growth  is  one 
showing  fine  grains.  These  deposit  along  the  sides  and  bottom  of  the 
tube,  leaving  the  broth  nearly  clear.     In  some  cultures  for  twenty-four 


Tin-:   BLOOD  SEllVM   MIXTIUIES;    CULTURES.  051 

or  forty-oight  hours  there  is  a  more  or  less  dilfiise  (;l<»ii(liiiess,  and,  exeej)- 
tionally,  a  lihn  forms  over  the  surface  of  tlic  broth.  On  shakinjr  the 
tube  this  film  breaks  up  and  slowly  sinks  to  the  bottom.  As  a  rule,  the 
baeilli  eause  the  alkaline  broth  to  beeome  aeid,  or  at  least  distinctly  less 
alkaline,  within  forty-eight  hours.  As  a  rule,  within  a  week  the  acid 
reaction  changes  again  to  the  alkaline.  This  may  occur  in  forty-eight 
hours  or,  exceptionally,  not  at  all.  These  differences  are  due  largely 
to  the  cluiraeter  of  the  meat  from  which  the  broth  is  made,  especially 
upon  the  amount  of  glucose  contained. 

AiiiiiKil  Iiwcn/dfioii.s  as  (t  Test  of  Mrtilcucc. — Animal  ex[)eriments 
form  the  only  reliable  method  of  determining  with  certainty  the  viru- 
lence of  .the  diphtheria  bacillus.  For  tliis  purjjose  alkaline  broth 
cultures  of  forty-eight  hours'  growth  should  be  used  for  the  subcutaneous 
inoculation  of  guinea-pigs.  The  amount  injected  may  vary  from  ^  to  i- 
per  cent,  of  the  body  weight  of  the  animal  inoculated.  In  the  great 
majority  of  cases,  when  the  bacilli  are  virulent,  this  amount  causes  death 
within  seventy-two  hours.  Some  bacilli  are  so  virulent  that  y-J-jj  of 
of  this  amount  causes  death.  In  the  autopsy  the  characteristic  lesions 
described  by  Loffler  are  found — namely,  at  the  seat  of  inoculation  there 
is  a  grayish  focus  surrounded  by  an  area  of  congestion  ;  the  subcutaneous 
tissues  for  an  extensive  area  around  are  congested,  and  at  times  very 
oedematous ;  the  adjacent  lymph  nodes  are  swollen,  and  the  serous 
cavities — especially  the  pleura — frequently  contain  an  excess  of  fluid, 
usually  clear,  but  at  times  turbid ;  the  lungs  are  usually  congested.  If 
the  organs  are  subjected  to  microscopical  examination,  the  lesions 
described  by  Welch  and  Flexner,  Babes,  and  others  are  found.  There 
are  numerous  smaller  and  larger  masses  of  necrotic  cells,  which  are 
permeated  by  leucocytes.  The  heart  and  the  voluntary  muscular  fibres 
usually  show  degenerative  changes.  The  number  of  leucocytes  in  the 
blood  is  increased.  From  the  area  surrounding  the  point  of  injection 
virulent  bacilli  may  be  obtained,  but  in  distant  areas  and  organs  they 
are  only  occasionally  found. 

Bacilli  which  in  cultures  and  in  animal  experiments  have  shown 
themselves  to  be  characteristic  may  be  regarded  as  certainly  true  diph- 
theria bacilli,  and  as  capable  of  producing  diphtheria  in  man  under  favor- 
able conditions. 


The  Preparation  of  Lopfler's  Blood  Serum  Mixtures  ;  the 
Media  Used  for  Making  Cultures  for  Diagnostic  Pur- 
poses. 

Collection  of  the  Blood  Serum  and  /fe  Preparation  for  Z^f<e  i)i  Cid- 
tures. — A  covered  glass  jar,  which  has  been  thoroughly  cleansed  with 
hot  water,  is  taken  to  the  slaughter-house  and  filled  with  freshly  shed 
blood  from  a  calf  or  sheep.  The  blood  is  received  directly  in  the  jar  as  it 
spurts  from  the  cut  in  the  throat  of  the  animal.  After  wiping  the  edge  of 
the  jar,  it  is  covered  w^ith  the  lid  and  set  aside  where  it  may  stand  quietly 
until  the  blood  has  thoroughly  clotted.  It  is  then  placed  in  a  cool 
place.  It  is  well  to  inspect  the  blood  in  the  jar  after  it  has  been  stand- 
ing a  few  hours,  and,  if  the  clot  is  found  adhering  to  the  sides,  to  sepa- 
rate it  by  a  rod.     The  blood  is  allowed  to  remain  twenty-four  hours  on 


652  DIPHTHERIA. 

the  ice,  cand  then  the  serum  which  surrounds  the  clot  is  siphoned  off  by  a 
rubber  tube  and  mixed  with  one  third  its  quantity  of  nutrient  beef 
broth,  to  which  1  per  cent,  gkicose  has  been  added.  This  constitutes 
the  LdjESler  blood  serum  mixture.  The  broth  used  to  mix  with  the 
serum  is  prepared  as  follow^s  :  One  pound  of  finely  chopped  lean  beef  is 
allowed  to  soak  in  one  litre  of  water  in  a  cool  place  for  twelve  to  twenty- 
four  hours.  The  meat  and  fluid  are  now  dumped  into  a  cheese-cloth  or 
towel  and  the  fluid  squeezed  out.  To  this  solution  1  per  cent,  of  peptone, 
1  per  cent,  of  glucose,  and  0.5  per  cent,  of  common  salt  are  added.  It 
is  well  to  test  tlie  reaction  of  the  mixture,  and,  if  it  is  found  to  be  acid, 
to  render  it  neutral  by  adding  a  few  drops  of  a  solution  of  caustic  soda 
or  carbonate  of  soda.  The  w^hole  is  now  boiled  for  half  an  hour  and 
filtered  through  sterilized  absorljent  cotton  or  filter  paper.  If  the  broth 
is  to  be  kept,  it  should  be  placed  in  flasks  and  sterilized.  The  Loffler 
blood  serum  mixture  when  ready  is  poured  into  tubes,  wdiich  should  be 
about  four  inches  in  length  and  two  thirds  of  an  inch  in  diameter. 
These  tubes  should  first  be  plugged  with  cotton  and  sterilized  by  dry 
heat  at  1 50°  C.  for  one  hour.  Care  should  be  taken  in  filling  the  tubes 
to  avoid  the  formation  of  air  bubbles,  as  they  leave  a  ])ermauently 
uneven  surface  when  the  serum  has  been  coagulated  by  heat.  To  pre- 
vent this,  the  end  of  the  pipette  or  funnel  which  contains  the  serum 
should  be  inserted  well  into  the  test  tube.  About  2  c.c.  are  sufficient 
for  each  tube.  The  tubes,  having  been  filled,  are  now  to  be  coagulated 
and  sterilized.  They  are  placed  at  the  proper  angle,  and  then  kept 
for  two  hours  at  a  temperature  just  below  the  boiling  point.  For  this 
purpose  a  Koch  serum  coagulator  or  a  double  boiler  serves  best,  though 
a  steam  sterilizer  will  suffice.  If  the  latter  is  used,  a  wire  frame  must 
be  arranged  to  hold  the  tubes  at  the  proper  inclination,  and  the  degree 
of  heat  must  be  carefully  watched,  as  otherwise  the  temperature  may  go 
too  high,  the  serum  be  actually  boiled,  and  the  culture  medium,  becom- 
ing full  of  bubbles,  thus  spoiled.  After  sterilization  by  this  process  the 
tubes  containing  the  sterile,  solidified  blood  serum  can  be  placed  in 
covered  tin  boxes  and  kept  for  months.  The  serum  thus  prepared  is 
quite  opaque  and  firm.  A  mixture  of  blood  cells  renders  the  serum 
darker,  but  it  is  not  less  useful. 

The  Swab  for  Inoculating  Culture  Tubes. — The  swab  to  inoculate  the 
serum  is  made  as  follows  :  A  stiff,  thin  steel  rod,  like  a  knitting  needle, 
six  inches  in  length,  is  roughened  at  one  end  by  a  few  blows  of  a  ham- 
mer, and  about  this  end  a  little  absorbent  cotton  is  firmly  wound. 
Each  swab  is  then  placed  in  a  separate  glass  tube,  and  the  mouths  of 
the  tubes  are  plugged  with  cotton.  The  tubes  and  rods  are  then  steril- 
ized by  dry  heat  at  about  150°  C.  for  one  hour,  and  stored  for  future 
use.  These  cotton  swabs  have  proved  much  more  serviceable  for  mak- 
ing inoculations  than  platinum  wire  needles,  especially  in  young  children 
and  in  laryngeal  cases.  It  is  easier  to  use  the  cotton  swab  in  such 
cases,  and  it  gathers  up  so  much  more  material  for  the  inoculation 
that  it  has  seemed  more  reliable. 

For  convenience  and  safety  in  transportation  a  "  culture  outfit "  may 
be  devised,  which  consists  of  a  small  wooden  box  containing  a  tube  of 
blood  serum,  a  tube  holding  a  swab,  and  a  record  blank.  These  "  cul- 
ture outfits  "  may  be  carried  or  sent  by  messenger  or  express  to  any 


THE  BLOOD  SKRC^f   .\f/\'/'l'JiJ:S;    t'LLTURES.  (353 

place  desired,  or  kept  l)v  the  Health  Hoard  at  stations  scattered  through- 
out the  cities  for  the  tree  use  ot"  physicians. 

Directions  for  laocu/afiiir/  (^it/fitrc  Tubes  with  the  K.vuthite  in  Cases 
of  Suspected  ])ij)htheri<i. — The  patient  should  be  placed  in  a  good  light 
and,  if  a  child,  properly  held.  The  swab  is  removed  from  its  tube,  and 
while  the  tongue  is  depressed  with  a  spoon  it  is  [)assed  into  the  pharynx 
(if  possible  without  touching  the  tongue),  and  is  rubbed  gently  but 
firmlv  against  any  visible  membrane  on  the  tonsils  or  in  the  ])harynx, 
and  then,  without  laying  the  swab  down,  it  is  immediately  inserted  in 
the  blood  serum  tube,  and  the  portion  which  has  been  previously  in 
contact  with  the  exudate  is  rubbed  a  number  of  times  back  and  forth 
over  the  whole  surface  of  the  serum.  This  should  be  thoroughly  done, 
but  it  is  to  be  gently  done,  so  as  not  to  break  the  surface  of  the  serum. 
The  swab  is  replaced  in  its  tube,  and  both  tubes,  their  cotton  plugs 
having  been  inserted,  are  returned  to  the  box  and  sent  to  the  collecting 
station. 

Where  there  is  no  visible  membrane  (it  may  be  present  in  the  nose 
or  ])harvnx)  the  swab  should  be  thoroughly  rubbed  over  the  mucous 
membrane  of  the  pharynx  and  tonsils,  and  in  nasal  cases,  when  possible, 
a  culture  should  also  be  made  from  the  nose.  In  little  children  care 
should  be  taken  not  to  use  the  swab  when  the  throat  contains  food  or 
vomited  matter,  as  then  the  bacterial  examination  is  rendered  more 
difficult.  Under  no  conditions  should  any  attempt  be  made  to  collect 
the  material  shortly  after  the  application  of  disinfectants  (especially 
solutions  of  corrosive  sublimate)  to  the  throat.  If  any  of  these  instruc- 
tions have  not  been  carried  out,  the  fact  should  be  carefully  noted  on  a 
record  blank. 

The  Examination  of  Cultures. — The  culture  tubes  which  have  been 
inoculated  as  described  above  are  kept  in  an  incubator  at  37°  C.  for 
twelve  hours,  and  are  then  ready  for  examination.  On  inspection  it 
will  be  seen  that  the  surface  of  the  blood  serum  is  dotted  with  very  nu- 
merous colonies,  which  are  just  visible.  Xo  diagnosis  can  be  made  from 
simple  inspection  (if,  however,  the  serum  is  found  liquefied  or  shows 
other  evidences  of  contamination,  the  examination  will  probably  be  un- 
satisfactory). A  platinum  needle  is  now  inserted  in  the  tube,  and  quite 
a  large  number  of  colonies  are  swept  with  it  from  the  surface  of  the  cul- 
ture medium.  The  bacteria  adherent  to  the  needle  are  washed  oif  in 
the  drop  of  water  previously  placed  on  the  cover-glass  and  smeared 
over  its  surface.  The  bacteria  on  the  glass  are  then  alloMed  to  drv  in 
the  air.  The  cover-glass  is  then  passed  quickly  through  the  flame  of 
a  Buusen  burner  or  alcohol  lamp  three  times  in  the  usual  way,  covered 
with  a  few  drops  of  Loffler's  solution  of  alkaline  methyl  blue,  and  left 
without  heating  for  ten  minutes.  It  is  then  rinsed  oif  in  clean  water, 
dried,  and  mounted  in  balsam. 

In  the  great  majority  of  cases  one  of  two  pictures  will  be  seen  with 
the  j^  inch  oil  immersion  lens — either  an  enormous  number  of  charac- 
teristic Loffler  bacilli  with  a  moderate  number  of  cocci,  or  a  jnire  cul- 
ture of  cocci,  mostly  in  pairs  or  short  chains  (Plate  X.,  //).  In  a  few 
cases  there  will  be  an  approximately  even  mixture  of  Lcitiler  bacilli 
and  cocci,  and  in  others  a  great  excess  of  cocci.  Besides  these,  there 
will  be  occasionally  met  preparations  in  which,  with  the  cocci,  there  are 


654  DIPHTHERIA. 

mingled  bacilli  more  or  less  resembling  the  Loffler  bacilli.  These  bacilli, 
which  are  pseuclo-diphtheria  bacilli  (Plate  X., /),  are  especially  frequent 
in  cultures  from  the  nose. 

In  not  more  than  one  case  in  twenty  will  there  be  any  serious  diffi- 
culty in  making  the  diagnosis  if  the  serum  tube  has  been  properly 
inoculated.  In  such  a  case  another  culture  must  be  made  or  the  case 
treated  upon  its  clinical  history  alone. 

The  Direct  Microscopical  Examincdion  of  the  Exudate. — An  imme- 
diate diagnosis,  without  the  use  of  cultures,  is  usually  possible  to  an  ex- 
pert from  a  microscopical  examination  of  the  exudate.  This  is  made 
by  sm'earing  a  cover-glass  with  a  little  exudate  from  the  swab,  drying, 
staining,  and  examining  it  microscopically.  This  examination,  however, 
is  much  more  difficidt,  and  the  results  more  uncertain,  than  when  the 
covers  are  prepared  from  cultures.  The  bacilli  from  the  membrane  are 
often  less  typical  in  appearance  than  those  found  in  cultures,  and  they 
are  mixed  with  fibrin,  pus,  and  epithelial  cells.  They  may  also  be  very 
few  in  number  in  the  parts  reached  by  the  swab,  or  bacilli  may  be  met 
Avhich  closely  resemble  the  Loffler  bacilli  in  appearance,  but  which  differ 
greatly  in  growth  and  in  other  characteristics.  When  in  a  smear  con- 
taining mostly  cocci  a  few  of  these  doubtful  bacilli  are  present,  it  is 
impossible  either  to  certainly  exclude  or  make  the  diagnosis  of  diph- 
theria. Although  in  certain  cases  this  immediate  examination  may  be 
of  the  greatest  value,  it  is  not  a  method  suitable  for  general  use  when 
cultures  are  possible. 

Having  considered  the  technique,  it  is  well  to  review  carefully  and 
without  bias  the  question  as  to  how  much  reliance  can  be  placed  on  the 
bacteriological  diagnosis  made  from  the  examination  of  a  culture  inocu- 
lated with  the  exudations  in  the  throat  of  a  case  of  suspected  diphtheria. 

From  time  to  time,  in  order  to  test  the  results  of  examinations  and  to 
make  the  liability  to  error  as  slight  as  possible,  I  adopted  the  following 
plan  : 

A  certain  number  of  cases  in  which  the  cultures  yielded  no  diphtheria 
bacilli  were  turned  over  to  specially  trained  Health  Board  inspectors,  who 
made  a  second  culture,  and  followed  up  the  case  during  the  illness  and 
for  some  time  even  after  its  recovery. 

By  means  of  the  information  thus  obtained  we  were  able  more  and 
more  surely  to  decide  how  far  we  could  base  an  absolute  diagnosis  on  a 
culture,  especially  when  made  by  others.  It  was  found  that  many  phy- 
sicians, as  well  as  the  Health  Department  inspectors,  gradually  became  so 
skilled  in  making  inoculations  that  it  was  possible  to  rely  almost  certainly 
on  the  results  obtained  from  the  examination  of  their  cultures,  while,  on 
the  other  hand,  caution  was  necessary  in  accepting  the  inoculations  of 
others,  and  in  such  cases  a  second  culture  was  requested. 

After  a  two  years'  trial,  the  following  conclusions  have  been  arrived 
at : 

The  examination  by  a  competent  bacteriologist  of  the  bacterial  growth 
in  a  blood  serum  tube  which  has  been  properly  inoculated  and  kept  for 
fourteen  hours  at  the  body  temperature  can  be  thoroughly  relied  on  in 
cases  where  there  is  visible  membrane  in  the  throat  if  the  culture  is  made 
during  the  period  in  which  the  membrane  is  forming,  and  no  antiseptic, 
especially  no  mercurial  solution,  has  lately  been  applied. 


cri/rriiKS;  i>fi>jiTifEiii.i  hacilij.  055 

In  cases  in  which  the  disease  is  confined  to  the  hirvnx  or  hntnchi,  and 
where,  therefore,  there  is  no  visible  exndate  against  wliich  the  swab  can 
be  rnl)l)cd,  snr|)risini«;ly  accnrate  resnlts  can  be  obtained  from  the  exam- 
ination ot"  cnltnres,  but  in  a  certain  [)roj)ortion  of  cases  no  diphtheria 
bacilli  will  be  fotuul  in  the  first  culture,  and  yet  will  be  abundantlv 
jjresent  in  later  ones,  the  bacilli  having  probably  l)een  coughed  up  more 
freely  as  the  disease  progressed.  I  believe,  therefore,  that  absolute  reli- 
ance for  a  diagnosis  cannot  l)e  placed  on  a  negative  result  in  cultures 
from  the  ])harynx  in  purely  laryngeal  cases. 

In  nasd  diphthci'ia  a  negative  result  may  be  obtained  from  a  culture 
made  from  the  throat,  and  yet  the  i)acilli  be  found  in  cultures  from  the  nose. 

In  making  a  diagnosis  from  a  culture  it  is  essential  to  know  the  dura- 
tion of  the  disease  in  the  case  from  which  it  was  made,  becanse,  although 
bacilli  may  remain  present  and  alive  in  some  throats  for  manv  weeks,  it 
is,  nevertheless,  important  to  remember  they  may  vanish  early  and  sud- 
denly, and  that,  therefore,  the  cultures  cannot  I)e  certainly  relied  im  after 
the  meml)rane  begins  to  disappear. 

The  use  of  antiseptics  shortly  before  making  the  inoculation  of  a  cul- 
ture tube  may  render  the  culture  useless  for  diagnosis.  It  has  been  found 
in  a  few  instances  that  a  culture  made  from  a  case  of  diphtheria  shortlv 
after  a  thorough  irrigation  with  a  1 :  4000  solution  of  bichloride  of  mer- 
cury gave  no  diphtlieria  bacilli,  though  one  made  just  before  and  one  made 
some  time  later  gave  them  al)undantly.  It  is  a  curious  fact  that  under 
such  circumstances  a  vigorous  growth  of  other  organisms  may  take  place. 

The  above  conclusions  are  true  only  when  the  inoculations  have  been 
properly  made,  and,  in  judging  cultures  received  from  physicians  in 
general,  the  greatest  care  must  be  taken.  Some  cultures  are  made  care- 
lessly, and  some  evidently  without  taking  the  pains  to  even  read  the 
instructions,  which  should  always  accompany  the  outfit,  or  to  glance  at 
the  condition  of  the  coagulated  serum  in  the  tube.  If,  therefore,  when 
nr)  diphtheria  bacilli  are  found  the  bacterial  gro\\'th  is  scanty,  the  media 
dry  or  contaminated,  or  the  inoculation  in  any  way  faulty,  the  case  nnist 
be  referred  back  for  another  culture.  The  second  culture  in  these  cases 
not  infrequently  contains  the  bacilli  when  the  first  did  not. 

The  absence  of  bacilli  in  a  culture  proves  the  case  to  be  one  of  false 
diphtheria  only  when  it  has  been  possible  to  make  it  under  the  proper 
conditions. 

A  most  important  practical  question  is  the  following  :  If,  in  cultures, 
bacilli  are  found  wliich  possess  the  shape,  size,  and  staining  character- 
istics of  the  diphtheria  bacillus,  can  they,  without  further  cultural  or 
animal  experiments,  be  considered  as  virulent  diphtheria  bacilli  ? 

Since  it  is  the  custom  of  many,  following  the  example  of  the  Xew 
York  City  Health  Department,  to  make  a  bacteriological  diagnosis  in 
suspected  cases  of  diphtheria  from  the  examination  of  the  growth  on  the 
original  blood  serum  tul)e  without  waiting  for  further  cultural  or  animal 
experiments,  it  is  of  the  greatest  practical  im])ortance  to  ascertain  to  what 
extent  Ijacilli  appearing  upon  the  serum  in  every  way  characteristic  of 
the  diphtheria  bacilli  can  be  assumed  to  be  virulent. 

To  test  the  virulence  of  bacilli,  four  days  at  least  are  required,  for 
before  inoculating  it  is  necessary  to  obtain  them  in  pure  culture,  for 
otherwise  it  would  be  impossible  to  determine  whether  the  changes  pro- 


656 


DIPHTHERIA. 


duced  in  the  inoculated  animal  were  due  to  the  supposed  diphtheria 
bacilli  or  to  other  micro-organisms  injected  with  them.  It  is  further 
necessary  to  grow  the  bacilli  in  proper  media,  and  to  inoculate  suscep- 
tible animals  at  a  period  when  the  growth  of  the  bacilli  in  the  media  has 
reached  its  maximum.  It  is  only  when  these  precautions  have  been  fol- 
lowed that  accurate  results  will  be  obtained.  The  present  almost  uniform 
practice  is  to  inoculate  half-grown  guinea-pigs  with  from  0.25  to  0.5  per 
cent,  of  their  body  weight  of  a  twenty-four  or  forty-eight  hours'  cul- 
ture of  the  bacilli  grown  at  37°  C.  in  simple  nutrient  or  glucose  alkaline 
broth.  It  is  important  to  remember  that  it  is  not  safe  to  decide,  because 
the  growth  derived  from  one  bacillus  is  not  virulent,  that  all  the  bacilli 
from  that  thi'oat  are  not  virulent.  The  cultures  from  several  bacilli 
must  be  tried.  The  majority  of  those  who  have  inoculated  bacilli  de- 
rived from  pseudo-membranes  and  possessing  the  characteristics  of  the 
Loffler  bacilli  have  found,  as  Loffler  did,  that  they  were  always  virulent. 
The  researches  of  Hofmann,  Beck,  and  others,  however,  showing  that  in 
a  certain  number  of  healthy  throats  there  were  bacilli  which  closely  re- 
sembled the  L5ffler  bacillus,  and  yet  were  not  virulent,  stimulated  others 
to  subject  the  bacilli  from  large  numbers  of  cases  of  suspected  diphtheria 
to  the  test  of  animal  inoculation. 

In  1890,  Eoux  and  Yersin  published  the  results  of  some  examina- 
tions as  to  the  virulence  of  the  bacilli  obtained  from  100  cases  of  diph- 
theria :  55  of  these  were  fatal  cases,  and  in  all  of  them  virulent  bacilli 
were  found,  although  in  a  few,  together  with  many  virulent  bacilli,  there 
were  a  few  non-virulent  ones.  Among  the  45  cases  which  recovered 
many  were  very  mild,  and  in  10  of  them  they  found  no  bacilli  of  suf- 
ficient virulence  to  cause  the  death  of  guinea-pigs  when  injected  in  mod- 
erate amount.  From  all  of  them,  however,  they  obtained  bacilli  capable 
of  causing  inflammation  in  the  guinea-pig  at  the  point  of  injection.  This 
varied  from  slight,  transient  oedema  to  extensive  necrosis.  From  further 
experiments  they  proved  similar  bacilli  were  capable  under  proper  condi- 
tions of  regaining  their  virulence.  They  further  showed  that,  in  these 
milder  cases,  among  many  non-virulent  or  slightly  virulent  bacilli  there 
were  usually  a  few  virulent  ones ;  therefore  they  believed  that  in  most 
of  these  10  cases  fully  virulent  bacilli  may  have  been  present  in  the 
throat  with  the  slightly  virulent  ones  which  by  chance  were  used  for 
the  inoculations. 


Virulence  of  the  Bacilli  found  in  Ten   Cases  of  Throat  Inflammation 
of  such  a  Character  as  to  Arouse  a  Suspicion  of  Diphtheria. 


Severity. 


Weight 

Amount 

of 

of 

guinea- 

culture 

pig, 

injected, 

gms. 

CO. 

390 

1.33 

210 

0.5 

220 

0..5 

620 

3.33 

■niiratinn  nf   Persistence  of 
iSfter      Loffler  bacillus 

inoculatfon     ^^^er  recovery 
inocuiauon.       ^^  patient. 


1.  Milfi  case . 

2.  Mild  case ;  adult ;  never  in  bed 

3.  Removed  to  Diphtheria  Hospital ;  severe  case 

4.  Rather  mild  ease 

5.  Very  mild  case      479 

6.  Fatal  case  ;  croup     ....   - I      675 

7.  Fairly  severe  case,  followed  by  measles  ....        443 

8.  Moderately  severe  case 435 

9.  Very  mild  case 500 

10.  Contracted  from  a  mild  case  ;  no  membrane 

present 250 


1.5 
1.33 
1.33 
1.66 


40  hours  .   . 
50  hours  .   . 
40  hours. 
25  hours  .   . 
No  reaction. 
40  hours. 
40  hours  .   . 
4  days    . 
40  hours. 

40  hours. 


38-41  days. 
44  days. 

42  davs. 
20-24  days. 

15-23  days. 
15-19  days. 


VULTURES;   DIPHTHERIA   RACILLI.  G57 

In  order  to  cleterniiiie  tlio  vinilciu'c  ni"  the  Wacilli  ()l)taiii('(l  in  the  or- 
dinary rontine  examinations  from  snspected  eases  of"  diplitlieria  hlood 
serum  eultures  from  40  eases  were  selected  in  wliieli  haeilli  were  found 
having;  the  characteristic  appearance  of  the  virulent  diphtheria  bacilli. 
The  cultures  tested  were  selected  before  any  information  was  possessed 
of  the  severity  of  the  cases  from  which  they  were  obtained,  and  were  used 
for  experiments  on  animals.  The  table  given  on  the  preeeding  page 
presents  average  exam[)les  of  the  cases. 

We  found  that  the  bacilli  obtained  from  40  cases  of  suspected  diph- 
theria, two  thirds  of  which  were  mild,  proved  in  every  case  except 
1  to  be  virulent,  and  in  all  but  3  fully  so.  If  these  results  are  con- 
sidered in  connection  with  those  obtained  by  other  American  and  by 
European  observers,  we  must  conclude  that  for  diagnostic  purposes  all 
bacilli  found  in  throat  inflammations  of  cases  suspected  to  be  (li])htheria, 
which  possess  the  morpliological  and  cultural  characteristics  of  the 
Loffler  bacilli,  must  be  regarded  as  virulent,  unless  animal  inoculations 
prove  otherwise.  Further,  it  should  be  remembered  (as  shown  by  Roux 
and  Yersin,  and  as  confirmed  by  others  and  by  ourselves)  that  the  ab- 
sence of  virulence  in  a  culture  derived  from  one  bacillus  is  not  sufficient 
to  prove  that  cultures  fi'om  other  bacilli  from  the  same  case  would  not 
be  virulent.  This  may  have  been  true  in  the  only  case  out  of  the  40 
in  which  virulent  bacilli  were  not  found. 

In  3  of  the  above  cases  the  cultures  from  the  first  colony  selected 
were  not  virulent,  while  from  others  they  were  fully  so. 

If  a  piece  of  membrane  be  removed  from  the  throat  during  the 
period  of  invasion  of  diphtheria  and  examined  microscopically  or  by 
cultures,  the  presence  of  abundant  diphtheria  bacilli  will  be  noted.  If, 
a  few  days  later,  when  the  membrane  has  begun  to  loosen,  another  bit 
be  examined,  the  diphtheria  bacilli  will  be  found  to  be  partly  or  at 
times  wholly  replaced  by  other  micro-organisms,  mostly  cocci.  If, 
several  days  later,  after  the  complete  disappearance  of  the  membrane, 
cultures  be  made  from  the  mucus  of  the  throat,  it  will  be  found  the 
bacilli  of  diphtheria  in  many  of  the  cases  will  have  disappeared  from 
the  throat.  This  rule  is  not,  however,  without  many  exceptions,  for  it 
will  be  frequently  found,  days  after  the  complete  disappearance  of  the 
membrane  and  after  the  return  of  the  throat  to  a  healthy  condition,  that 
fully  virulent  bacilli  linger  in  the  throat. 

In  order  to  test  the  virulence  of  the  bacilli  in  the  throats  of  con- 
valescent cases,  they  were  obtained  in  pure  culture  from  a  large  number 
of  healthy  throats  in  convalescent  diphtheria  cases  and  used  for  the 
inoculation  of  the  guinea-pigs.  The  table  of  selected  cases  (see  next 
page)  gives  the  average  results  of  these  experiments. 

In  each  case,  in  testing  the  virulence  of  the  bacilli  derived  from  it, 
we  employed  the  last  culture  or  the  next  to  the  last  culture  made  from 
it  in  which  the  bacilli  were  found  to  be  present.  The  results  in  these 
cases  tested,  as  well  as  in  those  before  recorded  by  others,  prove  con- 
clusively that  the  bacilli,  which  in  a  certain  proportion  of  cases  persist 
in  the  throat  after  an  attack  of  diphtheria,  are  always  virulent  for  some 
time.  In  the  exceptional  cases  in  which  the  bacilli  persist  for  a  very 
long  time  it  is  found  they  occasionally  lose  their  virulence  a  few  days 
before  their  final  disappearance,  while  in  other  cases  they  retain   their 

Vol.  I.— 42 


658 


DIPHTHERIA. 


virulence  to  the  end.  That  the  cases  themselves  are  not  so  liable  to 
spread  diphtheria  is  probably  because  of  the  relatively  small  number  of 
bacilli  present  in  convalescent  throats  as  compared  with  the  number 
found  in  those  showing  the  lesions  of  diphtheria. 


Case 

No. 

Severity  of  the 
diphtherial!!  the  case. 

The  bacilli 
tested  had 
persisted 
after  recov- 
ery for— 

Virulence. 

Weight 
guinea- 
pig,  gms. 

Amount 

injected, 

c.c. 

Life  of  guinea-pig  after 
injection. 

1 
2 

3 

4 
6 
6 

7 

Mild  case 

Very  mild  case 

Mild  case 

Severe  case 

Very  mild  case 

Fairly  severe  case  .... 
Mild  case 

10  days  .  .   . 
12    "     ... 

33    "     ... 

18    "      ... 

25  "... 

26  "      ... 
50    "      ... 

250 
440 

226 

229 
505 
347 
410 

0.5 
1.5 

1.00  1 

1.00 
1.66 
1.33 
3.00 

8  days. 
40  hours. 

Extensive    necrosis     with 
final  recovery. 

9  days. 
40  hours. 

5  days. 
2    " 

The  Pseudo-  and  Non-virulent  Diphtheria  Bacillus. — Since  the  general 
adoption  of  bacteriological  examinations  for  purposes  of  diagnosis  in 
diphtheria  the  characteristics  of  the  non-virulent  bacilli  and  the  fre- 
quency with  which  they  occur  have  had  added  to  their  scientific  a  very 
practical  interest. 

In  1888,  Hofmann  published  the  results  of  the  bacteriological 
examinations  of  a  number  of  diseased  and  healthy  throats,  which  for  a 
time  threw  doubt  on  the  specific  character  of  the  Loffler  diphtheria 
bacillus.  Further  research  has  largely  dispelled  the  confusion  which 
his  discoveries  seemed  to  make. 

Hofmann's  results  were  similar  to  those  of  Loffler,  in  that  he  found 
the  virulent  bacillus  in  all  of  8  cases  of  true  diphtheria,  but  in  further 
search  he  was  surprised  to  find  in  the  throats  of  26  out  of  45  persons, 
none  of  whom  was  suffering  from  diphtheria,  a  bacillus  which  very 
closely  resembled  the  Loffler  bacillus.  The  bacilli  from  a  number  of 
these  healthy  throats  were  obtained  in  pure  culture  and  inoculated  into 
animals.  The  majority  had  no  virulence  whatever.  The  bacilli  from 
the  different  cases  varied  somewhat  in  their  characteristics.  Some  in 
appearance,  manner  of  staining,  and  growth  on  media  seemed  identical 
with  the  Loffler  bacillus,  while  others  presented  slight  but  constant  dif- 
ferences.    Between  the  extremes  were  many  gradations. 

Those  bacilli  which  did  not  possess  all  the  characteristics  of  the 
virulent  bacillus  differed  in  the  following  respects :  They  were  shorter, 
thicker,  and  more  uniform  in  size.  On  agar  they  grew  in  whiter  and 
thicker  colonies,  whose  circumference  was  more  circular  and  less  notched. 
They  also  grew  at  a  lower  temperature  than  the  virulent  bacilli  (20°  to 
22°  C). 

Hofmann  was  undecided  whether  all  of  these  bacilli  were  really 
Loffler  diphtheria  bacilli  which  had  lost  their  virulence,  or  whether  they 
were  a  different  species  of  bacteria  and  of  a  saprophytic  nature.  He  was 
also  undecided  whether,  even  among  these  non-virulent  bacilli,  there 
might  not  be  included  different  species. 

Roux  and  Yersin  found  in  a  hospital  for  children  in  Paris,  wdiere 
cases  of  diphtheria  occurred  from  time  to  time,  that  15  out  of  45  children 
contained    in  their  healthy  throats  non-virulent  bacilli  resembling  the 


rSKL'DU-DlI'lJTIIJJJllA    BACILLI.  GoO 

L()tHei'  l)acilliis.  In  a  Freiit'li  villa<;e  where  no  diphtheria  liad  been 
present  tor  a  h)ni>:  time  they  made  eultnres  from  tiie  healthy  throats  of 
55)  ehildreii  liviiii;'  in  a  school.  In  2()  of  tiiese  non-virulent  bacilli 
were  found.  In  an  examination  of  the  throats  of  10  attendants  in  a 
(hphtheria  iK)S})ital  non-\irnlent  haeilli  were  fonnd  once.  Thus  in  114 
liealthy  throats  the  non-virnlent  bacilli  were  found  42  times.  In  all  of 
these  throats  the  bacilli  were  present  in  very  small  numbers. 

The  bacilli  found,  when  studied  in  ])nre  culture,  ditfi^'red  somewliat 
from  each  other.  The  majority  were  identii-al  in  all  their  characteristics 
with  the  Lofiler  bacillus,  except  as  to  their  lack  of  virulence.  The 
minority  resembled  those  described  by  Hofmann.  Roux  and  Yersin 
regarded  the  occasional  slight  diii'erences  in  growth,  shape,  and  staining 
as  too  slight  and  inconstant  to  distinguish  the  virulent  from  the  non- 
virulent  bacilli.  Animal  experiments  alone  sutficcd  to  determine  the 
(piestion  of  virulence,  and  they  regarded  as  arbitrary  a  division  founded 
on  the  reaction  of  the  guinea-pig  to  inoculation,  since  they  found  that  ba- 
■cilli  from  cases  of  diphtheria  may  possess  every  degree  of  virulence,  from 
those  which  cause  death  within  twenty-four  hours  to  those  which  caused 
only  a  temporary  (pdema.  With  such  variations  it  is  a  difficult  matter 
to  determine  what  should  be  the  proper  line  of  division  between  the 
virulent  and  the  non-virulent  bacilli. 

To  fully  prove  that  these  bacilli  belong  to  the  same  species  they 
believe  it  is  necessary  to  derive  non-virulent  bacilli  from  the  virulent 
ones,  and  to  give  virulence  to  those  entirely  lacking  it. 

They  found  it  was  possible  to  produce  an  attenuation  of  the  viru- 
lence of  the  bacilli  in  a  number  of  ways.  They  also  found  it  possible  to 
greatly  increase  the  virulence  of  bacilli  by  injecting  them  together  with 
2i  virulent  culture  of  the  streptococcus  of  erysipelas ;  but  were  unable, 
on  the  other  hand,  to  give  back  virulence  to  those  bacilli  which  had 
been  completely  robbed  of  their  virulence  by  the  above  methods,  or  to 
those  w*hich  had  no  virulence  when  obtained  from  the  throat. 

If  we  now  turn  to  the  work  of  Escherich,  we  find  results  which  tend 
to  show  that  the  virulent  and  some  of  the  non-virulent  bacilli  are  differ- 
ent species  of  bacteria.  He  found  the  bacilli  from  every  case  of  diph- 
theria examined  to  be  fully  virulent,  and  in  a  few  cases,  where  he  ob- 
tained characteristic  bacilli  from  the  healthy  throats  of  persons  exposed 
to  diphtheria,  he  found  them  also  to  be  virulent. 

Escherich  did  indeed  find  in  a  moderate  number  of  throats  of  per- 
sons not  suifering  from  diphtheria  bacilli  similar  to  those  described  by 
Hofmann.  Thus  in  Munich  he  found  this  non-virulent  bacillus  in  2 
throats  out  of  70,  and  in  Grez  in  11  out  of  250,  or  13  times  in  320 
•cases.  These  bacilli,  however,  all  possessed  certain  cultural  and  mor- 
phological characteristics  which  were  sufficient  to  separate  them  from 
the  virulent  bacilli.  They  were,  as  in  some  described  l)y  Hofmann, 
plumper  and  shorter  than  the  Lofffer  bacilli  and  more  uniform  in  size. 
He  noticed  two  new  points  of  difference  which  seemed  to  him  important. 
The  non-virulent  or  pseudo-diphtheria  bacilli,  when  spread  on  a  cover- 
glass,  lie  in  parallel  row'S,  while  the  virulent  diphtheria  bacilli  lie  at 
every  angle  and  the  most  varied  positions.  The  second  diff'erence  was 
still  more  marked.  He  found,  as  had  all  others  wdio  had  noticed  this 
point,  that  the  virulent  l^acilli  in  their  growth  in  neutral  or  slightly 


660  DIPHTHERIA. 

alkaline  bouillon  changed  the  reaction  of  the  bouillon  to  acid  in  the 
course  of  forty-eight  hours.  The  amount  of  acid  formed  differed  in 
different  cultures  and  liad  no  relation  to  the  degree  of  virulence.  He 
then  noticed  that  the  substance  produced  during  the  growth  of  the 
pseudo-diphtheria  bacilli  always  made  the  bouillon  more  alkaline  instead 
of  acid.  Therefore,  if  at  the  end  of  forty-eight  hours  litmus  was  added 
to  the  different  bouillon  cultures,  it  turned  red  in  the  virulent  ones  and 
blue  in  the  pseudo-diphtheritic  non-virulent  ones.  It  should  be  noticed 
that  this  difference  in  reaction  was  not  found  by  Roux  and  Yersin  in 
the  cultures  of  the  non-virulent  bacilli  tested  by  them. 

Escherich,  in  conclusion,  states  his  position  as  follows  :  "  Since  we 
have  found  constant  cultural  differences  between  the  true  and  the 
pseudo-diphtheria  bacilli,  we  can  give  the  pseudo-diphtheria  bacilli  no 
diagnostic  value." 

If  we  review  the  remaining  literature  of  this  subject,  we  find  some 
investigators  have  been  led  by  their  results  to  adopt  views  similar  to  those 
of  Roux  and  Yersin,  others  to  those  of  Escherich,  and  still  others  have 
been  forced  to  content  themselves  with  the  position  of  Hofmann — viz. 
that  we  are  not  in  a  position  to  affirm  whether  all  these  bacilli  are  of 
one  or  of  different  species  of  bacteria. 

The  relationship  between  these  bacilli  is  not  only  a  matter  of  great 
interest,  but  has  also  been  one  of  great  practical  importance  in  bacterio- 
logical examination  carried  on  for  purposes  of  diagnosis. 

In  order  to  study  these  various  bacilli,  especially  the  non-virulent 
forms,  and  to  clear  up,  if  possible,  some  of  the  questions  connected  with 
their  classification,  cultures  were  made  upon  blood  serum  from  330 
healthy  throats. 

When  any  of  the  varieties  of  bacilli  described  above  were  discovered 
in  the  cultures,  they  were  isolated,  and  in  the  great  majority  of  cases 
tested  as  to  their  virulence  on  guinea-pigs.  In  these  examinations  I 
had  the  help  of  Mr.  Alfred  Beebe.  The  results  are  given  in  the  tables 
below. 

Results  of  Cultures  made  from  the  Throats  of  Healthy  Persons  lohere  there 
had  been  no  History  obtained  of  Direct  Contact  ivith  Diphtheria. 


From  where. 

Total 
cases. 

Virulent  cha- 
racteristic 
diphtheria 
bacilli. 

Non-virulent    Non-virulent 
characteristic        pseudo- 
diphtheria     1  diphtheria 
bacilli.        1      bacilli! 

New  York  Dispensary,  by  Dr.  J.  H.  Huddleston 
Northern  Dispensary 

Nos. 

1  to  151 
152  to  16.3 
164  to  189 

}  •■■ 

5 

12                           21 

Throughout  the  city  of  New  York 

College  of  Physicians  and  Surgeons— Students 

New  York  Foundling  Hospital  Dispensary    . 

Orthopsedic  Hospital  (through  kindness"  of 

Dr.  Chappell). 

Female  ward 

190  to  193 
194  to  242 
243  to  257 

258  to  267 
268  to  275 
276  to  330 

330 

4 
2 

3 

1 

Male  ward .... 

New  York  Foundling  Hospital,  by  Dr.  Adams 

Totals 

3 

1              i 

S          ■                 24                          27 

The  bacilli  found  may  be  divided  into  three  groups  : 
(1)  Bacilli  identical  with  the  Loffler  diphtheria  bacillus  in  growth, 
producing  acid  in  bouillon,  but  having  no  virulence. 


I)[l'llTUi:niA    BACILLI  L\  HEALTHY   THROATS.  GGl 

(2)  Bacilli  not  luivini:  all  the  cliaractoristics  of  the  Loffler  bacillus 
in  growth,  ])r(>(liiciii<j:  alkali  in  hoiiilloii  and  having  no  virulence. 

(3)  ^'iruk'nt  LiUHcr  diphtiicria  Uacilli,  characteristic  in  growth,  pro- 
ducing acid  in  bouillon. 

Two  liundred  and  eighty  of  the  330  healthy  persons  from  whose 
throats  cultures  were  made  were  children  under  twelve,  while  50  were 
adults.  In  24  of  these  characteristic  but  non-virulent  bacilli  were 
found,  and  in  only  9  of  the  24  were  there  present  noticeable  pathologi- 
cal changes  in  the  throat,  such  as  enlarged  tonsils.  The  bacilli  persisted 
in  4  of  the  throats  for  four  weeks,  in  1  for  three  weeks,  in  3  for  two 
weeks,  and  in  some  of  the  others  for  shorter  periods. 

These  bacilli  were  abundant  in  the  primary  cultures  from  17  cases, 
and  present  in  small  numbers  only  in  the  cultures  from  7. 

l^pon  l)lood  serum  the  l)acilli  grew  in  a  manner  characteristic  of  the 
Loffler  bacillus. 

Column  III.  of  the  table  shows  that  in  27  cases  bacilli  were  found 
corresponding  to  those  described  by  Hofmann.  These  were  smaller, 
shorter,  thicker,  and  more  uniform  in  size  than  the  characteristic  Loffler 
bacilli,  and  always  formed  alkali  in  their  growth  in  broth,  but  no  acid.  On 
agar  thev  grow  as  the  less  characteristic  varieties  of  the  virulent  bacilli. 
These  bacilli  were  never  virulent  in  animals.  Guinea-pigs  were  inocu- 
lated with  large  amounts  (^  to  1  per.  cent,  of  their  weight)  of  broth  cul- 
tures of  bacilli,  obtained  from  8  cases,  without  showing  any  reaction. 

As  is  shown  in  Column  I.  of  the  table,  virulent  diphtheria  bacilli 
were  found  in  8  of  the  330  cases.  They  were,  in  all  probability, 
derived  from  mild  cases  of  unrecognized  diphtheria  or  from  healthy 
children  who  were  carrying  the  bacilli  in  their  throats. 

Cultures  from  a  number  of  pseudo-diphtheria  bacilli  were  carried 
through  a  series  of  generations  without  losing  their  characteristics,  thus 
differing  from  most  acid-producing  bacilli,  which  after  a  little  cultivation 
usually  show  the  characteristic  appearances  of  diphtheria  bacilli. 

Whether  or  not  these  pseudo-diphtheria  bacilli  are  descendants  of  the 
virulent  or  non-virulent  diphtheria  bacilli  is  perhaps  a  c^uestion  impos- 
sible to  answer.  They  have  at  present  certain  well  defined  differences 
which  seem  to  be  fixed. 

The  Frequency  tcith  which  Virulent  Diphtheria  Bacilli  are  Present  in 
the  Throats  of  Healthy  Persons  who  have  been  Brought  in  Contact  with 
Diphtheria. — The  search  for  the  origin  of  obscure  cases  of  diphtheria  has 
revealed  the  fact  that  it  is  possible  for  the  human  throat  to  become  the 
habitat  of  the  virulent  Loffler  bacillus  without  any  visible  lesions  resulting. 
Thus,  Loffler  found  the  virulent  bacillus  once,  Frankel  twice,  and  Esche- 
rich  found  it  in  several  cases.  In  one  of  Escherich's  cases  the  history  is 
so  significant  as  to  be  worth  repeating.  It  was  noticed  that  among  the 
children  coming  under  the  care  of  a  certain  apparently  healthy  nurse  a 
number  of  cases  of  diphtheria  were  developing.  A  bacteriological  exam- 
ination being  made,  her  throat  was  found  to  contain  very  numerous 
virulent  diphtheria  bacilli.  These  remained  present  and  virulent  for 
weeks.  A  similar  and  interesting  case  is  reported  by  Feer.  In  a  diph- 
theria epidcL'iic  occurring  in  a  hospital  ward,  due  to  a  single  infection, 
the  throats  of  7  children  became  infected.  The  infection  caused  fatal 
diphtheria  in  4,  an  acute  angina  without  membrane  in  2,  and  no  symp- 


662 


DIPHTHERIA. 


toms  whatever  in  1.  In  all  of  these  the  bacilli  were  abundant  and 
equally  virulent.  Many  similar  examples  liave  been  met  with  in  New 
York  City. 

A  very  interesting  investigation  has  been  carried  on  to  determine 
how  frequently  the  throats  of  healthy  children  become  infected  in 
families  where  one  is  sick  with  diphtheria,  and  where  little  or  no  isola- 
tion is  possible. 

As  will  be  seen  by  the  following  tables,  the  throats  of  the  healthy 
children  of  14  families,  in  which  one  or  more  of  the  other  members  had 
diphtheria,  were  examined.  There  were,  in  all,  48  healthy  children.  In 
50  per  cent,  of  these  diphtheria  bacilli  were  found ;  40  per  cent,  of  these 
developed  later,  to  a  greater  or  less  extent,  the  lesions  of  diphtheria. 
In  considering  the  high  percentage  of  cases  in  which  this  virulent  Lof- 
fler  bacillus  was  found,  it  must  be  remembered  that  in  these  families  the 
conditions  were  the  best  possible  for  the  transmission  of  the  contagium. 

In  numerous  instances  cultures  have  been  made  from  the  throats  of 
healthy  children  in  families  where  the  diphtheria  case  was  well  isolated ; 
in  such  cases  the  bacilli  have  been  found  in  less  than  10  per  cent,  of  the 
children.  Even  here  contact  with  the  sick  was  allowed  up  to  the  time 
the  disease  was  diagnosticated. 


Family. 

Number  of  cases  ex- 
amined aside  from 
the  original   case 
of  diphtheria. 

Lofiler  bacilli. 

Remarks. 

Found  in 

Not  found  in 

A. 

B. 

C. 

D. 

E. 

F. 

G. 

H. 

I. 

J. 

K. 

L. 

M. 

N. 

1 

3 

2 
1 
3 
4 
5 
4 
4 
8 
4 
3 
5 
1 

3 

1 

1 
1 
1 
3 
3 
1 
3 
1 
2 
3 
1 

1 

...    { 

1 

v 

3 
2 
1 
3 

5: 

3 
1 
2 

Isolation  partial. 

No  isolation ;  all  three  cases  subse- 
quently developed  diphtheria. 
No  isolation. 

Isolation  partial. 

No  isolation. 
Isolation  partial. 

No  isolation. 

14 

48 

24 

24 

Of  the  above  cultures  in  which  the  Loffler  bacilli  w^ere  found,  in  6 
the  virulence  Avas  tested  in  the  usual  way.  The  results  are  stated  in  the 
following  table  : 


Family 
No. 

Case 
No. 

Amount 

bouillon 

culture 

inoculated. 

Weight 
guinea- 
pig, 
gms. 

Virulence. 

Clinical  history. 

B. 

G. 

H. 
K. 

M. 

N. 

1 

2 

3 
4 
5 
6 

1.33  c.C. 

1 

1.33   " 
1.33  " 
1.66   " 
1       " 

337 

205 

202 
300 
490 
250 

Died  in  40  hours. 

Died  in  44  hours. 

Died  in  48  hours. 
Died  in  40  hours. 
Died  in  40  hours. 
Died  in  40  hours. 

f  Developed  fatal  diphtheria  one  day  after 

1     culture  was  taken. 

/  Developed  tonsillar  diphtheria  two  days 

i     after  culture  was  taken. 

No  subsequent  development  of  diphtheria. 

It  may  be  interesting  to  detail  here  2  instances  out  of  many  observed 
in  which  the  virulent  bacilli  of  diphtheria  derived  from  healthy  throats 
have  been  the  cause  of  diphtheria  in  others  : 


DTrUTIIElUA    BACILLI.  663 

1.  A  cliild  was  ndinittcd  into  a  Iu)S|)ital  ward  in  an  anioniic  conditicm 
and  with  a  chronic  i-orv/a.  Vwv  days  hitcr  4  chihh'cn  in  his  neit^lil^or- 
hood  dovoh)jKHl  diphtheria  ;  2  of  these  diech  In  seeking  the  cause  of 
the  diphtheria  suspicion  was  directed  to  the  chiUl  by  a  slight  nasal 
discliarge.  Bacteriological  examination  showed  that  this  secretion  con- 
tainetl  many  dij)htheria  bacilli.  On  further  examination  it  was  found 
the  chikl  came  from  a  family  in  which  three  weeks  before  there  had 
been  a  case  of  diphtheria. 

2.  In  a  family  of  8  children  1  child  sickened  with  diphtheria  and  a 
second  child,  a  baby,  was  sent  to  a  neighbor.  The  next  day  cultures 
showed  this  baby,  as  well  as  2  of  the  other  children,  all  of  whom  were 
apparently  healthy,  to  be  infected  with  diphtheria  bacilli.  The  .'>  appar- 
ently healthy,  but  infected,  children,  as  well  as  the  sick  one,  were  at 
once  quarantined,  but  already  1  of  the  family  to  which  the  baby  had 
been  sent  had  contracted  diphtheria  from  it. 

The  practical  value  of  bacteriological  examinations  of  the  throats  of 
liealthy  children  in  families  where  isolation  has  not  been  carried  out  in 
the  first  days  is  further  shown  by  the  fact  that  those  children  in  whom 
the  bacilli  are  found  are  extremely  apt  to  develop  diphtheria  in  the 
course  of  a  few  days,  when  no  cleansing  treatment  is  adopted,  while  they 
seem  much  less  liable  to  do  so  if  kept  under  treatment  or  immunized 
with  antitoxins. 

The  detection  of  the  virulent  bacilli  in  throats  prevents  the  dissem- 
ination of  diphtheria  by  allowing  us  to  isolate  those  infected. 

A  very  striking  instance  of  this  was  the  following :  In  a  family  of  4 
children  1  was  sick  with  diphtheria.  The  Department  inspector  found  3 
other  children  in  the  same  bed  with  the  sick  child,  who  was  constantly 
spitting  upon  and  soiling  the  bedclothes.  He  made  cultures  from  these 
3  children,  whose  throats  appeared  healthy,  as  Avell  as  from  the  sick  one ; 
all  contained  abundant  characteristic  L5ffler  bacilli  (these  were  later 
shown  to  be  virulent  by  the  inoculation  of  guinea-pigs).  When  the 
inspector  visited  the  same  family  three  days  later  he  found  2  of  the 
previously  healthy  children  had  meanwhile  sickened  and  died,  and  that 
the  third  was  severely  ill.     This  child  finally  recovered. 

From  the  observation  detailed  above  we  cannot  escape  the  conclusion 
that  all  members  of  an  infected  household  should  be  regarded  as  under 
suspicion,  and  in  those  cases  where  isolation  is  not  enforced  the  healthy 
as  well  as  the  sick  should  be  prevented  from  mingling  with  others  until 
cultures  from  the  throat  have  shown  the  absence  of  bacilli  or  a  sufficient 
lapse  of  time  gives  the  presumption  that  they  are  not  carriers  of  the  con- 
tagium. 

Summarij  and  Conclusions  on  Diphtheria  Bacilli  in  HealfJii/  Throats. — 
It  has  been  shown  that  children,  and  to  a  less  extent  adults,  who  are 
brought  in  direct  contact  with  true  cases  of  diphtheria  very  often  receive 
the  diphtheria  bacilli  into  their  throats,  and  that  these  bacilli  may  persist 
and  develop  in  these  throats  for  days  or  weeks.  In  some  cases  Ave  have 
found  that  true  diphtheria  followed  the  appearance  of  the  bacilli  in  the 
res])iratory  passages,  M'hile  in  others  no  disease  developed,  though  they 
might  be  the  source  of  diphtheria  in  others.  The  examination  of  the 
throats  of  330  healthy  persons  dwelling  in  Xew  York  tenements  in 
whom  no  contact  with  diphtheria  was  known  revealed  the  presence  of 


664  DIPHTHERIA. 

virulent  bacilli  in  but  8  persons,  2  of  whom  later  developed  diph- 
theria. 

We  must  conclude,  then,  that  virulent  diphtheria  bacilli  are  to  be 
found  in  the  throats  of  a  small  proportion  of  healthy  persons  throughout 
localities  where  diphtheria  prevails,  and  that  they  have  been  derived 
either  directly  from  diphtheria  cases  or  from  those  who  have  been  in 
contact  with  them.  The  examinations  of  the  throats  of  the  330  healthy 
persons  showed  that  in  24  bacilli  existed  in  every  way  identical  with  the 
Loffler  bacillus,  except  that  they  were  not  virulent  in  animals.  As  some 
of  the  bacilli  in  cases  of  true  diphtheria  are  known  to  gradually  lose 
their  virulence,  and  as  this  loss  can  be  caused  artificially,  it  seems  that 
these  bacilli,  characteristic  except  as  to  virulence,  should  be  regarded  as 
true  diphtheria  bacilli  which  have  lost  it.  They  are  probably  incapable 
of  causing  diphtheria. 

The  examination  of  the  same  throats  showed  that  in  27  there  were 
bacilli  present  which  were  so  uniform  in  their  peculiarities,  as  to  staining, 
size,  shape,  and  the  production  of  an  alkali  instead  of  an  acid,  that  there 
seems  to  us  to  be  even  more  reason  to  separate  them  from  the  diphtheria 
bacillus  than  there  is,  for  example,  to  separate  the  colon  bacillus  from 
that  of  typhoid. 

We  have  never  found  bacilli  possessing  these  peculiarities  to  be  viru- 
lent, nor  have  they  appeared  to  have  any  connection  with  diphtheria. 
It  seems  to  us  that  to  these  bacilli  alone  the  name  pseudo-diphtheria 
bacillus  should  be  given. 

The  Persistence  of  Bacilli  in  the  Throats  of  Convalescent  Cases. — The 
length  of  time  elapsing  between  the  inception  of  the  disease  and  the 
date  on  which  a  culture  showed  the  absence  of  the  Klebs-Loflfler  bacillus 
from  the  throat  of  the  patient  was  tabulated  for  1736  cases. 

In  many  of  the  cases  cultures  were  made  at  infrequent  intervals, 
and  the  bacilli  may  therefore  have  disappeared  at  an  earlier  period  than 
that  recorded.  In  cases  where  cultures  show  the  disappearance  of  the 
bacilli  on  the  fourteenth  day  or  over,  the  average  interval  between  these 
cultures  and  the  last  culture  showing  the  presence  of  the  bacilli  is  prob- 
ably about  eight  days. 

The  tabulation  is  as  follows  : 

Time  from  inception  of  dis- 1         ^^^^  ^  ^g^l^  ^  42d  day.  35th  day. 

ease  bacilli  disappeared,      j                      .>  j                     •/                      j 

Number  of  cases 1721  1706  1676                 1622 

Per  cent,  of  total  cases  (1736)     .    .     99.13  98.27  96.54  93.43 

Time  from  inception  of  dis-  \       _  28th  day.  21st  day.  14th  day.  7th  day. 

ease  bacilli  disappeared,       j                       ^  ■  .z  •- 

Number  of  cases 1468  1131  558  57 

Per  cent,  of  total  cases      84.57  65.09  31.91  3.28 

Time  from  inception  of  dis- j          g^j^^.^^.  ^^^  ^  4th  day.  3d  day. 

ease  bacilli  disappeared,       j                     .  .'  .^                       ^ 

Number  of  cases 34  24  14                     4 

Per  cent,  of  total  cases 1.96  1.38  0.81  0.23 

In  the  remaining  15  cases,  or  0.87  per  cent,  of  the  total,  the  bacilli 
were  found  to  have  disappeared  as  follows  :  On  the  57th  day,  1 ;  59th 
day,  2 ;  60th  day,  1  ;  62d  day,  1  ;  64th  day,  1  ;  65th  day,  2 ;  68th, 
72d,  73d,  74th,  75th,  77th,  and  93d  days,  1  each. 


DIl'IITHKRIA    BACILLI.  665 

TliL'^o  tiirurc's  cornjhorato  the  oonclu.sion  drawn  from  observation  of 
cases  dnring  the  previous  year — viz.  tliat  in  a  large  proportion  of  all 
cases  (about  four-hftiis)  the  lvlei:)s-Lot!ler  InieiUus  disappears  by  the  end 
of  the  fjurth  week  from  the  beginninn;  of  the  disease;  that  in  about 
two-thirds  of  all  eases  it  disa[)})ears  hy  the  end  of  the  third  week  ;  and 
in  one-third  of  all  eases  by  the  end  of  the  second  week  ;  while  in  a  small 
proportion  of  eases  (about  3  per  cent.)  disappearance  occurs  within  one 
week  from  the  inception  of  the  disease. 

The  length  of  time  elapsing  between  the  inception  of  the  disease  and 
the  date  of  the  last  culture  showing  the  presence  of  the  Klebs-Lofiler 
bacillus  in  the  throat  of  each  patient  was  tabulated  for  the  above  1736 
cases,  and  tor  414  atlditional  cases,  making  a  total  of  2150  cases.  This 
increased  number  is  due  to  the  fact  that  for  various  reasons  (death  of 
the  ]>atient,  etc.)  no  final  culture  showing  the  disappearance  of  the 
bacilli  was  made  in  the  additional  cases.  As  stated  for  the  previous 
tabulation,  the  average  interval  between  the  last  culture  showing  the 
presence  of  the  bacilli  and  that  showing  their  disappearance  is  probably 
about  eight  days,  the  additional  cases  in  which  no  final  culture  was 
taken,  of  course,  excepted.  The  bacilli  may,  therefore,  have  persisted 
in  many  cases  for  a  longer  period  than  that  recorded. 

Of  the  2150  cases  tabulated,  in  864  the  last  cultures  showing  ba- 
cilli to  be  present  were  made  within  six  days  or  less  from  the  incep- 
tion of  the  disease,  and  may  be  considered  in  the  main  as  made  for 
diagnosis. 

The  remaining  1286  cases  are  tabulated  as  follows : 

Time  from  inception  of  dis-  I  -^r,  i  -,  i  i.i    i  j 

,      .,,.     ^        ^  r  ■    ■     '  th  dav  and  over.  14th  da v  and  over. 

ease,  bacilli  present,  J 

Number  of  cases 1286  7-11 

Per  cent,  of  total  cases  (2150)  .    .  59.81  34.46 

Time  from  inception  of  dis-  \  /  21st  day  28th  day  35th  day  42d  day 

ease,  bacilli  present,             J    '    '  I  and  over.  and  over.  and  over,  and  over. 

Number  of  cases 328  155  68  31 

Per  cent,  of  total  cases 15.25  7.21  3.16  1.44 

Time  from  inception  of  dis-1  .ri»i    i  j  'a^\    ^  ^ 

^  ease,  bacilli  present,  f  "    "  ^^'^  ^^^  ^°^  '^^^^^  ^^'^  *^^-^'  ^^^  °^^^- 

Number  of  cases 16  9 

Per  cent,  of  total  cases 0.79  0.42 

In  the  9  cases  in  which  cultures  showed  the  presence  of  the  bacilli 
for  56  days  and  over  from  the  inception  of  the  disease  these  cultures 
were  made  as  follows  :  One  each  on  the  57th,  58th,  60th,  61st,  62d,  63d, 
64th,  88th,  90th,  and  91st  days,  respectively.  The  above  tabulation  is 
chiefly  <jf  interest  as  showing  the  long  persistence  of  the  Klebs-Loffler 
bacillus  in  the  throat  in  exceptional  cases. 

The  virulence  of  the  bacilli  thus  persisting  has  been  tested  in  a  num- 
ber of  cases,  Avith  results  entirely  confirmatory  of  those  reported  for  the 
previous  year.  In  every  case  tested  the  bacilli  retained  their  virulence 
irrespective  of  the  duration  of  persistence  in  the  throat.  The  case  in 
which  the  bacilli  were  found  to  be  present  on  the  91st  day  presents 
points  of  special  interest.  It  was  that  of  a  child  three  months  old 
when  first  coming  under  observation,  in  which  the  clinical  symptoms 
were  confined  to  a  simple  nasal  discharge.    There  were  no  constitutional 


666  DIPHTHERIA. 

symptoms  whatever.  The  nurse,  and  later  the  mother  of  the  child,, 
contracted  diphtheria  from  it,  the  disease  in  the  mother's  case  being  of 
a  severe  type.  The  bacilli  were  tested  at  frequent  intervals  up  to  five 
wrecks  from  the  inception  of  the  disease,  and  were  found  to  be  virulent 
in  every  instance. 

The  presence  of  non-virulent  diphtheria  bacilli  in  a  certain  number 
of  healthy  throats  made  it  necessary  to  test  the  virulence  of  bacilli  from 
mild  sore  throats  before  being  able  to  diagnosticate  them  as  certainly 
diphtheria  bacilli.  For  practical  reasons,  however,  we  are  satisfied  with 
establishing  extreme  probability  from  the  simple  microscopical  examina- 
tion of  the  bacilli. 

What  are  the  means  by  which  diphtheria  is  transmitted  ? 

The  facts  detailed  already  throw  important  light  on  the  manner  in 
which  diphtheria  is  transmitted. 

As  related  to  this  question,  let  us  first  consider  very  briefly  what  is 
known  of  the  duration  of  life  of  the  Loffler  bacillus  outside  of  the  body. 
In  actual  experiment  it  has  been  found  to  live  for  long  periods  of  time — 
namely,  by  Hofmann,  on  blood  serum  for  one  hundred  and  fifty-five 
days ;  by  Loffler  and  by  myself  for  seven  months ;  and  in  gelatin,  by 
Klein,  for  eighteen  months.  The  bacilli  have  been  found  to  live  in  bits 
of  dried  membrane  by  Loffler  for  fourteen  weeks,  by  myself  for  seven- 
teen, and  by  Roux  and  Yersin  for  twenty  weeks.  Dried  on  silk  threads^ 
Abel  reports  they  may  sometimes  live  for  one  hundred  and  seventy-two 
days,  and  upon  a  child's  plaything,  which  had  been  kept  in  a  dark  place, 
they  lived  for  five  months. 

As  examples  of  the  manner  in  which  diphtheria  may  be  contracted 
he  gives  the  following  from  Johannessen  :  A  teacher  developed  diph- 
theria from  passing  the  night  in  a  room  in  which  three  weeks  before  a 
fatal  case  had  occurred.  A  child  developed  diphtheria  after  putting  on 
the  clothing  worn  by  a  child  which  had  died  of  diphtheria  two  months 
before.  In  a  number  of  isolated  dwellings  diphtheria  developed  nearly 
a  vear  after  previous  outbreaks,  without  there  being  any  apparent  possi- 
bility of  a  new  infection  taking  place  from  the  outside.  I  have  met 
with  a  number  of  cases  where  the  infected  bedding  or  clothing  ha& 
undoubtedly  been  the  source  of  the  infection. 

The  Sources  of  the  Virulent  Bacilli  are — 1.  From  the  pseudo-mem- 
brane, exudate,  or  discharges  from  diphtheria  patients.  2.  From  the 
secretions  of  the  nose  and  throat  of  convalescent  cases  of  diphtheria  in 
which  the  virulent  bacilli  persist.  3.  From  the  throats  of  healthy 
individuals  wdio  acquired  the  bacilli  from  being  in  contact  with  others 
having  virulent  germs  on  their  persons  or  clothing.  In  such  cases  the 
bacilli  may  sometimes  live  and  develop  for  days  or  weeks  in  the  throat 
without  causing  any  lesion. 

When  we  consider  that  it  is  only  the  severe  types  of  diphtheria  which 
remain  isolated  during  actual  illness,  the  wonder  is,  not  that  so  many,, 
but  that  so  few  persons  contract  the  disease.  This  seems  to  be  more 
remarkable  when  we  observe  that  in  a  city  like  New  York  the  whole 
tenement-house  district,  at  least,  is  an  infected  area.  This  has  become 
evident  from  the  observations  made  by  the  Department. 

It  has  been  the  practice  of  the  New  York  Health  Department  during 
the  last  year  to  plat  upon  a  city  map  the  location  and  date  of  every  case 


DIPIITUERIA    BACILLI.  007 

of  (li|)hllu>ri:i  in  wliicli  the  (lini^^nosis  had  been  sottlod  by  bacteriological 
examination.  After  several  months  the  niaj)  presented  a  very  strikin*^ 
appearance.  Wherever  the  densely  crowded  tenements  were  located, 
there  the  marks  were  very  numerons,  wiiile  in  the  districts  occujiied  by 
private  residences  very  few  cases  were  indicated  as  having  occurred.  It 
was  also  aj)})arent  that  cases  were  far  less  ahundant,  as  a  rule,  where  the 
tenements  were  in  small  groups  than  in  tlie  regions  of  the  city  Avhere 
they  covered  large  sections.  At  the  end  of  six  months  tiiere  were 
square  miles  in  which  nearly  every  block  occupied  by  tenement-houses 
contained  marks  indicating  the  occurrence  of  1  or  more  cases  of  diph- 
theria;  and  in  some  blocks  many  cases  (15  to  25)  had  occurred. 

As  the  platting'  went  on  from  time  to  time  the  map  showed  the  infec- 
tion of  a  new  area  of  the  city,  and  often  the  subsequent-ap])earance  of 
a  local  epidemic.  It  was  interesting  to  note  two  varieties  of  these  local 
epidemics :  in  one  the  subsequent  cases  evidently  were  from  neighbor- 
hood infection,  while  in  the  second  variety  the  infection  was  as  evidently 
derived  from  schools,  since  a  whole  school  district  would  suddenly 
become  the  seat  of  scattered  cases.  At  times,  in  a  certain  area  of  the 
city  from  whicli  several  schools  drew  their  scholars,  all  the  cases  of 
diphtheria  would  occur  (as  investigation  showed)  in  families  Avhose 
children  attended  one  school,  the  children  of  the  other  schools  being  for 
the  time  exempt. 

Another  fact  noted,  perhaps  as  important  as  the  foregoing,  was  that 
Avith  the  most  careful  inquiry  it  was  impossible  to  find  any  connection 
with  preceding  cases  of  diphtheria  in  about  one  half  of  the  first  cases 
of  diphtheria  occurring  in  diiferent  houses. 

The  two  following  histories  are  instructive  as  showing  that  special 
conditions,  which  are  largely  unknown  to  us,  determine  in  every  indi- 
vidual the  occurrence  or  escape  from  diphtheria  under  exposure  :  Two 
children  in  a  family  were  taken  sick  with  diphtheria  and  removed  to  the 
hospital.  The  servant  (who  was  and  remained  apparently  healthy)  went 
to  another  family,  where  the  youngest  child  developed  diphtheria  a  week 
later.  In  the  mean  time  a  case  developed  in  the  family  living  in  the 
next  apartments.  There  were  in  this  latter  family  three  otlier  children 
who  were  not  isolated  at  all  from  the  sick  child,  yet  none  of  these 
developed  diphtheria. 

The  child  of  a  man  who  kept  a  candy  store  developed  diphtheria ; 
there  were  four  other  children  in  the  family,  and  these  were  in  no  way 
isolated  from  the  sick,  yet  none  of  them  acquired  the  disease ;  but 
children  who  bought  cand}'  at  the  store  and  other  children  coming  in 
contact  with  these  in  school  developed  it.  The  secondary  cases  ceased 
to  develop  as  soon  as  the  candy  store  had  been  closed. 

Many  similar  histories  could  be  given  to  illustrate  the  fact  that  the 
majority  of  persons,  and  even,  perhaps,  the  majority  of  children,  are  not 
ordinarily  very  susceptible  to  diphtheria,  and  that  in  addition  to  receiving 
the  germs  of  the  disease  into  the  respiratory  passages  they  must  be  in  a 
condition  favorable  to  the  development  of  the  disease. 

It  seems  to  be  generally  true  that  the  more  malignant  a  case  of  diph- 
theria is  the  more  likely  it  is  to  cause  diphtheria  in  others.  This  may 
be  due  to  the  high  grade  of  virulence  possessed  by  the  bacilli,  or  to  the 
peculiar  association  of  other  micro-organisms  in  the  membrane,  or  to 


668  DIPHTHERIA. 

the   wider  dissemination    of    the    infectious    matter    through    the    dis- 
charges. 

It  is  also  well  known  that  young  children  are  much  more  susceptible 
to  diphtheria  than  older  persons.  It  is  comparatively  rare  for  the  parents 
of  children  sick  with  diphtheria  to  contract  the  disease,  although  in 
nearly  every  case  they  must  at  some  time  receive  the  germs  into  their 
throats. 

The  blood  of  many  adults  has  been  shown  to  have  antitoxic  proper- 
ties to  the  diphtheria  poison.  At  times,  however,  parents  and  nurses 
become  infected,  as  in  the  following  cases : 

(^A)  Two  months  before  a  child  living  on  the  floor  below  the  present 
case  had  diphtheria.  Until  a  few  days  before  the  sickness  of  the  patient 
the  two  families  had  kept  apart.  For  the  last  few  days  they  had  visited 
each  other,  and  the  first  patient,  the  mother,  carried  the  child  who  had 
recovered  from  diphtheria.  When  the  mother  became  ill  she  was  still 
allowed  to  nurse  and  carry  her  children.  Three  days  later  her  two 
children  were  discovered  to  have  contracted  the  disease.  The  mother, 
too  sick  longer  to  nurse  her  children,  confided  their  care  to  the  father, 
who  himself  became  infected.  Antiseptic  cleansing  of  the  nostrils  and 
throat  was  neither  used  in  treatment  nor  prophylaxis  in  these  cases  before 
their  admission  to  the  hospital. 

(jB)  In  another  case,  five  weeks  before,  there  existed  diphtheria  in  the 
flat  below.  The  first  new  patient  taken  sick  was  a  child,  aged  two  and 
a  half  years,  three  days  later  another,  aged  four,  and  then  the  mother 
herself  became  ill.  The  children  died ;  the  mother  went  to  the  hospital 
and  finally  recovered.  When  she  left  home  her  seven  months' baby  went 
to  a  friend's,  where,  three  days  later,  two  of  the  children  developed  diph- 
theria, and  then  finally  the  baby  itself.  The  baby  came  to  the  hospital 
and  died,  and  one  of  the  other  children  died. 

From  the  throat  the  bacilli  may  be  deposited  upon  the  hands,  other 
parts  of  the  person,  on  handkerchiefs,  bed  linen,  clothes,  toys,  and  eating 
utensils.  Under  favorable  conditions  they  may  live  from  one  to  eight 
weeks  on  these  infected  substances,  and  under  exceptional  circumstances, 
as  when  the  light  is  excluded  and  sufl&cient  moisture  is  present,  for  eight 
or  nine  months.  As  the  infected  persons  and  things  are  scattered,  the 
bacilli  may  be  carried  to  healthy  persons  long  distances  away  from  the 
original  disease.  As  time  passes  the  number  of  living  bacilli  diminish, 
and  where  they  are  dry  enough  to  float  as  dust  they  soon  die. 

Conditions  Favoring  the  Groioth  of  the  Bacillus  and  its  Length  of 
Life  Outside  of  the  Body. — Diphtheria  bacilli  probably  do  not  increase 
in  water,  on  walls,  carpets,  etc.,  but  they  may  possibly  in  milk,  meat, 
and  soups ;  but  even  here  the  saprophytic  bacteria  are  apt  to  crowd 
them  out.  Low  temperature,  moist  air,  and  darkness  protect  the  life 
of  the  bacilli.  In  warm  weather  either  the  germs  quickly  dry  and  die, 
or  if  moisture  is  present  other  germs  grow  and  displace  them.  The 
prolonged  light  of  summer  also  aids  in  killing  them.  Artificial  heat 
in  wdnter  may  do  the  same.  Sea  air  is  more  favorable  to  the  life  of 
the  germs  than  the  drier,  clearer  climates. 

Thus  in  dark,  damp  cellars  and  basements  we  would  expect  most 
favorable  conditions  for  the  increase  of  disease.  The  habit  of  quickly 
cleansing  dirty  clothing  prevents  the  spread  of  diphtheria,  while  putting 


j>ii'nTii/:n/A  jiac/lij.  (j(j9 

iiitri'tcd  clothiiiii'  away  in  dark  closets  li<'l|ts  to  spread  tlie  iideetiou  later. 
Ill  many  teiieiiu'iit-lioiises  an  epidemic  of  diplitheria  lasts  IVom  two  to 
three  months.  First  one  case  occurs,  then  in  several  weeks  another  in 
the  same  family,  and  then  hiter  in  other  families;  sometimes  after  six  or 
sev'on  months  another  case  develoi>s,  hut  this  perhaps  is  another  infection 
from  outside. 

Seldom  area  nuinher  of  families  at  once  attacked.  In  li(t\'  houses 
with  ej)idemics  only  three  were  a,<;ain  atta(;ked  with  mnnei'ous  cases. 
Nowhere  is  it  shown  that  a  special  locality,  the  gi'ound,  or  the  air  has 
any  marked  influen(!e  upon  diphtheria,  but  the  people  themselves,  their 
communication  with  each  other,  and  their  habits  of  life  o-ive  rise  to  a 
slighter  or  greater  outbreak  of  diphtheria. 

The  history  of  an  e])idemic  of  di])htheria  which  started  on  h'isher's 
Island,  New  York,  in  the  sunnner  of  18U1  is  so  instructive  in  showing- 
how  unrecognized  and  convalescent  cases  started  the  disease  that  J  will 
give  its  details,  for  many  of  Avhicli  I  am  indebted  to  my  friend  Dr.  li.  i\I. 
l^iinter.  From  a  number  of  the  later  cases  I  made  cultures,  so  that 
besides  the  clear  clinical  evidence  the  nature  of  the  cases  was  confirmed 
by  bacteriological  examinations. 

Fisher's  Island  lies  between  the  eastern  end  of  Long  Island  and  Con- 
necticut, and  is  a  summer  resort.  At  the  time  of  the  epidemic  ])erhaps 
one  thousand  people  w^ere  on  the  island.  On  Wednesday,  in  the  last 
week  of  August,  1891,  a  seven-year-old  boy,  and,  a  day  later,  his  mother, 
who  were  living  in  an  isolated  cottage,  were  taken  ill  with  ^\•hat  seemed 
to  be  a  simple,  well  marked  tonsillitis.  A  day  later  a  young  man  living 
in  one  of  a  cluster  of  cottages,  the  inmates  of  which  ate  at  a  common 
table,  developed  a  severe  croupous  tonsillitis,  which  would  be  suspected 
to  be  diphtheria  if  that  disease  were  prevalent. 

There  w^as  now  an  intermission  for  three  days,  when  suddenly  in  one 
day  15  cases  of  w'ell  marked  tonsillitis  and  half  a  dozen  slighter  sore 
throats  appeared.  The  day  before  a  severe  storm  had  swept  the  island. 
In  another  day  some  of  these  cases  began  to  resemble  true  dijihtheria, 
and  the  patients  were  quarantined;  some  of  the  children  died.  After 
this  day's  outbreak  only  6  further  cases  developed  on  the  island. 

These  25  cases  of  undoubted  diphtheria  and  half  a  dozen  of  a  more 
doubtful  character  occurred  in  eight  separated  cottages  or  groups  of 
cottages. 

More  instructive  still  than  the  outbreak  on  the  island  are  the  epi- 
demics started  in  other  places  by  the  scattering  summer  residents.  The 
following  cases  emphasize  the  danger  of  sending  away  or  receiving 
persons  from  diphtheria  households. 

Among  the  group  of  cottages  where  the  chief  outbreak  of  diphtheria 
occurred  was  a  family  in  M'hich  one  child  w^as  attacked  with  the  disease, 
who  afterward  died.  As  soon  as  the  case  was  considered  to  be  diphtheria 
the  nurse  and  another  child  M'ere  sent  home  to  a  town  in  New  Jersey. 
On  the  way  home  the  nurse  complained  of  a  slight  sore  throat,  but  no 
attention  was  paid  to  it.  Several  days  later  the  young  child  had  diph- 
theria, and  from  these  cases  24  others  developed  in  the  town. 

The  town  authorities  had  the  sanitary  conditions  thoroughly  investi- 
gated by  a  sanitary  engineer,  but,  although  in  some  of  the  houses  the 
sanitation  was  faulty,  in  others  there  w^as  nothing  to  complain  of. 


670  DIPHTHERIA. 

From  one  of  the  isolated  island  cottages  a  mother,  a  nurse,  and  two 
children  left  the  island  for  their  home  on  the  mainland  at  the  time  of 
the  outbreak,  but  before  its  nature  was  suspected.  The  nurse  com- 
plained of  a  sore  throat,  and  when  at  home  developed  diphtheria.  Being 
in  a  physician's  family,  the  nurse  was  carefully  isolated.  After  recovery 
everything  which  had  been  in  contact  with  her  was  burned  or  disin- 
fected. Ten  days  after  she  returned  to  the  care  of  the  children,  and 
three  days  later  the  eldest  child  contracted  diphtheria  and  died.  Here 
a  person  who  was  supposed  to  have  entirely  recovered  still  carried 
infection. 

From  another  cottage  on  the  island,  after  diphtheria  had  broken  out, 
a  grandmother  with  one  of  the  children  returned  home  to  New  Haven, 
developed  diphtheria,  and  died.  This  was  the  origin  of  other  cases  in 
that  city,  A  young  man  who  was  mentioned  as  coming  to  the  cottages 
ill  on  the  day  of  the  first  cases  returned  home  three  days  later  and 
died  of  diphtheria. 

It  may  be  stated  that  although  the  drainage  and  sanitary  conditions 
on  the  island  were  not  at  that  time  first  class,  yet  they  were  no  worse 
than  in  many  other  resorts,  and  to  them  could  not  be  attributed  the  out- 
break.   In  the  year  following  but  two  cases  occurred  on  Fisher's  Island. 

The  Bacteriology  op    Pseudo-diphtheria. 

The  pseudo-membranous  inflammations  which  frequently  complicate 
scarlatina  (page  594),  and  to  a  less  extent  other  infectious  diseases,  are, 
as  a  rule,  not  diphtheritic  in  character,  and  bacteriological  examinations 
will  show  the  diphtheria  bacilli  to  be  absent.  The  same  is  true  for  the 
ordinary  acute  cases  of  tonsillitis  and  pharyngitis  and  for  some  of  the 
cases  of  acute  pseudo-membranous  laryngitis. 

Thus  in  the  exudate  in  40  cases  of  this  character  which  I  carefully 
examined  bacteriologically,  the  cultures  from  all  contained  streptococci, 
and  on  most  of  the  plates  the  streptococci  far  outnumbered  all  other 
micro-organisms. 

As  in  normal  throats,  so  here,  the  streptococci  taken  from  different 
■cases,  or  even  from  different  colonies  of  the  same  case,  differed  greatly 
in  their  growth  and  appearance.  In  most  of  the  plates  the  long  chained 
streptococci  resembling  the  streptococcus  pyogenes  were  the  most  numer- 
ous, but  in  quite  a  number  the  short  chained  cocci  were  in  the  majority. 
Staphylococci  were  often  present  in  large  numbers,  and  other  bacteria 
were  frequently  added. 

Communicabilify. — Persuaded  by  my  clinical  experience  and  by  the 
results  of  examinations  of  normal  throats,  that  streptococci  were  prob- 
ably harmless  while  the  mucous  membranes  were  intact,  I  tried  the 
following  experiment : 

Inoculation  of  Human  Throats  with  Streptococci. — A  very  thick  cul- 
ture was  made  on  agar  plates  from  a  severe  follicular  tonsillitis  in  a 
young  child,  so  that  there  was  obtained  a  luxuriant  growth  of  strepto- 
cocci growing  both  in  long  and  short  chains,  and  also  of  other  micrococci. 
A  large  amount  of  these  mingled  bacteria  were,  with  the  permission  of 
a  patient,  plastered  on  a  swab  and  then  rubbed  gently  on  his  right  tonsil 
and  into  its  crypts.     He  felt  a  peculiar  sensation  in  the  tonsil  for  some 


TlIK'llAcrKinolJKIY   OF  J'SEUDO-DIPIITHERIA.  071 

twelve  hours  ;  this  then  jKisscd  away,  and  was  jn'cjl^ahly  simply  the 
result  of  the  nieehanieal  irritation. 

The  next  inorninii"  the  tonsil  aj)])eare(l  healthy  exeept  for  a  small 
[)ateh  in  a  erypt ;  from  this  and  from  the  throat  eultures  were  made.  The 
j)lates  _i»;ave  very  numerous  eolonies  of  streptocoeei,  while  etdtures  made 
from  the  same  regions  the  day  previous  t(j  the  experiment  gave  \ery 
few  streptocoeei. 

A  second  trial  was  made  in  a  similar  way  from  a  culture  of  strepto- 
coccus pyogenes,  eighteen  hours  old,  from  a  case  of  extensive  pseud<j- 
niembrane  and  tonsillar  abscess.  The  results  here  were  also  entirely 
negative,  exeept  for  the  increase  of  streptococci  in  the  throat  for  some 
days.  AVith  this  same  streptococcus  the  tonsils  of  two  other  adults  were 
danbed,  and  with  similar  negative  results. 

These  trials  having  shown  that  in  three  throats  the  application  of 
streptococci  from  cultures  made  from  virulent  cases  of  tonsillitis  pro- 
duced no  effect,  a  different  experiment  was  tried.  On  two  separate 
occasions  a  sterile  swab  was  rubbed  on  the  tonsils  in  a  case  of  severe 
tonsillitis,  and  then  immediately  rubbed  on  a  healthy  tonsil.  In  neither 
case  was  there  any  inflammation  excited.  On  the  third  day  after  the 
last  experiment  a  sudden  fall  in  the  temperature  occurred,  and  after 
exposure  a  follicular  tonsillitis  developed,  such  as  frequently  has  fol- 
lowed previous  similar  exposures. 

After  rubbing  the  bacteria  on  the  tonsils  patients  were  cautioned 
against  eating  or  drinking  for  some  hours,  and  used  no  antiseptic  gargles 
for  several  days.     They  were  also  carefully  guarded  against  taking  cold. 

Though  these  trials  are  only  a  few  in  number,  they  are  enough  to 
make  it  seem  probal>le  that  the  pyogenic  cocci  are  not  sufficient,  as  a 
rule,  to  excite  an  inflammation  in  the  throat.  A  change  appears  neces- 
sary in  the  mucous  membranes,  either  from  the  influence  of  some  infec- 
tious disease  or  of  some  exposure,  before  the  bacteria  find  the  throat  a 
proper  soil  for  rapid  increase  and  the  mucous  membrane  vulnerable  to 
their  action. 

The  following  clinical  cases  confirm  these  views,  and  are  cases  in 
which  the  communication  of  the  disease  seems  at  first  glance  certain  : 

(1)  A  family  of  eight — mother  aged  forty-five,  six  children  whose 
ages  ranged  from  twenty-five  to  ten,  and  a  grandchild,  aged  two — slept 
in  two  rooms  of  a  tenement  just  under  the  roof.  Two  days  previously 
a  heavy  snow  had  fallen,  and  the  day  before  the  roof  leaked,  thus  caus- 
ing the  rooms  to  be  very  damp.  The  next  morning  four  of  the  chil- 
dren had  more  or  less  marked  tonsillitis,  with  follicular  deposits  or 
croupous  patches,  and  on  the  following  day  the  baby  had  an  attack  of 
croup. 

(2)  In  a  school  for  young  girls,  on  a  day  early  in  the  winter,  five 
were  taken  with  follicular  tonsillitis,  and  on  the  next  day  three  more 
were  attacked. 

(3)  A  nurse  attends  a  patient  with  croupous  tonsillitis,  and  has  to 
pass  frequently  from  the  warm  room  to  a  much  cooler  hallway.  On  the 
third  day  the  nurse  is  attacked  with  an  inflammation  much  like  that  of 
his  patient.  The  physician  in  charge  ascribes  it  to  a  direct  infection 
from  the  patient  to  the   nurse. 

In  many  other  similar  cases  the  same  exposure  to  cold,  wet^  or  other 


672 


DIPHTHERIA. 


deleterious  influences  which  caused  the  first  cases  is  the  probable  cause 
of  the  later  cases,  and  not  a  direct  infection. 

Of  very  many  cases  of  pseudo-diphtheria  examined,  only  a  minority 
have  been  in  known  contact  with  others  having  similar  inflamma- 
tions. Another  important  consideration  tending  to  show  that  exposure 
rather  than  direct  infection  is  usually  the  exciting  cause  is  the  fact  that 
these  inflammations  are  very  prevalent  in  the  cold  and  wet  months. 
About  the  first  of  December  they  begin  to  multiply  in  dispensary  and 
private  practice,  and  increase  till  April ;  then  slowly  diminish  until 
June,  to  remain  very  infrequent  until  winter  approaches.  This  rapid 
increase  in  the  late  winter  and  early  spring  is  not  found  to  be  true  to 
the  same  degree  in  diphtheria.  The  histories  of  many  of  these  cases 
would  indicate  that  the  bacteria  already  present  in  the  throat  had  been 
excited  to  a  new  growth  by  some  exposure,  rather  than  that  a  new  infec- 
tion had  been  received. 

Some  of  these  croupous  inflammations  may  indeed  be  due  to  a  recent 
direct  infection,  for  one  would  expect  that  the  bacteria  from  a  fresh 
inflammation  would  be  somewhat  more  virulent  than  those  which  had 
long  lain  dormant  in  the  throat.  The  proof  of  this  is,  however,  diffi- 
cult, for  it  is  impossible  to  tell  from  cultures  and  the  histories  often  give 
no  assistance.  Where  attendants  on  the  sick  or  persons  in  scliools  and 
hotels  are  attacked  after  other  cases  have  developed,  it  is  difficult  to 
determine  whether  they  have  derived  the  disease  directly  from  the  pre- 
vious patients  or  have  developed  it  simply  because  they  were  subjected 
to  the  same  sanitary  influences  as  the  first.  The  important  fact  is  that 
if  persons  keep  themselves  from  exposure  to  cold  and  other  deleterious 
influences  they  are  in  little  danger  of  contracting  this  variety  of  acute 
throat  inflammation. 

In  order  to  test  to  what  degree,  if  any,  pseudo-diphtheria  is  commu- 
nicated from  one  person  to  another,  450  cases,  as  nearly  consecutive  as 
possible,  were  investigated,  all  sources  of  infection  were  sought  for,  and 
the  cases  were  followed  up  for  two  weeks  after  complete  convalescence. 
In  none  of  these  was  isolation  or  disinfection  enforced  by  the  Health 
Department.  This  is  such  an  important  question  that  the  results  of  the 
investigation  of  the  first  100  consecutive  cases  is  summarized  below  in 
tabular  form.  As  a  comparison,  a  summary  is  given  of  50  consecutive 
cases  of  true  diphtheria  which  were  taken  from  the  same  district  and  at 
the  same  time  of  the  year  as  the  first  50  cases  of  pseudo-diphtheria  : 

Summary  of  Tabulated  Cases. 


Total  number  of  eases 

History  of  contact  with  other  cases 

No  history  of  contact 

Families  in  which  more  than  one  ease  developed 

Recovered 

Died 

Cases  complicated  with  scarlet  fever 


Table  1 

Table  2 

Table  3 

(50  families). 

(50  families). 

(50  families). 

Pseudo- 

Pseudo- 

True 

diphtheria. 

diphtheria. 

diphtheria. 

56 

57 

60 

7 

7 

33 

49 

50 

27 

5 

4^ 

13 

56 

53 

46 

42 

17 

4 

63 

1  Two  had  scarlet  fever.  ^  Three  had  scarlet  fever._ 

3  Six  others  had  been  in  contact  with  scarlet  fever,  but  never  showed  any  characteristic 
rash. 


I'ATllULOUU'AL   AyAKJMY    Of  DJl'llTlIKIilA.  ()73 

We  find,  therefore,  in  113  cases  of  false  or  pseudo-diphtheria  oe- 
enrrin>»;  in  100  families,  that  14  oeciirred  at  tlie  same  time  with  or 
shorth'  after  some  otlier  ease,  and  that  it  is  j)ossihle  to  assdnu;  tlie  dis- 
ease liad  been  direetly  eommunieated  to  them.  In  9  of  tlie  100  families 
more  than  1  case  devel<)ped.  In  these,  as  in  the  other  350  cases  of 
})seudo-diphtheria  investigated,  it  did  not  seem  that  secondary  cases  were 
any  less  liable  to  occur  when  the  primary  case  was  isolated  than  when 
it  was  not.  In  this  connection  one  should  remember  that  mild  throat 
inflammations  are  very  freciuent,  especially  in  the  early  spring  months, 
and  that  it  is  quite  possible,  where  two  cases  occurred  in  a  family 
together  or  within  a  short  time  of  each  other,  that  they  may  have  both 
been  due  to  exposure  to  some  common  conditions  rather  than  to  direct 
transmission.  The  presence  of  streptococci  in  nearly  all  healthy  throats 
in  New  York  City  renders  this  assumption  almost  a  probaliility.  The 
presence  of  the  same  germs  in  healthy  throats  as  well  as  in  those  of 
patients  suffering  from  pseudo-diphtheria  prevents  us  from  deciding  the 
point  by  bacteriological  examinations. 

All  of  the  14  cases,  except  the  3  who  had  scarlet  fever,  were  mild, 
and,  indeed,  leaving  out  of  consideration  the  cases  which  occurred  as 
complications  of  scarlet  fever,  there  was  only  1  death  in  113  cases  of 
pseudo-diphtheria,  and  in  this  case  there  was  no  history  of  infection  or 
contact  with  other  cases. 

Pathological  Anatomy  of  Diphtheria. — The  most  charac- 
teristic feature  of  diphtheria  is  the  formation  of  an  exudate  or  pseudo- 
membrane.  This  usually  appears  on  the  mucous  membrane  of  the 
tonsils,  uvula,  soft  palate,  pharynx,  and  nose.  It  frequently,  however^ 
attacks  the  larynx  and  bronchi,  either  primarily  or  as  an  extension 
from  the  pharynx.  Upon  the  mucous  membrane  of  the  tonsils  and 
adjacent  organs  the  lesions  usually  first  appear  as  white  thin  patches  of 
exudate  or  pseudo-membrane.  Later  in  severe  cases  the  membrane 
becomes  thick,  covering  a  large  portion  of  the  mucous  membrane,  and 
mav  have  a  dirtv  grav  or  vellowish  tinoe. 

The  tissues  underlying  and  surrounding  the  pseudo-membrane  are 
more  or  less  intensely  hypersemic  and  swollen.  When  the  membrane  is 
thick  and  adherent,  it  leaves  on  being  torn  off  a  bleeding  surface  which 
is  quickly  covered  anew  by  false  membrane.  In  some  of  the  milder 
cases  the  exudate  may  easily  be  rubbed  off  and  no  bleeding  occurs. 

The  membrane  may  be  made  of  visible  layers,  and  they  may  be 
peeled  off  one  from  another.  This  is  especially  true  of  that  covering' 
the  uvula  and  soft  palate,  both  of  which  may  be  oedematous  and  enor- 
mously swollen.  The  membrane  in  the  larynx  and  trachea  is  of  less 
thickness,  and  usually  is  less  tough,  than  that  of  the  pharynx  and  soft 
palate. 

Although,  as  a  rule,  the  exudate  in  the  larynx  is  thin  and  friable^ 
yet  at  other  times  it  is  thick  and  fibrous,  so  that  a  complete  cast  of  the 
larynx  and  trachea  may  be  coughed  up  or  torn  off.  The  swelling  of 
the  submucous  connective  tissue  in  the  region  of  the  ventricles  of 
Morgagni,  the  false  cords,  and  the  aryepiglottic  folds  may  give  rise  to 
marked  obstruction  to  the  breathing  space. 

The  formation  of  the  ]>seudo-niembrane  is  due  partially  to  the 
necrosed  epithelium,  and  partly  to  the  deposition  of  a  coagulable  serous 

Vol.  I.— 43 


674  DIPHTHERIA. 

exudate  upon  it.  This  is  thrown  out  gradually,  and  thus  may  be  formed 
in  several  layers. 

The  connective  tissue  of  the  mucous  membrane  is  hypera?mic  and 
infiltrated.  Sooner  or  later  the  epithelium  under  the  pseudo-membrane 
is  partly  or  completely  lost,  and  the  underlying  tissue  is  covered  instead 
with  a  network  of  fibrin  which  contains  more  or  less  partly  or  com- 
pletely degenerated  epithelial  cells  and  leucocytes. 

This  network  of  fibrin  frequently  extends  down  into  the  submucous 
tissues.  The  fibrinous  mass  may  be  composed  of  a  very  fine  reticulum 
of  fibrin  or  of  a  narrow  meshed  network  of  tolerably  thick  bands.  It 
may  either  contain  many  leucocytes  in  the  spaces  of  the  network  or  be 
mostly  devoid  of  cellular  elements.  The  superficial  layer  of  the  false 
membrane  is  frequently  found  early  in  the  disease  already  broken  down 
into  granular  detritus  and  permeated  by  masses  of  cocci  and  diphtheria 
bacilli.  The  degenerated  epithelium  usually  disappears  entirely  by  solu- 
tion or  desquamation,  but  isolated  vestiges  may  still  be  met  with  beneath 
the  membrane  when  the  epithelium  has  not  become  necrotic  in  its  whole 
thickness,  and  also  when  the  exudation  has  spread  over  adjoining  portions 
of  mucous  membrane  where  the  epithelium  has  not  degenerated.  The 
tissues  beneath  the  pseudo-membrane  are  always  more  or  less  the  seat  of 
small-celled  infiltration,  and  frequently  also  of  fibrinous  exudate  or 
hemorrhage.  The  bloodvessels  are  congested,  the  lymph  channels 
dilated  and  filled  with  fluid  rich  in  fibrin. 

If  the  necrosis  in  diphtheria  restricts  itself  to  the  epithelium,  healing 
Avill  take  place  without  the  formation  of  a  scar. 

The  necrosis  may,  however,  extend  to  the  connective  tissue,  in  which 
case  the  tissue  of  the  latter,  including  the  vessels,  may  be  entirely  de- 
stroyed. There  may  be  also  in  the  tonsils  and  adenoid  tissues  areas  of 
necrosis.  In  these  cases  a  depression  is  left  which  fills  up  with  gran- 
ulation or  cicatricial  tissue. 

Heart. — The  pathological  changes  in  the  heart  are  among  the  most 
important  lesions  in  severe  diphtheria.  Marked  parenchymatous  degen- 
eration of  the  heart  fibres  up  to  almost  complete  fatty  metamorphosis 
may  occur.  The  muscle  fibres  are  degenerated,  the  nuclei  are  broken 
down  or  have  disajjpeared,  and  the  fibres  themselves  cease  to  be  continu- 
ous. The  endothelium  of  the  vessels  is  swollen  and  the  leucocytes  are 
increased,  and  hemorrhages  may  be  present  between  the  muscle  fibres. 
These  alterations  are  only  marked  in  the  late  cases ;  in  those  quickest 
fatal  only  slight  parenchymatous  (changes  are  apparent.  The  valves  of 
the  heart  may  be  the  seat  of  fibrinous  deposits.  In  the  pericardium 
there  may  be  collections  of  serous  or  more  rarely  purulent  fluid. 

Kidneys. — In  most  severe  cases  the  kidneys  are  in  a  state  of  more  or 
less  acute  nephritis.  The  kidneys  are  usually  hypersemic  and  enlarged, 
more  rarely  anaemic.  The  capsule  is  commonly  non-adherent;  the  sur- 
face of  the  kidney  is  smooth,  and  is  frequently  the  seat  of  small  hemor- 
rhages. Upon  the  cut  surface  the  markings  are  indistinct  and  shoAV 
degenerative  parenchymatous  changes.  The  cortex  is  thickened  and 
reddish  gray  or  yellowish  gray  in  color.  Microscopically,  the  signs  of 
marked  parenchymatous  changes  are  evident  up  to  complete  necrosis  of 
the  epithelium  lining  the  tubules.  In  these  tubules  evidences  of  hemor- 
rhages and  casts  are  found.     The  epithelium  of  the  glomerular  capsules 


.vr.i//'7v>.i/.s'  (H-  i'u.\nYS(;i:.\L  i>ii'iiriii:i:i.[.  <;7.'> 

is  swollen  and  pml iterated,  and  the  vessels  of"  tlie  tufts  an;  e()m])ressed 
by  hcmorriiajies  and  exudates  into  tiie  eapsule.  The  endothelium  in  the 
walls  of  the  ki(hiey  vessels  is  found  proliferated  or  nnderj^oing  degenera- 
tion. Frequent  and  small  hemorriiages  oeeur  through  the  walls  of  tlie 
vessels.  In  severe  eases  tlic  urine  contains  ahundant  alhumin,  degen- 
erated kidney  epithelium,  leucocytes,  and  hyaline  easts,  and  in  the  most 
severe  coarse  and  fine  granular  casts.      Blo(^d  cells  are  infrequent. 

The  adenoid  tissue  of  the  spleen,  intestines,  and  lymphatic  glands 
shows  the  same  areas  of  increased  leucocytes  and  the  same  necrosis  and 
hyaline  degeneration  of  the  tissue  cells  as  are  found  in  the  kidneys  and 
other  organs. 

The  submaxillary  lymph  glands  are  enlarged,  often  hemorrhagic,  and 
may  even  be  the  seat  of  su})])uration.  The  lungs  in  cases  dying  of 
laryngeal  diphtheria  are  frequently  the  seat  of  areas  of  broncho-pneu- 
monia or  of  general  bronchitis.  Subpleural  ecchymosis  is  frequent,  and 
the  lungs  exhibit  areas  of  atelectasis  or  emphysema. 

Nervous  St/stem. — Paralyses  of  the  muscles  of  the  palate,  pharynx, 
heart,  and  voluntary  muscles  are  due  to  degeneration  of  the  peripheral 
nerves.  The  degeneration  extends  the  whole  length  of  the  affected 
nerves,  including  the  anterior  and  posterior  roots.  This  is  also  true  of 
the  phrenic  and  cranial  nerves.  Minute  hemorrhages  are  frequently  pres- 
ent in  the  nerves.     The  spinal  cord  and  brain  show  no  marked  lesion. 

Symptoms  of  Pharyngeal  Diphtheria. — 3Iild  Cases. — Those  in 
which  the  local  lesions  are  moderate  in  degree  and  in  which  the  constitu- 
tional symptoms  are  not  serious.  These  may  be  divided  into  two  classes. 
In  the  first  the  onset  is  sudden  ;  the  temperature  rises  to  103°  F.  in  the 
first  twelve  hours,  and  then  rapidly  falls,  so  as  to  reach  the  normal  one 
to  two  days  later.  With  the  rise  of  temperature  the  throat  symptoms 
develop.  The  mucous  membranes  appear  hyperseraic  and  congested,  and 
after  a  few  hours  more  or  less  extensive  patches  appear  on  the  swollen 
tonsils,  soft  palate,  pharynx  or  uvula.  The  loc^al  symptoms  increase 
for  twenty-four  hours,  and  then  remain  stationary.  With  the  rise  in 
temperature  and  the  local  signs  of  inflammation  there  are  rapid  pulse, 
loss  of  appetite,  and  some  prostration.  At  the  end  of  forty-eight  hours 
the  constitutional  symptoms  abate.  The  temperature  is  rarely  above 
101°  F.  The  pulse  may  still  be  rather  rapid,  but  is  regular  and  of  good 
force.  The  local  inflammation  subsides  in  from  three  to  seven  days, 
and  the  patient  is  fairly  well  except  for  a  slight  anaemia. 

In  the  second  class  the  throat  inflammation  develops  slowly.  There 
is  a  little  pain  on  swallowing.  The  glands  at  the  angle  of  the  jaw  are 
usually  a  little  swollen  and  the  throat  feels  sore.  Inspection  will  show 
slightly  swollen  tonsils,  with  follicular  deposits  of  exudate  or  small 
patches  of  pseudo-membrane.  The  temperature  is  not  elevated  more 
than  one  or  two  degrees  or  it  may  be  normal.  Except  for  slight  loss 
of  appetite,  restless  sleep,  and  slight  prostration  the  symptoms  are 
mainly  those  of  a  subacute  throat  inflammation.  The  exudate  may  be 
strongly  adherent,  so  that  it  can  only  be  removed  by  force,  or  it  may 
be  loosely  attached.  The  diphtheritic  deposit  remains  from  two  to  seven 
days,  and  then  recovery  is  established.  A  moderate  amount  of  ansemia 
persists  for  some  weeks.  Some  cases  in  either  of  these  two  types  may, 
instead  of  recovering,  suddenly  begin  to  extend  and  develop  into  the 


676  DIPHTHERIA, 

most  severe  type.  Even  in  these  mild  cases  slight  paralysis  may  occur 
up  to  three  weeks  after  apparent  recovery. 

Severe  Cases. — Here,  again,  two  extreme  types  of  invasion  are  noted. 
The  local  and  constitutional  symptoms  may  slowly  develop,  or  they  may 
become  fully  developed  within  the  first  twenty-four  to  forty-eight  hours, 
either  with  or  without  high  temperature.  In  exceptional  cases  a  chill 
is  the  first  symptom  noticed. 

The  mind  is  usually  clear,  although  in  the  worst  cases  mild  delir- 
ium or  stupor  may  develop.  The  mucous  membrane  of  the  pharynx 
and  tonsils  is  reddened  and  swollen.  The  uvula  may  be  oedematous, 
elongated,  and  greatly  swollen.  Portions  or  all  of  the  mucous  mem- 
brane of  the  tonsils,  the  pharynx,  and  the  soft  palate  are  covered  with 
more  or  less  thick  and  fibrinous  pseudo-membrane  of  a  grayish  color. 
The  glands  of  the  neck  and  their  adjacent  tissues  may  be  slightly  or 
markedly  swollen.  If  the  nasal  cavities  are  involved,  the  breathing  and 
voice  are  affected.  From  the  nose  flows  a  discharge  which  may  be  of  an 
intensely  irritant  character.  The  nasal  obstruction  may  be  partial,  in 
which  case  the  irrigating  fluid  passes  easily,  or  it  may  be  total,  so  that 
it  is  only  possible  to  force  fluid  through  the  nose  under  high  pressure. 

After  forty-eight  to  seventy-two  hours  the  fever,  if  present,  com- 
monly subsides.  In  favorable  cases  the  pulse  becomes  less  frequent, 
and  remains  of  fair  force  and  regularity.  The  appetite  improves  and 
the  intellect  remains  clear.  After  forty-eight  hours  the  local  symp- 
toms remain  stationary  from  the  third  to  the  fifth  day,  and  then  the 
swelling  subsides ;  the  membrane  begins  to  loosen  at  the  edges,  and  soon 
peels  off,  leaving  a  superficially  ulcerated  surface,  or  it  may  more  grad- 
ually melt  away.  The  glands  of  the  neck  decrease  in  size,  and  the 
jjatient  is  convalescent  and  certain  to  recover  unless  dangerous  par- 
alysis develops. 

In  other  cases  the  course  of  the  disease  is  unfavorable.  The  temper- 
ature may  fall  nearly  to  the  normal,  but  the  pulse  becomes  more  rapid, 
feeble,  and  irregular,  or  it  may  in  certain  toxic  cases  suddenly  for  a  time 
become  very  sIom^,  40  to  50  to  the  minute.  Before  death  the  heart's  ac- 
tion usually  becomes  more  irregular  and  rapid.  Other  patients  grow 
apathetic.  The  urine  is  apt  to  be  scanty  and  contain  albumin  and  casts. 
These  cases  may  suddenly  develop  ursemic  convulsions  and  die,  or  may 
gradually  waste  away.  Some  develop  a  persistent  nausea  and  vomit  all 
food.  Others  suffer  from  paralysis  of  deglutition  and  of  the  muscles 
of  respiration.  Still  others  seem  to  be  recovering  from  the  diphtheria 
when  the  symptoms  and  physical  signs  of  pneumonia  develop.  The 
temperature  then  rises  to  103°  or  104°  or  even  106°  F. 

In  other  cases  the  false  membrane  does  not  limit  itself  to  the  pharynx, 
but  spreads  to  the  larynx.  These  patients  then  have  added  the  special 
symptoms  due  to  obstruction  to  the  breathing.  Finally,  there  are  a 
group  of  cases  that  seem  to  die  as  if  from  gradual  systemic  poisoning  by 
toxin.  They  lose  weight,  become  pale  and  anaemic,  have  no  appetite, 
the  tongue  is  dry  and  coated,  and  they  gradually  sink  away. 

Malignant  Cases. — There  are  certain  cases  of  diphtheria  which  run  an 
especially  malignant  course  both  in  children  and  adults.  Within  twenty- 
four  hours  the  tonsils,  palate,  and  lateral  portions  of  the  pharynx  are 
covered  with  thick  membrane  and  are  enormously  swollen,  the  breath  is 


SYMPTOMS   OF  LMiyyOICAL    DlVUTllKlllA.  077 

sweetish,  the  saliva  dribbles  from  the  mouth,  the  uUmds  of  the  neck  and 
their  siirroiiiidinu'  (issues  are  g-reatly  swollen.  The  tt'uiperatiire  is  fre- 
(|ueutlv  but  slightly  elevated  or  it  may  be  subuoi-mal.  The  heart's  acti(jii 
is  rapid  :uul  feeble  or  it  may  be  very  slow  aud  irregular.  'I'he  intellect,  at 
first  clear,  becomes  cloudy.     Within  three  to  live  days  the  most  robust  die. 

Another  class  of  malignant  cases  are  the  so-called  septic  cases.  The 
amount  of  local  swelliuii:  and  exudate  on  the  tonsils  and  palate  may  not 
be  very  extensive,  but  it  is  of  a  dirty,  oauu-renous  appearance.  If  the 
nostrils  are  invaded,  there  is  a  bad-smell int;-,  thin  discharge. 

The  temperature  runs  a  hi.uh,  irregular  course  from  103°  to  106°  F. 
The  tongue  is  dry  and  coated  and  the  appetite  is  poor.  The  glands  of 
the  neck  are  moderately  or  greatly  swollen.  The  extremities  are  cool, 
the  pulse  is  rapid  and  feeble.  Pneumonia  or  su])puration  of  the  middle 
ear  frequently  develops.  With  an  irregular  high  temperature  the  chil- 
dren become  more  and  more  apathetic  until  death  usually  supervenes. 

Symptoms  of  Laryngeal  Diphtheria. — The  symptoms  in  laryn- 
geal diphtheria  differ  somewhat  according  as  to  whether  the  process  is  a 
primarv  one  or  is  an  extension  of  a  pharyngeal  diphtheria  to  the  larynx. 
In  the  first  case  laryngeal  symptoms  are  added  to  those  already  present. 

In  larvngeal  diphtheria  the  symptoms  are  those  due  both  to  the 
absorption  of  the  poison  of  diphtheria  and  to  the  mechanical  obstruc- 
tion of  the  larynx.  The  obstruction  occurs  more  quickly  in  children 
than  in  adults. 

The  symptoms  may  develop  slowly  ;  the  child  complains  of  a  sore 
throat,  of  a  little  hoarseness,  has  loss  of  appetite  and  slight  fever.  There 
may  be  a  dry,  hard  cough.  In  some  within  twelve  to  twenty-four  hours 
the  hoarseness  becomes  marked,  the  breathing  is  somewhat  obstructed,  the 
temperature  reaches  100°  to  103°  F.,  and  the  child  is  restless.  Soon,  un- 
less relief  is  given  or  the  process  subsides,  the  symptoms  of  laryngeal 
obstruction  are  fully  developed.  The  respiration  is  noisy ;  inspiration 
and  expiration  are  labored  and  prolonged.  Cyanosis  is  developed,  and 
there  is  marked  recession  of  the  soft  parts  of  the  chest  in  the  epigastric 
and  jugular  regions.  The  accessory  muscles  of  respiration  are  called 
into  action  and  the  chest  is  held  expanded.  In  spite  of  every  exertion 
inspiration  and  expiration  are    insufficient. 

At  short  intervals  the  child  will  sink  back  as  if  exhausted,  the 
breathing  is  feebler,  and  for  a  moment  or  two  the  child  dozes,  only  to 
awaken  again  to  struggle  for  air.  It  throws  itself  about  the  bed — lies 
first  on  one  side,  then  on  the  other.  Until  cyanosis  is  marked  the  intel- 
lect may  be  clear.  Frequent  desire  to  urinate  is  manifested,  which  adds 
to  the  distress  of  the  child.  As  the  obstruction  increases  attacks  of 
almost  complete  suffocation  take  place  ;  the  child  struggles  violently  for 
air,  sitting  up  and  using  all  its  powers.  After  a  time  respiration  may 
become  freer,  and  the  child  sinks  back  only  to  have  renewed  spasms 
later.  Sooner  or  later  it  becomes  exhausted  ;  the  breathing  becomes 
more  and  more  feeble ;  the  extremities  are  cold  and  the  skin  is  of 
cadaveric  hue.  Death  follows  from  an  attack  of  suffocation  or  slowly 
by  asthenia.  The  duration  of  life  in  fatal  cases  is  usually  from  two 
to  seven  days  when  operative  relief  is  not  given. 

In  purely  laryngeal  cases,  when  operative  relief  is  not  given  and 
death  results  early,  the  temperature  frequently  remains  but  little  ele- 


678  IHPIITIIKRTA. 

vated,  although  in  a  few  it  may  reach  103°-104°  F.  If,  on  the  other 
hand,  the  kings  are  involved,  the  temperature  is,  as  a  rule,  elevated 
to  102°  or  104°,  or  exceptionally  106°,  F. 

After  intubation  or  tracheotomy  the  temperature  frequently  rises,  in 
the  more  severe  cases,  within  twelve  hours  to  102°-104°  F.  When 
operative  relief  is  attained  the  breathing  becomes  natural,  mucus  and 
shreds  of  membrane  are  coughed  out,  and  the  child  sinks  back  to  sleep. 
In  a  portion  of  the  cases  the  relief  is  permanent,  and  the  patient 
progresses  uninterruptedly  to  recovery.  In  others  the  symptoms  of 
obstruction  again  appear,  while  in  still  others  a  secondary  pneumonia 
develops  to  delay  convalescence  or  cause  death. 

Symptoms  of  Diphtheria  in  Detail. —  General  Condition. — 
There  are  a  moderate  number  of  cases  having  very  limited  patches 
of  pseudo-membrane  in  which  no  appreciable  symptoms  of  constitu- 
tional poisoning  show  themselves.  They  are  mostly  discovered  be- 
cause of  their  association  with  more  marked  cases.  Even  mild  cases 
show  loss  of  appetite  and  of  the  desire  for  work  or  play.  They  become 
more  or  less  pale  and  anaemic.  The  more  grave  cases  soon  exhibit 
severe  constitutional  effects.  They  soon  have  marked  prostration,  are 
restless  or  apathetic,  or  both  by  turns.  If  they  live  long  enough,  they 
become  emaciated.  The  sleep  is  uneasy.  In  septic  cases  mild  delirium 
or  stupor  may  develop.  These  cases  give  the  impression  of  being  very 
dangerously  ill. 

Temperature. — The  cases  differ  greatly.  Many,  both  mild  and  severe, 
begin  with  a  temperature  of  102°  to  104°  F.  In  the  great  majority  the 
fever  subsides,  and  even  in  the  most  severe  uncomplicated  cases  the 
temperature  is  apt  to  range  from  98°  to  101°  after  the  first  forty-eight 
hours.  Some,  severe  from  the  start,  have  a  normal  or  even  subnormal 
temperature. 

A  certain  proportion  of  septic  cases,  and  all  having  a  complicating 
pneumonia,  develop  a  high  temperature.  Other  complications,  such  as 
otitis  or  the  development  of  an  abscess,  will  cause  elevation  of  temperature. 

A  rise  of  temperature  to  103°-104°  F.  in  a  case  of  laryngeal  diph- 
theria indicates  usually  a  beginning  bronchitis  or  pneumonia. 

Nervous  System. — In  the  mild  cases,  except  for  a  certain  amount  of 
apathy,  no  symptoms  are  present ;  in  the  more  severe,  there  may  be 
also  observed  the  general  symptoms  of  mild  delirium,  restlessness,  and 
rarely  convulsions ;  also,  apathy  and  stupor  in  the  severest  cases. 

Cireulatory  Apparatus. — In  mild  cases  the  pulse  is  frequent,  and 
perhaps  slightly  irregular.  In  bad  cases  it  may  be  very  frequent^ 
120-160,  and  weak.  The  force  of  the  heart  apex  beat  is  diminished 
and  the  sounds  indistinct.  After  the  third  or  fourth  day  the  rapid 
pulse  may  suddenly  become  markedly  slowed.  From  120  it  may  fall 
as  low  as  45  or  50.  It  is  irregular  and  varies  in  force.  This  is  an 
extremely  grave  symptom.  After  twenty-four  to  forty-eight  hours,  if 
the  patient  lives,  the  pulse  is  apt  to  again  become  rapid  and  feeble,  and 
so  remain  until  death. 

Digestive  System. — In  the  mildest  cases  there  is  little  digestive  dis- 
turbance, but  in  those  of  any  severity  loss  of  appetite  is  noted.  In  the 
worst  toxic  cases  no  food  at  all  may  be  retained.  The  bowels  are  not, 
as  a  rule,  affected. 


COMPLICATIONS   OF  DIl'lITIir.mA.  079 

Tlw  Urine. — In  the  mildest  cases,  usually  no  all)iimin  is  found  in 
the  urine,  but  exceptionally,  after  the  third  or  fourth  day,  it  may  aj)pear. 
in  the  more  severe  cases  casts,  kidney  detritus,  and  large  quantities  <)f 
albumin  are  usually  present.  In  the  worst  cases  partial  or  total  suj)- 
pression  of  urine  is  apt  to  occur.  These  may  later  develop  uraemic 
symptoms. 

Lymph  (rlands. — The  lymphatic  glands  in  the  neck  are  usually 
somewhat  enlarged.  In  the  more  septic  cases  they  may  become  enor- 
mously swollen.     Suppuration  is  rather  infrequent. 

Skin. — A  small  percentage  of  cases  develop  a  general  erythema,  which 
niav  resemble  scarlet  fever  or  measles.  An  urticaria  may  also  appear. 
In  severe  and  septic  cases  hemorrhages  occur  in  the  skin  as  well  as  in 
the  mucous  membranes. 

Joints. — The  joints,  except  in  septic  cases,  are  very  seldom  affected 
in  diphtheria. 

CoMPLiCATroxs  OF  DIPHTHERIA. — Pneumonia. — The  most  feared 
complication  of  laryngeal  diphtheria  is  broncho-pneumonia.  In  pharyn- 
geal diphtheria  it  occurs  but  seldom.  It  may  develop  within  twenty- 
four  hours  or  it  may  not  occur  till  convalescence  is  established.  In 
these  a  little  fever  remains,  and  the  lungs  give  the  signs  of  a  mode- 
rate bronchitis.  The  temperature  then  slowly  or  quickly  rises  and 
the  respirations  become  more  rapid.  Physical  examination  shows  be- 
ginning broncho-pneumonia,  perhaps  in  one  or  both  lower  lobes  be- 
hind, or,  again,  in  disseminated  areas  throughout  both  lungs.  In  these 
cases  the  pneumonia  is  apt  to  run  a  subacute  but  progressive  course. 
After  one  to  three  weeks  the  child  succumbs  to   exhaustion. 

Heart  Failure. — From  the  beginning  of  the  separation  of  the  mem- 
brane until  well  into  the  fifth  week  all  severe  cases  are  in  danger  of 
heart  failure.  When  this  symptom  is  threatening  the  patient  is  pale 
and  the  pulse  is  small  and  irregular.  It  is  usually  rapid  and  weak  or 
verv  slow  and  irregular,  40—50.  The  extremities  are  cold.  The  mind 
remains  clear  and  anxious.  The  attack  may  pass  off  or  the  pulse  may 
be  lost :  the  patient  loses  consciousness  and  death  comes  gradually. 
Others,  apparently  well,  suddenly  become  unconscious,  and  die  almost 
instantaneously  of  heart  failure. 

Paralysis. — This  is  one  of  the  most  characteristic  symptoms  of  diph- 
theria. Frequently  with  the  final  separation  of  the  membrane,  but  also 
often  after  weeks,  paralysis  develops  in  the  muscles  of  the  soft  palate,  less 
frequently  in  those  of  deglutition,  of  the  eye,  of  the  respiratory  organs, 
or  finally  of  groups  of  muscles  throughout  the  body.  AVhen  the  palate 
is  affected  speech  is  nasal  and  fluids  regurgitate  into  the  nostrils.  When 
the  muscles  of  accommodation  are  affected,  the  child  cannot  read  and 
the  pupils  do  not  react.  When  the  voluntary  muscles  in  general  are  af- 
fected the  patient  may  be  completely  helpless.  As  a  rule,  complete  recov- 
ery takes  place  within  from  three  to  eight  weeks,  but  in  the  worst  cases 
marked  atrophy  occurs  and  months  elapse  before  recovery  takes  place. 

Relapses. — In  a  small  number  of  cases,  after  partial  or  complete 
disappearance  of  the  membrane,  a  slight  recurrence  results.  With  the 
exudate's  appearance  the  temperature  may  rise  and  the  glands  of  the 
neck  become  swollen.  As  a  rule,  the  lesions  clear  up  in  a  few  days. 
The  lymphatic  glands  may  remain  slightly  enlarged  for  weeks  or  months. 


680  DIPHTHERIA. 

The  only  cases  in  which  a  relapse  is  serious  are  the  laryngeal  ones.  A 
relapse  may  occur  as  late  as  the  fourth  week. 

Diagnosis  of  Diphtheria. — In  deciding  whether  a  doubtful  case 
is  one  of  diphtheria  or  not  it  is  necessary  to  take  into  account  whether 
the  patient  has  been  exposed  to  diphtheria,  to  scarlet  fever,  or  to  other 
infectious  diseases. 

If  in  any  case  exposure  to  diphtheria  is  known  to  have  occurred,  even 
a  slightly  suspicious  sore  throat  must  be  regarded  as  probably  a  mild 
diphtheria.  If,  on  the  other  hand,  no  cases  of  diphtheria  have  been 
known  to  exist  in  the  neighborhood,  even  cases  of  a  very  suspicious 
nature  would  probably  not  be  diphtheria. 

In  judging  from  the  appearance  and  symptoms  of  a  case  one  must 
first  acknowledge  that  there  are  certain  mild  exudative  inflammations  of 
the  throat  ])elonging  both  to  diphtheria  and  pseudo-diphtheria  which 
appear  exactly  alike,  have  similar  symptoms,  and  similar  duration.  It 
is  even  possible  to  examine  two  cases,  knowing  that  one  is  surely  diph- 
theria and  the  other  surely  is  not,  and  yet  be  unable  to  determine  which 
is  true  diphtheria  and  which  is  pseudo-diphtheria.  It  is  not  meant  to 
imply  that  a  case  is  one  of  true  diphtheria  simply  because  the  diphtheria 
bacilli  are  present,  but  rather  that  the  doubtful  cases  not  only  have  the 
diphtheria  bacilli  in  the  exudate,  but  are  capable  of  giving  true  charac- 
teristic diphtheria  to  others,  or  later  developing  it  themselves ;  and  that 
those  in  whose  throats  no  diphtheria  bacilli  exist  can  under  no  conditions 
give  true  characteristic  diphtheria  to  others  or  develop  it  themselves. 
It  is  indeed  true,  as  a  rule,  that  cases  presenting  the  appearance  of  ordi- 
nary follicular  tonsillitis  in  adults  are  not  diphtheria.  It  is  also  true 
that  now  and  then  a  case  having  this  appearance  is  one  of  diphtheria, 
and  almost  every  physician  has  seen  such  cases  from  time  to  time  in 
households  infected  with  diphtheria.  On  the  other  hand,  in  small  chil- 
dren mild  diphtheria  very  frequently  occurs  with  the  semblance  of  ordi- 
nary follicular  tonsillitis,  and  in  large  cities  where  diphtheria  is  prevalent 
all  such  cases  must  be- regarded  as  more  or  less  suspicious. 

Appearances  Characteristic  of  Dijjhtheria. — The  presence  of  irregular 
shaped  patches  of  adherent  grayish  or  yellowish  gray  pseudo-membrane, 
especially  if  they  are  on  some  other  ]3ortions  than  the  tonsils,  is,  as  a 
rule,  diagnostic  of  diphtheria. 

Occasionally  in  scarlatinal  angina  or  in  any  severe  phlegmonous  sore 
throats  patches  of  exudate  may  appear  on  the  uvula  or  borders  of  the 
faucial  pillars,  and  still  the  case  may  not  be  one  of  true  diphtheria ;  these 
are,  however,  exceptional.  Thick  grayish  pseudo-membranes  which 
<!Over  large  portions  of  the  tonsils,  soft  palate,  and  nostrils  are  almost 
invariably  the  lesions  of  true  diphtheria. 

The  majority  of  cases  of  pseudo-membranous  laryngitis,  whether  an 
exudate  is  present  in  the  pharynx  or  not,  are  cases  of  true  diphtheria. 
Nearly  all  cases  in  which  membrane  is  present  in  the  nose  are  true  diph- 
theria. Where  the  membrane  is  limited  to  the  nose  the  symptoms  are, 
as  a  rule,  very  slight. 

Most  cases  of  pseudo-membranes  and  exudates  entirely  confined  to  the 
tonsils  in  adults  are  not  diphtheria,  although  a  few  cases  presenting  these 
symptoms  are.  Cases  presenting  the  appearances  found  in  scarlet  fever, 
in  which  a  thin  grayish  membrane  lines  the  borders  of  the  uvula  and 


pr{(>(;\()sis  or  i>ii'irriii:i:iA.  081 

fiiucial  j)illars,  arc  rarely  diplitliurilic.  As  a  rule,  pst'iidd-incnibrancMtus 
inHaiMiuatitms  (■(miplicatinn:  scarli-t  IV-vci-  and  otlicr  intcc-tiou.s  diseases 
are  not  diphtheria.  But  from  time  to  time  such  cases,  if  they  have  been 
exposed  to  diphtheria,  may  he  (;omplieated  by  it. 

Tin'  K.viuUifc  III  hijihtlicrKi  contr<isf('<1  irifli  f/mf  in  P.s<ii(l()-(lijj/illi(/-i(i. 
— As  a  rule,  the  exiuhite  in  dij)htheria  is  firmly  incorjioratccl  with  the 
underlyiiio-  mtieous  memi)rane,  and  eaiuiot  be  removed  without  Icavinjj^ 
a  bleedinu"  surface,  at  least  until  convalescence.  The  tissues  surrounding 
the  exudate  are  more  or  less  inHamed  and  swollen.  In  ])sendo-diph- 
theria  the  exudate  is  usually  loosely  attached,  collected  in  small  masses, 
and  easily  removable.  Exceptions,  however,  occur  in  both  these  diseases, 
so  that  in  true  diphtheria  the  exudate  may  be  easily  removed  and  in 
pseudo-diphtheria  the  exudate  may  l)e  firmly  adherent.  It  is  therefore 
impossible  to  make  diagnosis  certain  from  the  adherence  of  the  exudate 
to  the  mucous  membrane. 

The  occurrence  of  albuminuria  with  casts  may  enal)le  a  probable 
diagnosis  of  diphtheria  to  be  made.  This  may  aid  both  in  a  case  in 
Avhicli  the  jnemiirane  is  in  a  part  removed  from  observation  or  in  one 
already  convalescent.  Some  pseudo-membranous  inflammations  Avhich 
are  not   diphtheria  give  rise  to  nephritis  and  albuminuria. 

Paralysis  following  a  pseudo-membranous  inflammation  is  an  almost 
positive  indication  that  the  case  was  one  of  diphtheria. 

Peooxosis  of  Diphtheria. — Diphtheria  is  one  of  the  most  dif- 
flcult  of  diseases  in  which  to  make  prognosis.  A  case  which  in  the 
first  twenty-four  hours  seems  mild  may  steadily  increase  in  extent  and 
severity  until  it  ends  fatally.  A  case  seemingly  convalescent  may  sud- 
denly develop  heart  paralysis.  Laryngeal  diphtheria  is  especially  apt 
to  be  complicated  by  pneumonia. 

In  the  smaller  cities  epidemics  vary  greatly  in  their  severitv  from 
year  to  year.  In  the  largest  cities,  however,  there  are  praeticallv  alwavs 
a  number  of  epidemics  going  on  all  the  time,  and  the  average  severitv 
for  the  whole  city  does  not  vary  so  much.  Age  has  a  very  marked  influ- 
ence on  mortality. 

The  sjiecial  dangers  to  be  feared  in  diphtheria  are  the  invasion  of  the 
larynx,  the  development  of  broncho-pneumonia,  serious  paralysis,  espe- 
cially of  the  heart  and  respiratory  muscles,  sepsis,  and  nephritis. 

The  following  division  of  the  cases  of  true  diphtheria,  based  on  the 
extent,  character,  and  location  of  the  pseudo-membrane  or  exudate,  after 
sufficient  time  has  elapsed  for  the  development  of  the  local  lesions,  has 
seemed  to  me  to  be  of  considerable  value  in  prognosis  : 

(1)  Cases  in  which  the  ])seudo-membranes  are  very  extensive,  thick, 
and  firmly  incorporated  with  the  underlying  swollen  mucous  membrane. 
In  these  the  constitutional  symptoms  are  marked,  the  mortality  at  all 
ages  is  large,  and  the  danger  of  paralysis  great. 

(2)  Cases  in  which  the  development  of  the  pseudo-membranes  is 
largely  confined  to  the  larynx  and  bronchi.  This  form  occurs  mostlv 
in  young  children,  is  very  fatal  at  all  ages,  and  apt  to  be  complicated 
by  bronchitis  or  pneumonia. 

(3)  Cases  in  which  the  pseudo-membrane  is  moderate  in  amount, 
involving  the  tonsils  and  irregular  portions  of  the  uvula  and  soft 
palate.     These  often  have  marked  constitutional  and  local  symptoms 


682  DIPHTHERIA. 

for  a  few  days,  but  nearly  always  recover  except  in  very  young  chil- 
dren. 

(4)  Cases  in  which  the  pseudo-membrane  or  exudate  is  confined  to 
the  tonsils.  These  resemble  those  in  the  third  division,  but  the 
symptoms  are  less  marked.    They  all  recover  unless  complications  exist. 

(5)  Cases  in  which  very  little  or  no  exudate  is  ever  present,  the 
mucous  membrane  being  simply  slightly  swollen  and  hypersemic.  These 
have  usually  slight  syraj^toms  and  recover,  but  are  important  to  diagnose, 
as  they  may  infect  others. 

(6)  Cases  of  pseudo-membranes  confined  throughout  their  course  to 
the  nose.  These  occur  chiefly  in  young  children.  The  constitutional 
symptoms  are  slight,  and  all  so  far  recorded  have  recovered.  These 
cases  are  seldom  met  with. 

(7)  Exudates  or  pseudo-membranes  confined  to  the  eyelids,  skin, 
rectal,  and  vaginal  mucous  membranes.  The  cases  confined  to  the  first 
two  locations,  as  a  rule,  present  few  constitutional  symptoms  if  the  throat 
is  unaffected.  When  the  rectum  and  vagina  are  attacked  the  severity 
of  the  symptoms  will  depend  on  the  extent  of  the  lesions. 

Though  the  association  of  streptococci  and  other  bacteria  with  the 
Klebs-L5ffler  bacilli  undoubtedly  influences  the  local  and  general  symp- 
toms, yet,  as  far  as  can  be  judged  from  cultures,  they  have  little  influence 
on  the  mortality.  In  the  shape  and  size  of  the  Loffier  bacilli  I  found 
no  constant  differences  which  could  be  utilized  for  prognosis. 

Treatment  of  Diphtheria. — Prophylaxis. — The  patient  ill  with 
diphtheria  is  to  be  isolated  as  far  as  circumstances  permit.  Wherever 
possible  he  should  have  a  separate  room.  Those  who  care  for  the  sick 
should  wear  a  special  outer  garment.  Before  leaving  the  room  this 
gown  should  be  thrown  off  and  the  hands  carefully  washed  and  rinsed 
with  an  antiseptic  solution. 

The  patient  should,  when  old  enough,  expectorate  into  some  recepta- 
cle containing  a  disinfectant.  Everything  soiled  by  the  mouth  dis- 
charges should  be  disinfected  by  soaking  in  some  disinfectant  solution, 
by  boiling,  or  by  burning.  The  throat  secretions  are  to  be  considered 
dangerous  until  at  least  three  weeks  after  the  beginning  of  the  attack. 

Wherever  possible  the  disappearance  of  the  diphtheria  bacilli  should 
be  established  by  the  bacteriological  examination  of  cultures.  At  the 
conclusion  of  the  illness  the  bedding  and,  where  possible,  the  carpets 
should  be  disinfected  by  steam,  and  the  furniture,  floor,  and  walls  wiped 
off  with  a  1  :  500  solution  of  bichloride  of  mercury.  Finally,  it  is  well 
to  burn  3  pounds  of  sulphur  to  each  1000  cubic  feet  of  air  space  in  the 
patient's  room. 

The  disposal  of  the  apparently  healthy  members  of  an  infected 
family  is  a  matter  of  great  importance.  They  frequently  have  already 
become  infected  before  the  first  case  is  diagnosticated,  and  if  sent  away 
they  may  carry  the  disease  to  the  children  in  the  families  which  they 
visit.  It  is  wise,  therefore,  not  to  send  them  away,  unless  they  have 
not  been  exposed  to  the  one  taken  sick,  and  only  then  to  places  where 
there  are  no  children.  All  those  who  have  been  exposed  or  expect  to 
be  exposed  should  receive  a  moderate  injection  of  antitoxin  as  a  pre- 
ventive, 100  to  300  units  (see  page  703)  according  to  age.  It  is  well 
also  to  frequently  gargle  the  throat  and  cleanse  the  nostrils  with   some 


TREATMKST  OF   ]>I I'llTII IlIUA. 


083 


mild  clciiiisin^  solution,  siidi  :is  Dohdl's,  oi-  a  weak  disinfectant,  siidi 
a.s  1  :  10,000  atiiU'oiis  solution  of  hicliloridc  of  nuTcnrv.  ,Vn  imnHiiii/- 
inj;  dose  of  antitoxin,  tojxotiier  with  the  fre(|nent  cleansint.''  of  the  thnnit, 
will  practically  ensure  an  iinmunity  from  diphtheria. 

Local  Treatment. — If  one  could  destroy  the  diphtheria  bacilli  at  a 
time  when  they  are  localized  to  one  spot  of  mucous  membrane,  the  dis- 
ease miirht  be  at  once  aborted  and  its  extension  to  distant  ]»arts  mi^iht 
be  prevented. 

Many  clinicians  of  great  experience  in  the  treatment  of  diphtheria 
have  advised  various    methods  to  accomjdish   this    desired  residt,   but 

Fig.  49. 


Position  of  child  during  irrigation. 


personally  I  believe  that  their  success  must  always  be  limited,  and  for 
the  followino;  reasons  :  The  diphtheria  bacilli  are  not  limited  to  the 
£,exact  spot  where  the  pseudo-membrane  has  developed.  They  are  pres- 
ent in  the  throat  secretion,  bathing  all  parts  of  the  pharynx  and  tonsils 


684  DIPHTHERIA. 

before  even  tlie  local  lesions  are  manifest.  Lying  thus  in  the  crypts  • 
and  recesses  of  the  parts,  they  are  not  all  killed  by  such  antiseptic  fluids 
as  are  attempted  to  be  applied  to  them.  Further,  at  those  places  where 
local  lesions  are  apparent  the  bacilli  are  already  present  lieneath  the 
superficial  layers  of  membrane,  and  cannot  be  directly  influenced  by 
antiseptic  fluids. 

If  the  bacteria  were  upon  a  dead  surface,  we  could  kill  them,  but  to 
destroy  tliem  without  injuring  the  living  epithelium  is  a  very  different 
undertaking.  Just  a  year  ago  a  series  of  experiments  were  carried  out 
by  the  resident  physicians  of  the  jN'ew  York  Hospital  for  Contagious 
Diseases  (Drs.  White  and  Somerset)  to  test  the  comparative  value  of 
irrigating  the  nose  and  throat  with  simple  cleansing  solutions  and  with 
disinfectants  (1  :  4000  bichloride  of  mercury  and  5  to  10  volume  solu- 
tions of  peroxide  of  hydrogen).  After  a  pretty  thorough  trial  it  was 
very  difficult  to  see  more  than  a  trifling  advantage  in  the  antiseptic 
solutions. 

If  we  attempt  to  kill  the  bacilli  by  caustics  or  actual  cautery,  we  are 
apt  to  injure  the  tissues  without  killing  all  of  the  bacteria,  so  doing  prob- 
ably more  harm  than  good.  I  believe,  therefore,  that  we  should  not  use 
any  treatment  which  will  irritate  or  lacerate  the  mucous  membrane.  I 
believe  that  no  swab  should  be  used  to  make  applications  to  the  mucous 
membrane  unless  it  is  done  by  the  physician  or  by  a  trained  nurse,  and 
only  then  with  the  greatest  care.  Personally  I  prefer  to  trust  to  irriga- 
tion. For  the  nostrils  I  prefer  a  simple  tepid  salt  solution.  This  is 
best  applied  through  the  fountain  syringe.  If  the  nostrils  are  so  firmly 
plugged  that  great  pressure  is  needed,  then  an  ordinary  hard-rubber 
syringe  can  be  used.  To  its  point  is  attached  a  short  rubber  tube,  end- 
ing in  a  bulb  to  fit  the  nostrils.  The  force  needed  may  be  very  great, 
but  the  shock  is  of  less  harm  than  the  continued  total  occlusion  of  the 
nostrils  with  the  probable  production  of  sepsis. 

When  the  local  lesions  of  diphtheria  are  limited  to  the  tonsils,  irri- 
gation of  the  nostrils  is  unnecessary,  but  when  the  posterior  nares  are 
involved,  the  nostrils  should  be  irrigated  three  to  six  times  a  day. 
Even  weak  solutions  of  peroxide  of  hydrogen  are  often  very  irritating 
to  the  nasal  mucous  membrane.  Great  care  should  be  taken  if  it  is 
thought  desirable  to  use  this  substance  in  the  nostrils.  For  the  irriga- 
tion of  the  mouth  and  pharynx  either  a  normal  salt  solution  or  a 
1  :  4000  bichloride  of  mercury  or  a  five-volume  peroxide  of  hydrogen 
solution  may  be  employed.  If  antiseptic  solutions  are  used  small  blunt- 
pointed  glass  or  rubber  syringes  are  employed. 

In  older  children  and  adults  the  cleansing  and  soothing  effects  of  irri- 
gation are  often  marked.  In  these  cases  I  prefer  to  use  irrigation  with 
warm  salt  solution  every  hour  or  two,  and  then  every  three  to  six  hours 
to  irrigate  with  some  antiseptic  solution,  especially  a  1  :  1000  bichloride 
solution.  The  irrigation  of  the  throat  is,  as  in  the  case  of  the  nostrils, 
best  carried  out  by  the  fountain  syringe.  In  young  children  the  irriga- 
tion of  the  nose  and  throat,  either  with  simple  salt  solution  or  with  an- 
tiseptics, every  few  hours,  is  of  great  service  unless  they  struggle 
against  it.  Such  cases  to  be  handled  properly  need  the  greatest  amount 
of  good  judgment. 

When  the  strength  is  good  and  the  nostrils  and  pharynx  are  full  of 


TREATMEXT  OF  J.ARYSfn-.AL    DTPJTTTTKnrA.  085 

discharge  and  niemUrano,  it  is  well  to  insist  on  flcansin<r  hv  irrijxation. 
When,  however,  tlie  child  is  much  prostrated,  and  strug<^les  a<:;ainst  it, 
irrigation  may  have  to  be  omitted. 

The  ,e:ivinf>:  internally  of  the  tincture  of  the  chloride  of  iron  or  of 
the  bichloride  of  mercury  in  small  fre(|uent  doses  lias  considerable  local 
effect  upon  tlu>  niucoiis  membranes  of  the  throat  and  pharynx. 

In  hospital  cases  the  irrigation  of  the  nostrils  witli  salt  water,  1  per 
cent,  boric  acid  solution  or  1  :  4000  bichloride  solution,  has  not  appeared 
to  cause  ear  trouble.  Indeed,  suppuration  of  the  middle  ear  has  been 
rather  less  frequent  when  this  method  was  employed. 

General  Trcatmcni. — The  air  in  the  patient's  room  should  be  as  pure 
as  possible  and  kept  at  a  temperature  of  70°— 72°  F. 

The  treatment  of  diphtheria  by  antitoxin  will  be  considered  later 
(page  692). 

The  drugs  suggested  for  the  treatment  of  diphtheria  have  been  num- 
berless, but  few  of  them  have  proved  themselves  as  of  use  generally. 
At  the  New  York  Hospital  for  Contagious  Diseases  mild  cases  are 
given  an  abundance  of  light  diet,  milk,  broth,  eggs,  etc.,  and  a  dose 
of  1000  units  of  antitoxin.  This  and  the  local  treatment  is  all  they 
receive.  ]More  severe  cases  are  given  brandy  from  half  an  ounce  to 
twelve  ounces  in  the  twenty-four  hours,  according  to  the  severity  of  the 
disease  and  the  amount  of  prostration  and  the  weakness  of  the  heart 
action.  In  these  severe  cases  and  in  any  where  paralysis  threatens, 
strychnine  is  given  three  times  a  day  in  doses  of  -^-q  to  yto  grain.  As 
the  patients  begin  to  convalesce  they  are  given  the  carbonate  or  albu- 
minate of  iron  as  a  tonic  if  they  show  much  anaemia. 

A  complicating  pneumonia  is  treated  as  it  is  when  present  in  other 
conditions. 

The  antipyretics  are  to  be  avoided,  because  of  their  depressant  effect, 
and  also  because  the  temperature  is,  as  a  rule,  not  seriously  high  in 
diphtheria. 

The  tincture  of  the  chloride  of  iron  in  moderate  doses  may  be  of 
benefit,  both  locally  and  for  its  tonic  effect,  though  if  it  causes  nausea  or 
vomiting  it  should  be  stopped.  Large  doses  do  not  appear  to  have 
any  more  beneficial  effect  than  small,  and  are  more  apt  to  cause  irrita- 
tion of  the  stomach.  The  internal  administration  of  bichloride  of  mer- 
cury has  not  seemed  to  me  to  be  of  any  great  value.  Good  observers 
advocate  small  doses  of  quinine.  I  myself  have  had  but  little  experi- 
ence with  its  use. 

AVhenever  paralysis  of  the  muscles  of  deglutition  has  become  suf- 
ficiently marked  to  prevent  the  swallowing  of  food,  it  is  necessary  to 
feed  through  a  soft-rubber  tube  passed  through  the  nose  to  the  pharynx 
and  cEsophagus. 

Teeatmext  of  Laryngeal  Diphtheria. — For  the  relief  of 
obstruction  in  laryngeal  diphtheria  there  is  the  inhalation  of  the 
fumes  of  suljliming  calomel,  the  inhalation  of  warm  steam  with  or 
without  lime  or  other  additions,  the  application  of  warmth  or  cold  over 
the  larynx,  and  the  use  of  medicines  internally,  especially  those  causing 
nausea  or  vomiting. 

The  first  two  are  the  most  important  means  of  combating  the  begin- 
ning laryngeal  obstruction. 


DIPHTHERIA. 

Calomel  Fumigation. — This  was  first  advocated  by  Corbin  in  1881, 
and  has  since  been  extensively  used.  The  inhalation  of  subliming 
calomel  does  not,  as  some  claim,  destroy  the  diphtheria  bacilli,  but  it 
does  apparently,  in  some  cases,  greatly  relieve  the  obstruction  with  its 
accompanying  symptoms.  This  so  often  follows  each  employment  of  it 
that  there  seems  no  doubt  of  its  action.  It  does  not,  however,  afford 
relief  in  all  cases,  even  when  used  very  early. 

The  method  of  employing  calomel  fumigation  varies  with  the  appa- 
ratus at  hand.  The  child  should  be  put  in  an  im])rovised  tent  so  as  to 
confine  the  fumes  sufficiently  to  fill  the  tent  with  a  rather  dense  white 
smoke.  Ten  to  twenty  grains  can  be  thrown  on  a  few  live  coals  placed 
on  a  shovel  and  held  under  the  tent  while  it  sublimes,  or  a  lump  of  live 
coal  may  be  put  in  an  iron  or  earthenware  vessel  and  over  it  a  strip  of 
iron  or  an  iron  spoon  upon  which  the  calomel  is  placed.  In  the  larger 
cities  a  suitable  apparatus  can  be  bought  ready  for  use,  M^hich  is,  of 
course,  more  convenient. 

Steam. — The  inhalation  of  warm  steam  is  certainly  at  times  of  great 
benefit.  To  the  water  may  be  added  equal  parts  of  lime  water,  or  to 
each  pint  one  or  two  teaspoonfuls  of  compound  tincture  of  benzoin. 
The  warm  damp  vapor  is  the  chief  thing.  The  steam  should  be  inhaled 
as  warm  as  possible,  and  the  patient  is  protected  from  the  damj^ness  by 
a  covering  of  oil,  muslin,  or  a  thin  blanket. 

If  in  a  strong  child  the  laryngeal  symptoms  increase  so  that  it  seems 
as  if  intubation  will  soon  become  necessary,  it  is  well  to  try  the  effect 
of  vomiting.  For  this  purpose  a  dose  of  ^  to  1  fluidounce  of  syrup 
of  ipecac  should  be  given  every  ten  minutes  until  effective.  Instead 
of  ipecac,  tartar  emetic  or  the  yellow  subsulphate  of  mercury,  ij-v  gr. 
to  a  child  of  two  years,  and  repeated,  may  be  given.  If  an  attack  of 
vomiting  does  not  give  appreciable  relief,  it  is  not  well  to  repeat  it,  as  it 
exhausts  the  child  and  offers  but  slight  hope  of  benefit.  If  a  child  is 
much  prostrated,  it  is  unwise  to  resort  to  emetics  at  all. 

Intubation  and  Tracheotomy. — If  in  spite  of  treatment  the  laryn- 
geal stenosis  advances  so  far  that  actual  obstruction  to  breathing  is 
marked  and  increasing,  we  must  resort  to  intubation  or  tracheotomy. 

By  one  or  the  other  of  these  means  we  overcome  the  obstruction  to 
the  entrance  of  air  through  the  larynx,  and  thus  prevent  suffocation, 
unless  the  membrane  is  too  extensive  below  the  end  of  the  tube.  We 
also  aid  the  expulsion  of  mucus  and  portions  of  membrane  through  the 
opening  formed  by  the  tube.  The  insertion  of  the  tube  does  not,  of 
course,  limit  the  extension  of  the  disease  or  prevent  complications. 
The  apparent  improvement  due  to  the  removal  of  the  obstacle  to  respira- 
tion will  therefore  only  be  permanent  when  the  disease  itself  is  not  too 
severe. 

The  time  at  which  intubation  should  be  performed  is  a  question  of 
the  greatest  importance. 

The  insertion  of  a  tube  into  the  larynx  is  not  wholly  a  matter  of  in- 
difference even  in  trained  hands.  More  or  less  abrasion  of  the  swollen 
and  inflamed  laryngeal  mucous  membrane  may  be  caused  by  its  inser- 
tion, and  its  presence  for  several  days  is  very  likely  to  cause  a  superficial 
ulceration,  either  where  its  lower  end  impinges  on  the  trachea  or  where 
its  sides  cause  pressure. 


'n;/:  \r.]/i:.\T  or  lahysciwi.  nirirriih'h'/A. 


r,87 


On  the  other  IkukI,  so  soon  as  the  hirvn<^eal  stenosis  becomes  so 
marked  that  tlie  person  strn(i,<>;les  ibr  air,  and  in  spite  of"  tlie  struggle 
suftieioiit  aeration  of"  the  blood  does  not  take  place,  that  condition  is  a 
great  detriment  t(^  tlie  condition  of"  the  chihl  loiii;-  before  anv  a(;tnal  suf- 
focation is  impending. 

In  spite,  then,  of  tiie  j)ossibh'  injury  to  the  larynx  of  the  insertion 
and  retention  of  the  tube,  we  should  not  wait  too  long  and  thus  allow  a 
greater  injury  to  occur. 

If,  therefore,  the  stenosis  steadily  increases  and  the  retraction  of  the 
epigastric  and  jugular  regions  becomes  decided,  and  cyanosis  is  evident, 
it  is  better  not  to  wait  longer. 

If  it  is  expected  to  intubate,  one  would  operate  at  a  somewhat  earlier 

Fk;.  5U. 


O'Dwyer's  intubation  instruments. 


period  than  if  it  is  intended  to  do  tracheotomy,  since  the  latter  is  a  some- 
what more  serious  procedure. 

Intuhiition  Iii.sfriDnenta. — The  outfit  used  is  that  devised  by  O'Dwver. 


688 


DIPHTHERIA. 


It  consists  of  a  series  of  six  tubes  of  varying  sizes,  both  as  to  the  cali- 
bre and  length.  They  are  arranged  to  fit  the  larynx  at  diiFerent  ages  ; 
the  tubes  usually  supplied  are  those  suitable  for  children,  but  especially 
prepared  tubes  for  adults  can  also  be  procured. 

Besides  the  set  of  tubes  there  is  an  introducer,  an  extractor,  and  a 
mouth  gag.  The  tube  as  seen  in  the  photograph  is  enlarged  at  its  upper 
end  posteriorly ;  there  is  also  a  moderate  swelling  in  the  middle  portion, 
which  fits  into  the  ventricles  of  the  larynx.  Through  the  lip  of  the 
upper  end  of  the  tube  there  is  a  perforation  for  the  passage  of  a  strong 
thread. 

The  introducer  consists  of  a  straight  wooden  handle  ending  in  a  steel 
rod,  which  at  its  last  inch  is  curved  downward  at  an  angle  of  90°.  It 
ends  in  a  small  screw  tip  on  to  which  the  small  rod  which  holds  the  tube 
screws.  Over  the  rod  of  the  instrument  a  flexible  outer  tube  is  attached  ; 
this  may  be  shoved  down  over  the  rod,  thus  pushing  the  tube  from  the 
holder  after  it  has  been  placed  in  the  larynx. 

The  extractor  is  shaped  like  a  pair  of  laryngeal  forceps ;  the  lower 
arm  ends  in  a  wooden  handle.  Through  the  juncture  of  the  steel  and 
wooden  parts  there  passes  a  screw  which  is  so  placed  that  it  can  be  made 

Fig.  51. 


Position  of  child  during  operation  of  intubation. 


to  project  a  greater  or  lesser  distance  from  the  handle,  and  thus  prevent 
the  full  approximation  of  the  two  arms  of  the  extractor.  This  regulates 
the  extent  to  which  the  tips  can  be  separated.  If  by  any  means,  there- 
fore, the  tips  of  the  extractor  have  not  entered  the  tube,  they  are  thus 


TEEATMENT  OE  LARYXGEAL   DIPHTHERIA.  689 

prevented  from  sj)rcadinir  too  widely  apart  and  injuring  the  tissues  of 
the  hirynx. 

Intubdiion  hi  Ldrifiigeal  Diphihcria. — Position  for  Iniubation. — The 
child  f^hould  be  wrapped  in  a  sheet  or  in  a  blanket,  so  as  to  confine  the 
extremities,  but  leave  the  neck  exposed.  Pin  the  sheet  behind.  The 
child  should  i)e  held  in  the  lap  of  one  nurse,  sitting  in  upright  position 
with  the  la-ad  against  the  left  shoulder.  The  mouth  gag  is  inserted  in 
the  left  side  of  the  mouth,  and  held  in  place  by  a  second  nurse  who 
stands  behind  and  who  at  the  same  time  steadies  the  child's  head.  The 
head  should  be  kept  erect. 

If  necessary  the  child  can  be  intubated  lying  down,  and  some,  indeed, 
prefer  this  position. 

Insertion  of  the  Tube. — The  index  finger  of  the  left  hand  is  passed 
along  the  dorsum  of  the  tongue  until  it  feels  the  epiglottis.  It  is 
then  passed  behind  the  epiglottis  until  it  touches  the  arytenoids.  In 
a  small  child  the  epiglottis  is  often  difficult  to  feel,  and  in  any  case 
where  there  is  much  swelling  it  may  be  impossible  to  make  out  its  exact 
location. 

To  insert  the  tube,  which  has  been  selected  of  the  proper  size  and 
placed  on  the  introducer,  it  is  passed  along  the  iuuer  side  of  the  index 
finger  down  to  the  tip  of  the  finger ;  the  handle  bars  are  tlien  raised  and 
the  tube  is  passed  downward  and  forward  into  the  larynx.  In  doing 
this  the  finger  is  pushed  slightly  aside  by  the  tube.  The  beginner  is 
very  apt  not  to  pass  the  tip  of  the  tube  sufficiently  forward,  and  may 
thus  pass  it  into  the  cesophagus.  The  tube  having  passed  into  the  larynx, 
place  the  tip  of  the  index  finger  of  the  left  hand  on  its  upper  end,  push 
the  tube  off  with  the  obturator,  and  withdraw  it. 

In  the  insertion  of  the  tube  and  in  the  extraction  of  the  holder  one 
should  be  sure  to  keep  the  tube  in  the  median  line.  It  is  also  very 
essential  to  have  the  child's  head  kept  perfectly  still. 

A  thread  which  has  been  passed  through  the  eye  of  the  head  of  the 
tube  is  left  until  one  is  perfectly  satisfied  that  the  tube  is  not  clogged 
with  membrane  and  that  it  is  giving  proper  relief  to  the  child. 

It  is  also  necessary  to  be  sure  that  the  tube  has  not  passed  into  the 
pharynx  and  cesophagus. 

After  the  insertion  of  the  tube  it  is  well  to  give  the  child  a  little  water 
and  whiskey,  in  order  to  cause  it  to  cough  by  the  slight  irritation  ;  it  is 
also  valuable  as  a  stimulant  to  the  child  after  the  exertion  occasioned  by 
the  passage  of  the  tube. 

After  the  insertion  of  the  tube  the  operator  is  usually  able  to  ascer- 
tain whether  it  has  relieved  the  stenosis  within  a  few  minutes,  but  in 
exceptional  cases,  where  the  child  is  very  weak,  it  may  be  impossible  to 
determine  this  for  half  an  hour.  In  very  young  children  it  is  possible 
to  intubate  without  using  the  gag,  but  in  older  children  one  runs  the 
risk  of  being  severely  bitten  without  it. 

Treatment  of  the  Patient  ichile  Intubated. — It  is  frequently  the  cus- 
tom to  raise  slightly  the  foot  of  the  bed  on  A\hich  the  child  lies,  and  it 
is  always  well  to  keep  the  child  prostrate  if  possible. 

A  matter  of  vital  importance  is  the  feeding  of  the  child.  This  is 
first  attempted  with  the  child  lying  down,  with  the  head  depressed  be- 
low the  rest  of  the  body.     If  the  child  does  not  take  fluid  nourishment 

Vol.  I.— 44 


690  DIPHTHERIA. 

in  this  way,  it  is  allowed  to  drink  in  the  natural  manner.  If  it  is  im- 
possible to  feed  the  child  by  either  of  these  means,  it  must  be  fed  by 
a  stomach  tube  passed  through  the  nose  into  the  stomach.  For  a  child 
of  one  to  two  years  the  tube  should  be  the  size  of  a  No.  6  catheter ;  for 
a  child  of  three  to  four  years,  a  No.  8  catheter.  Some  physicians  pre- 
fer, instead  of  a  fluid  diet,  food  which  is  of  greater  consistency  or  even 

Fig.  52. 


^v 


reeding  child  wearing  intubation  tube. 

entirely  solid  At  the  Willard  Parker  Hospital  for  Contagious  Dis- 
eases, however,  fluid  diet  is,  as  a  rule,   preferred. 

Extraction  of  the  Tube. — At  any  time  after  the  insertion  of  the  tube 
it  may  be  coughed  up,  or  it  may  become  obstructed  by  membrane  either 
blocking  the  tube  or  filling  up  the  trachea  below.  Whenever  the  tube 
becomes  obstructed  it  must  be  instantly  removed.  In  those  cases  in 
which,  however,  the  tube  is  neither  coughed  up  nor  obstructed  it  is 
found  best  to  leave  it  in  for  such  a  period  that  seven  days  have 
elapsed  from  the  time  of  the  beginning  stenosis.  If  the  tube  is  re- 
moved earlier,  it  will  usually  have  to  be  replaced,  with  the  danger 
always  of  creating  slight  abrasions  or  injuries  of  the  larynx. 

Method  of  Eaytracting  the  Tube. — The  child  is  held  in  exactly  the 
same  position  as  for  intubation.  As  in  intubation  the  index  iinger  of 
the  left  hand  is  passed  along  the  dorsum  of  the  tongue,  then  behind  the 
epiglottis,  and  downward  until  it  feels  the  end  of  the  tube  and  makes 
out  its  lumen.  The  finger  should  detect  Avhether  the  tube  is  lying  in 
the  proper  position — that  is,  with  the  long  diameter  of  the  opening  lying 
from  before  downward.     The  extractor  is  then  passed  along  the  finger. 


TUKATMKST  OF  LAUYMIKM,   DJJ'JJTlIh'lUA.  091 

as  the  tube  was  in  iiituhation,  until  one  brings  the  ti])  of  the  extractor 
a<»aiiist  till'  side  ot"  the  tip  of  the  finger  and  the  opening  into  the  head 
of  tlie  tube.  A  beginner  must  be  eai'eful  that  he  does  not  mistake  tiie 
shouhU'r  of  tile  extraetor  for  tlie  tube.  Tlic  handle  of  tiie  extractor 
shouUl  be  raised  to  a  horizontal  jiosition,  as  otlierwise  only  the  tip  will 
enter  into  the  tube  and  the  danger  of  slij)ping  will  be  very  great.  'I"'he 
extraction  is  accomplished  by  lifting  the  extraetor  witli  its  tube  until  it 
touclu's  the  hanl  palate,  and  then  the  handle  is  lowered  through  an  arc 
of  90°  and  the  tube  removed.  In  young  chihb'en,  as  in  intubation,  a 
gag  is  not  necessary.  The  extractor,  as  stated  in  the  descrij)tion  of  the 
instrument  on  page  688,  is  provided  with  a  safeguard  in  the  shape  of  a 
screw  which  passes  through  the  lower  arm  of  the  handle  so  as  to  come 
in  contact  with  the  upper  arm.  This,  by  ])ro])er  adjustment,  serves  a 
double  purpose.  First,  it  })revents  the  opening  of  tiie  jaws  of  the  ex- 
tractor to  such  a  degree  as  to  injure  the  soft  parts  if  by  chance  it  should 
not  have  entered  the  lumen  of  the  tube  ;  and,  second,  it  gives  informa- 
tion as  to  wliether  the  tip  of  the  extractor  is  witliin  the  lumen  of  the 
tube.  For  with  the  screw  properly  set  it  will  be  impossible  to  obtain 
the  click  of  one  arm  of  the  extraetor  against  the  screw  if  the  tips  are 
within  the  lumen  of  the  tube.  When,  for  any  reason,  a  person  is  un- 
skilled in  the  extraction  of  the  tube — and  for  the  beginner  the  extrac- 
tion is  rather  more  difficult  than  the  insertion — it  is  possible  in  an 
emergency,  in  the  majority  of  cases,  to  easily  expel  the  tube  by  placing 
the  child  face  downward  with  the  body  slightly  elevated,  and  pressing 
gently  against  the  trachea  along  its  anterior  surface,  just  below  the  end 
of  the  intubation  tube.  This  method  should  not  be  used  when  one  is 
skilled  in  removing  the  tube  with  the  extractor,  because  there  is  always 
danger  of  causing  abrasions  of  the  mucous  membranes  by  too  forcible 
pressure.     The  tube  is  removed  from  the  mouth  by  the  finger. 

Another  form  of  extractor  has  been  used,  that  devised  by  Dillon 
Brown.  This  is  employed  like  the  previous  method  when  one  is  not 
skilled  in  handling  the  extractor  invented  by  O'Dwyer.  In  order  to 
use  the  Brown  extractor  a  special  set  of  intubation  tubes  is  necessary. 
These  have,  at  the  anterior  edge  of  the  head,  a  small  loop.  This  allows 
an  extraetor  to  be  used  which  is  attached  to  the  finger  and  which  ends  in 
a  little  hook.  The  finger  is  passed,  with  the  hook  attached,  over  the 
dorsum  of  the  tongue  until  it  touches  the  tube,  when  the  hook  is  passed 
into  the  loop  and  the  tube  thus  removed.  In  cases  where  a  great  deal 
of  swelling  is  present  the  swollen  tissues  are  apt  to  cover  up  the  little 
loop  on  the  end  of  the  tube  and  make  it  very  difficult  to  remove  the  tube 
by  this  extractor. 

At  the  hospital,  immediately  after  the  extraction  of  the  tube,  the 
child  is  given  A^  grain  of  morphine  hypodermically,  and  an  ice  bag 
is  applied  to  the  larynx.  It  is  sought  in  this  way  to  lessen  the  irrita- 
tion and  swelling  in  the  larynx.  The  child  is  still  kept  in  a  recumbent 
position  for  one  or  two  days. 

^yhen  the  tube  does  not  give  relief,  one  of  two  things  is  possible : 
either  a  tube  with  a  much  larger  lumen,  but  which  is  lighter  and  shorter, 
may  be  inserted,  or  tracheotomy  must  be  performed.  In  but  few  cases 
will  one  of  these  large  calibre  tubes  succeed  where  the  ordinary  tube  has 
failed.     Tracheotomv  will  more  often  o-ive  relief,  but  in  these  cases  the 


692  DIPHTHERIA. 

membrane  is  so  extensive  that  in  spite  of  the  temporary  improvement  tlie 
majority  of  the  cases  finally  succumb. 

Although  at  the  autopsy  frequently  a  moderate  degree  of  ulceration 
is  found,  yet  it  is  probable  that  this  takes  place  chieHy  in  those  cases 
where  the  resistance  of  the  tissues  has  been  greatly  lessened  by  the  severe 
toxic  infection. 

There  are  a  few  cases  where,  on  account  of  paralysis  or  the  growth  of 
granulations,  the  child  is  unable  to  breathe  without  the  tube.  Here  a 
secondary  tracheotomy  may  be  tried,  and  the  granulations  may  be  re- 
moved by  operation.  The  tube  probably  predisposes  somewhat  to  pneu- 
monia, and  in  some  cases  it  seriously  interferes  with  the  feeding  of  the 
child.  In  those  cases  where  the  ordinary  tube  does  not  afford  sufficient 
space  for  the  expectoration  of  the  mucus  and  loosening  membrane,  the 
wider  tube  devised  by  O'Dwyer  may  be  substituted.  These  are  usually 
bad  cases. 

The  Advantages  and  Disadvantages  of  Intubation  and  Tracheotomy 
Compared. — Intubation  has  the  following  advantages :  It  requires  no 
cutting  operation  and  causes  no  danger  of  hemorrhage  or  of  external 
wound  infection.  The  consent  of  the  parents  is  more  easily  obtained. 
It  is  generally  easily  performed  by  one  accustomed  to  the  procedure.  It 
requires  but  one,  or  preferably  two,  assistants.  The  time  of  leaving  the 
tube  in  the  throat  averages  less.     The  nursing  is  simpler. 

The  objections  are  :  the  danger  of  the  ulceration  of  the  tissues  from 
pressure,  the  difficulty  of  administering  nutriment,  and  the  more  frequent 
insufficiency  of  the  relief  afforded.  In  about  2  per  cent,  of  the  cases 
it  will  be  found  that  the  child  cannot  breathe  without  the  tube  for 
weeks  after  the  disappearance  of  all  other  symptoms.  If  this  is  due 
to  paralysis,  recovery  usually  takes  place  after  weeks  or  months.  If 
the  obstruction  is  due  to  a  growth  of  granulations,  it  may  be  necessary 
to  remove  them  by  operation,  and  to  do  this  a  preliminary  tracheotomy 
will  generally  be  necessary. 

Commonly  in  America  intubation  is  first  performed  in  all  cases,  and 
tracheotomy  only  in  those  in  ^vhich  the  relief  is  not  satisfactory,  either 
at  the  time  of  the  insertion  of  the  tube  or  later.  Here  tracheotomy  may 
give  free  breathing,  but  in  a  majority  of  these  cases  the  membrane,  still 
extending,  will  again  produce  obstruction,  and  thus  the  fatal  termination 
is  only  somewhat  delayed. 

Diphtheria  Antitoxin  in  the  Treatment  of  Diphtheria  and  as  an 
Immunizing-  Agent. — The  foundation  for  the  treatment  of  diphtheria, 
and  to  a  less  extent  of  certain  other  diseases,  with  antitoxin  rests  upon 
the  fact — and  it  is  well  to  keep  in  view  that  it  is  a  fact — that  the  blood 
and  serum  of  animals  immunized  against  certain  diseases  c(mtain  sub- 
stances, called  antitoxins,  which,  when  injected  into  healthy  animals, 
will  give  them  immunity  to  the  same  diseases.  Further,  not  only  will 
the  serum  confer  immunity  to  later  infection,  but  will,  if  not  given  too 
late,  prevent  the  otherwise  fatal  outcome  of  the  disease  in  animals  already 
ill.  The  result  is  much  the  same  whether  the  antitoxin  is  given  to  an 
animal  before  or  at  the  same  time  as  the  dose  of  toxin  or  virulent  bac- 
teria, but  varies  greatly  for  each  hour's  delay  in  giving  the  antitoxin 
after  the  infection  has  taken  place.  The  longer  this  period  is  the  greater 
the  amount  of  antitoxin  needed  and  the  more  doubtful  the  recovery. 


ANTITOXIS  L\  THE  TREATMENT  OF  DIPHTHERIA.  693 

TIk'  Hrst  jiiildicatiiiii  (Icinoiistratinir  the  antitoxic  power  of  the  serum 
of  atiiniuls  iiuimuii/etl  auainst  (lij)litheria  in  tlie  treatment  of  experimental 
diphtheria  was  maile  by  von  liehring-  in  Deeemher,  1890. 

The  first  trial  of  antitoxin  serum  in  human  diphtheria  was  made  in 
the  autumn  of  1.S91  in  the  city  (»f  Berlin. 

Mtidr  of  Action  of  ^intitoxiii. — It  seems  probalde  that  antitoxin  does 
not  aet  directly  in  any  way  upon  the  toxin,  but  rather  upon  the  tissue 
elements  in  such  a  way  as  to  make  them  insusceptible  to  the  poisonous 
action  of  the  toxin. 

After  the  cells  have  been  to  a  certain  extent  affected  bv  the  toxin, 
the  protective  power  of  the  antitoxin  can  no  longer  be  exerted 'and  the 
lesions  progress  in  spite  of  it. 

Derivation  of  Antitoxin. — From  the  fact  that  the  antitoxin  devel- 
oped in  the  blood  of  an  animal  is  only  antitoxic  for  the  special  toxin 
with  which  it  was  injected — that  is,  tetanus  antitoxin  only  immunizes 
against  tetanus  poison,  diphtheria  antitoxin  against  diphtheria  poison, 
etc. — it  would  ajipear  that  the  antitoxin  must  be  derived  from  the  toxin. 
A  substance  which  seems  to  be  the  same  as  diphtheria  antitoxin  has 
indeed  been  obtained  from  diphtheria  toxin  by  electrolvsis. 

There  are  certain  facts,  however,  which  teach  us  that  the  living  tissue 
elements  probably  are  actively  associated  in  the  transformation.  Thus 
in  animals  freshly  immunized  small  doses  of  toxin  will  produce  far 
larger  amounts  of  antitoxin  than  these  same  doses  will  produce  when 
the  animals  have  been  long  under  treatment.  The  amount  of  antitoxin 
produced  seems  to  depend  more  on  the  extent  of  the  reaction  of  the  an- 
imal to  the  injections  than  on  the  amounts  of  toxin  introduced.  The 
diphtheria  antitoxin  is  obtained  for  medicinal  purposes  almost  entirely 
from  horses.  These  animals  receive  repeated  doses  of  diphtheria  poison 
in  constantly  increasing  amounts  until,  after  from  two  to  four  months, 
their  blood  serum  contains  sufficient  amounts  of  antitoxin  to  be  service- 
able for  treatment  in  human  diphtheria. 

The  power  of  the  diphtheria  antitoxin  to  neutralize  the  poisonous 
effects  of  the  diphtheria  toxin  in  animals  is,  as  before  said,  an  absolute 
fact  which  has  been  shown  to  be  uniformly  true  in  thousands  of  experi- 
ments. AVe  have  every  reason  to  expect  that,  since  the  toxin  in  human 
diphtheria  is,  so  far  as  we  can  determine,  exactly  the  same  toxin  as  that 
in  diphtheria  in  animals,  this  power  of  the  antitoxin  to  make  harmless 
the  toxin  will  manifest  itself  in  man  under  similar  conditions. 

AVe  have  every  reason,  therefore,  to  expect  it  to  almost  certainlv  pre- 
vent, for  a  time  at  least,  an  attack  of  diphtheria,  but  as  to  its  exact 
value  at  different  stages  in  the  development  of  the  disease  onlv  clinical 
experience  can  determine. 

"  If,"  as  AA^elch  ^  so  well  states  it,  "  the  curative  effects  of  the  serum 
are  brought  about  through  the  agency  of  the  living  cells  of  the  bodv, 
we  can  understand  why  these  effects  ^vill  not  follow  the  injection  of  the 
serum  with  the  certainty  and  precision  of  a  chemical  reaction.  The  cells 
must  be  in  a  condition  to  respond  in  a  proper  way  to  the  introduction 
of  the  antitoxic  serum.  For  one  reason  or  another  this  responsive 
power  may  be  in  abeyance;  we  know  that  it  may  be  weakened  or 
destroyed  by  the  intense  or  prolonged  action  of  diphtheria  poisons,  or 

'  "Welch,  Bulletin  of  the  Johns  Hophins  Hospital,  July,  1895. 


694  DIPHTHERIA. 

by  other  previous  and  coexistent  diseases,  or  by  inherent  weakness,  or 
there  may  even  be  some  individual  idiosyncrasy  which  hinders  the  cus- 
tomary response  of  the  cells  to  the  antitoxin. 

"  Clinical  experience  shows  that  cases  of  diphtheria  inherently 
refractory  to  antitoxic  serum  are  exceptional,  although  they  do  certainly 
from  time  to  time  occur." 

The  antitoxic  serum  exerts  no  bactericidal  effect  upon  the  diphtheria 
bacillus,  although  when  administered  in  proper  quantities  sufficiently 
early  in  the  disease  it  arrests  the  spread  of  the  local  inflammation  which 
is  caused  by  the  bacillus.  Virulent  bacilli,  so  far  as  the  results  in  New 
York  gb,  seem  to  persist  in  the  throat  for  about  as  long  a  period  as  in 
the  cases  formerly  not  treated  with  antitoxin. 

One  of  the  most  important  characters  of  antitoxin  is  that  it  requires 
a  definite  quantity  to  neutralize  the  effects  of  a  definite  quantity  of 
toxin.  In  animals  the  curative  dose  of  antitoxin  stands  in  a  definite 
quantitative  relation  to  the  size  and  susceptibility  of  the  individual 
and  to  the  amount  and  intensity  of  the  poison  in  the  system.  If 
an  animal  does  not  receive  a  sufficient  amount  of  antitoxin,  it  fre- 
quently dies  almost  as  quickly  as  one  having  received  no  antitoxin 
at  all.  We  have  no  method  of  deternaining  how  much  and  how  viru- 
lent the  poison  may  be  in  a  given  case  of  human  diphtheria,  nor  how 
susceptible  to  toxin  the  patient  may  be.  The  dose  of  antitoxin,  there- 
fore, in  human  diphtheria  is  empirical,  the  main  factors  to  determine 
it  being  the  age  of  the  patient,  the  estimated  duration  of  the  disease  up 
to  the  time  of  the  administration  of  the  remedy,  and,  most  important 
of  all,  the  severity  and  extent  of  the  disease. 

As  the  serum  is  capable  of  inducing  unpleasant  symptoms,  it  is 
desirable  not  to  give  an  excessive  quantity.  It  is,  however,  necessary 
not  to  err  on  the  opposite  side  and  give  too  little,  for  it  is  far  more 
important  to  give  sufficient  to  overcome  the  dangers  than  to  endeavor  to 
avoid  by  too  small  a  dose  the  after  possible  unpleasant  effects. 

It  is  very  important  to  bear  in  mind  that  the  diphtheria  antitoxin 
only  immunizes  against  the  poison  of  the  diphtheria  bacilli,  and  that,  in 
so  far  as  the  lesions  in  any  case  of  diphtheria  are  due  to  the  action  of 
the  poisons  produced  by  other  bacteria,  these  lesions  will  be  in  no  way 
influenced. 

The  lesions  of  diphtheria  are,  as  a  rule,  at  the  beginning  mainly  due 
to  the  action  of  the  toxin  of  the  diphtheria  bacillus,  but  later  inflam- 
mation may  take  place,  due  to  other  bacteria,  so  that  septiceemia  or 
pneumonia  may  develop,  which,  being  due  not  so  much  to  the  diph- 
theria bacilli  as  to  streptococci  or  pneumococci,  will  of  course  advance 
without  regard  to  the  use  of  the  diphtheria  antitoxin. 

These  facts  impress  us  still  further  with  the  importance  of  using  the 
antitoxin  early,  for  we  are  not  only  thus  enabled  to  immunize  the  cells 
against  diphtheria  toxin,  but  by  preventing  the  advance  of  the  disease 
we  ward  off  these  later  infections. 

We  have  no  way  of  gauging  accurately  at  any  given  period  of  the 
disease  the  extent  of  the  damage  already  inflicted  upon  the  cells  of  the 
body.  If  the  nerve  cells  have  already  been  so  damaged  that  paralysis 
must  follow,  or  the  cardiac  nerve  cells  or  muscular  fibres  have  been 
similarly  injured,  or  the  renal  epithelium  so  affected  that  degeneration 


ANTITOXIN  IN   THE   TREATMENT  OF  DIPHTHERIA.  095 

ami  iiej)hritis  ensue,  the  admiiiistralion  of  antitoxin  cannot  restore 
those  cells  wliicli  arc    already  on   the  way   to   deti-cneration  and  death. 

The  eft'ects  wiiich  follow  the  injection  oi'  the  antitoxic  serum  in 
individual  cases  are  not  new  and  stran<j;e.  Xothinsz;  happens  which  the 
physician  may  not  have  occasionally  seen  to  happen  in  cases  treated  in 
the  ordinary  way.  In  severe  as  well  as  in  slight  cases  of  di])htheria 
he  may  have  seen  an  ai)i)arently  ])ro<i:ressive  local  ])rocess  (juickly 
arrested  and  the  ueneral  symj)tonis  j)romptly  abated. 

But,  as  ^yelcll  puts  it,  why  should  anything  new  and  strange  happen 
after  the  administration  of  antitoxin  ?  Cure  by  antitoxin  is,  if  our 
theories  are  correct,  by  nature's  own  remedial  agent.  That  which  is  new 
and  strange  is  the  frequency  with  which,  in  case  after  case,  the  early 
injection  of  antitoxin  promptly  arrests  the  local  inflannnation  and  checks 
the  constitutional  disturbances. 

Recovery  following  treatment  by  antitoxin  is  of  such  a  natural 
kind  that  in  any  favorable  case  a  physician  may  repeatedly  feel  that  the 
whole  process  might  have  resulted  without  the  use  of  the  remedy. 
One  can  therefore  understand  why  it  should  be,  as  a  rule,  those  with  the 
advantage  of  a  large  ex])erience  in  the  treatment  of  diphtheria  by  anti- 
toxin who  are  most  decided  in  expressing  their  opinion  as  to  its  bene- 
ficial effects. 

Antitoxic  Serum. — The  serum  should  be  clear  and  free  from  any  bac- 
terial growth.  Each  cubic  centimetre  should  contain  at  least  100  units. 
When  possible,  serum  of  five  times  that  strength  of  antitoxin  should  be 
used.  An  antitoxin  normal  unit  is  ten  times  the  amount  of  serum  re- 
quired to  protect  a  guinea-pig  weighing  250  grammes  from  death  when 
ten  times  the  fatal  dose  of  toxin  is  mixed  with  the  serum  and  the 
mixture  injected  subcutaneously  into  the  animal.  As  measured  by 
Roux's  method,  50  antitoxin  normal  units  are  equivalent  to  about  1  cc. 
of  serum  having  a  protective  power  of  1  to  50,000.  The  contents  of 
von  Behring's  vial  Xo.  1  are  therefore  about  equal  to  12  cc.  of  a 
serum  1  to  50,000.  The  contents  of  von  Behring's  vial  Xo.  2  about 
equals  10  cc.  of  a  serum  1  to  100,000,  or  20  cc.  of  a  serum  1  to  50,000. 
The  serum  manufactured  in  this  country  is  usually  put  up  in  vials  of  from 
5  to  10  cc,  each  cubic  centimetre  having  from  100  to  500  antitoxin  units. 

Dose. — The  size  of  the  dose  should  be  measured  chiefly  by  the  extent 
and  intensity  of  the  disease ;  also,  but  to  a  less  degree,  by  the  size  of 
the  patient  and  the  duration  of  the  illness.  For  yoinig  children  with 
but  moderate  lesions  of  the  tonsils  or  palate  a  single  dose  of  1000 
to  1500  units  will  suffice.  For  older  children  and  adults  1000  to  2000 
units  should  be  given.  In  children  who  are  already  seriously  ill  or 
who  alreadv  show  the  toxic  effects,  or  in  whom  the  larynx  is  involved, 
a  dose  of  'l500  to  3000  units,  10-14  cc.  Xo.  3  or  3  cc.  X^o.  7,  is 
necessary. 

If  the  symptoms  do  not  abate,  another  1000  to  2000  units  may  be 
given  on  the  following  day.  In  a  few  cases  still  a  third  injection  is 
required.  Exceptionally  a  week  or  ten  days  after  administering  the 
antitoxin  a  slight  return  of  exudate  may  appear ;  here  another  moder- 
ate injection  is  indicated.  Where  these  doses  have  not  benefited  it  is 
doubtful  if  larger  ones  will  succeed. 

At  the  Xew  York   Hospital   for  Contagious    Diseases  for   several 


696  DIPHTHERIA. 

months  one  half  of  the  severe  cases  received  on  admission  3000  units, 
and  again  on  the  following  day  3000  more.  If  no  improvement  fol- 
lowed, a  third  3000  nnits  were  given.  The  other  half  received  2000 
units  on  admission,  and  a  second  2000  in  eighteen  hours.  So  far  as  one 
could  judge,  those  receiving  the  lesser  amount  did  as  well  as  those 
receiving  the  very  large  amounts.  On  the  other  hand,  no  additional 
disagreeable  effects  were  noticed  from  the  larger  quantities. 

Immunization. — When  children  or  adults  have  been  much  exposed 
to  diphtheria  they  may  be  protected  by  the  administration  of  from  100 
to  300  antitoxin  normal  units  (5  to  15  minims  or  ^  to  1  cc.  of  a  high 
grade  antitoxin).  The  protection  lasts  from  three  to  eight  weeks.  The 
remedy  is  administered  by  deep  hypodermic  injection  from  an  ordinary 
hypodermic  syringe. 

Some  point  on  the  anterior  surface  of  the  body  should  be  chosen  for 
the  injection  where  there  is  an  abundance  of  subcutaneous  cellular  tissue, 
such  as  tlie  anterior  surface  or  side  of  the  thorax  or  the  outer  surface  of 
the  thigli.  Before  the  remedy  is  administered  the  skin  should  be  care- 
fully washed  with  some  disinfecting  solution. 

The  syringe  should  be  sterile.  The  solution  is  rapidly  absorbed,  and 
it  is  better  not  to  employ  massage  over  the  point  of  injection. 

Results  Obtained  by  Antitoxin  Treatment. — The  value  of  antitoxin  in 
diphtheria  is,  in  my  opinion,  established,  yet  the  treatment  is  so  recent 
that  it  seems  to  me  wise  to  give  certain  reliable  statistics,  so  that  readers 
may  tliemselves  to  a  certain  extent  have  a  basis  f(jr  forming  their  own 
opinions.  I  shall  select  for  this  purpose  figures  from  two  hospitals : 
first,  from  the  AVillard  Parker  Hospital  for  Contagious  Diseases  of  New 
York  Citv,  where  all  cases  of  diphtheria  occurring  in  the  city  and  need- 
ing hospital  treatment  are  sent.  I  select  this  hospital  because  I  have 
watched  nearly  all  the  cases  personally  and  am  familiar  with  the  results 
before  the  use  of  antitoxin.  For  the  second  hospital  I  have  selected 
the  Kaiser-und-Kaiserin  Friedrich  Augusta  Hospital  of  Berlin,  because 
Baginsky^  has  reported  these  cases  in  such  a  thorough  manner,  and 
because  the  figures  show  what  one  can  hope  to  accomplish  under  favor- 
able conditions.  First  I  will  give  a  statistical  summary  of  the  results 
obtained  in  the  treatment  of  diphtheria  with  antitoxin  at  the  Willard 
Parker  Hospital  during  the  year  1895  as  contrasted  with  the  previous 
year  : 

Mortality  in  Willard  Parher  Hospital  in  1895  and  First  Quarter  of  1896, 
when  Antitoxin  was  Employed  in  all  Cases,  and  in  1894-,  when  it  was 
Employed  in  but  few. 

AU  cases,  even  mori-  ^g^ggg  Deaths.  Percentage, 

bund,  included. 

1894      606  208  34.32 

1895 716  189  26.39 

1896  (first  quarter) 180  41  22.77 

It  is  necessary  to  state  that  the  cases  were  admitted  under  exactly  the 
same  conditions  during  1895  as  in  previous  years.  As  seen  in  this  table, 
in  the  fourth  quarter  of  1894,  the  time  just  preceding  the  use  of  anti- 
toxin, the  mortality  was  high.     Indeed,  during  the  month  of  Decem- 

^The  Serum  Therapy  in  Diphtheria,   Adolph  Baginsky,   Berlin,   1895. 


ANTITOXIN  IN  THE  TREATMENT  OF  Dfl'IITJIE/UA. 


097 


ber  nil  ol"  the  1 .!  iiitiil);i(('(l  ca.^c.-^  died.  Tlicre  is  no  rca.son  to  suppose 
that  till-  ('|)i(K'inic  was  of  a  milder  chai-acter  when  the  use  of  the  anti- 
to.xin   was  hcotin.     There  were  indeed  throu<^h   the  winter  months  an 

unusual   uumlici-  oi"  laryuti'eal  cases. 

Deaths  according  to  Day  of  Disease  upon  which  Treatment  was  Begun. 


Antitoxin,  1895. 

No  antitoxin,  1894. 

Day  ui>nn  will  ell  trcnunent  was  begun,  i       Cases.         ^^I}!lu}^l 

1 

Cases. 

57 
131 
131 

88 
199 

Mortality, 
percentage. 

First  flav  .   .           11:;                     8  85        i 

19.29 
35.11 
32.82 
37.50 
37  69 

Sei-ontl  (iav 1 IC.                   24.32        ' 

Third  dav l;!2                   24.27 

Fotirth  diiv i            102                    30.39 

Fifth  dav  and  over '           221                    34.36 

Total 1           714                   28.39 

606 

34.32 

Careful  investig-ation  at  the  homes  of  many  of  the  ]Mtients  showed  that 
they  had  been  siek,  as  a  rule,  longer  than  stated  in  the  hosj)itals  records. 
This  table  is  nevertheless  of  great  value.  It  shows,  in  the  first  place,  so 
far  as  figures  can  show,  that  the  epidemics  of  1895  and  1894  were  of 
about  the  same  severity,  the  cases  admitted  after  the  beginning  of  the 
fifth  day  having  about  the  same  mortality  in  both  years.  The  cases  ad- 
mitted, however,  on  the  first  two  days  show  a  very  different  mortalitv. 
This  is  true  also,  but  to  a  less  marked  extent,  for  the  cases  in  which 
treatment  was  begun  on  the  third  day.  Too  much  emphasis  cannot  be 
placed  upon  the  importance  of  giving  antitoxin  early  in  diphtheria. 
There  is  no  doubt  in  my  mind  that  most  cases  wdiich  die  in  spite  of  the 
early  administration  of  the  usual  treatment  would  be  saved  if  antitoxin 
were  given  within  the  first  thirty-six  hours  of  visible  disease. 

Let  us  now  turn  attention  to  the  .statistics  reported  bv  Baginskv. 
They  certainly  give  a  very  favorable  showing  for  antitoxin. 

Baginsky  ^  reports  the  following  as  the  results  of  the  treatment  of 
diphtheria  before  and  after  the  use  of  antitoxin  : 


Cases  receiving  no  antitoxin,  1890-1894. 

Cases  receiving  antitoxin,  1894-1895. 

Year. 

Cases. 

Deaths. 

Percentage. 

Cases. 

Deaths. 

Percentage. 

0-2 243 

2-1 333 

4-6 274 

6-8 197 

8-10 124 

10-12 73 

12-14    ......              43 

154 
176 
104 
54 
24 
11 
6 

63..36 
.52.85 
37.98 
27.41 

19.;% 

15.07 
13.95 

87 
146 
116 
79 
58 
20 
15 

22 
25 
20 

3^ 
2 
2 

25.28 
17.12 
17.24 
11.39 

5.17 
10.00 
13.30 

Laryngeal  Diphtheria  under  Antitoxin  Treatment  (Baginsky). 

Cases. 

Deaths.        |    Percentage 
mortality. 

Intubated 

Tracheotoraized    . 

25 
11 

5                        20 

8                        72 

Not  intubated 

36 
11 

13                        303^ 
0                          0 

Total  laryngeal  cases 

47                           13                         23 

'  Loc.  eit. 


698  ■         DIPHTHERIA. 

A  most  convincing  demonstration  of  the  power  of  antitoxin  is 
furnished  by  the  experience  of  Baginsky  during  an  involuntary  pause 
in  the  serum  treatment  caused  by  failure  in  the  supply  of  serum. 
Between  March  15,  1894,  and  March  15,  1895,  there  were  treated  in 
Baginsky's  service  by  antitoxin  525  children,  with  a  fatality  of  15.6 
per  cent.  During  the  period  of  forced  interruption  of  the  serum  treat- 
ment, this  period  being  chiefly  the  months  of  August  and  September, 
126  children  were  treated  without  antitoxin,  with  a  fatality  of  48.4 
per  cent.  There  was  absolutely  no  selection  of  cases  in  either  group. 
In  his  comments  upon  this  experience  Baginsky  says  :  "  It  is  all  the  more 
remarkable  as  the  ratio  of  mortality  of  those  treated  with  the  serum 
both  before  and  after  the  period  of  interruption  varied  within  very 
small  percentage  figures. 

"  If  one  will  permit  figures  to  speak  at  all,  there  has  scarcely  been 
made  on  human  beings  a  more  demonstrative  test  of  the  curative  power 
of  a  therapeutic  agent.  It  was  an  experiment  ibrced  upon  us,  but  it 
proved  to  us  how  terrible  was  the  form  of  disease  which  we  were  treat- 
ing, and  how  numerous  would  have  been  the  victims  without  the  use  of 
the  healing  serum." 

Another  proof  that  the  cause  of  the  lower  death  rate  is  not  due  to 
the  cases  being  milder  is  seen  in  the  universal  lowering  of  the  death 
rate  in  laryngeal  diphtheria.  I  quote  again  a  paragraph  from  Welch's 
summary:  "No  one  can  claim  that  laryngeal  diphtheria  requiring  in- 
tubation or  tracheotomy  is  anything  but  a  severe  disease. 

"  If  the  benefits  of  antitoxin  are  unmistakably  manifested  in  these 
operated  cases  of  croup,  then  the  test  is  an  experimentum  crucis,  and  puts 
an  end  to  the  objection  of  those  's^ho  assert  that  the  apparently  favorable 
results  of  serum  therapy  in  diphtheria  are  attributable  mainly  to  the  large 
proportion  of  mild  cases  treated. 

"  Before  the  introduction  of  the  serum  treatment  a  collective  investi- 
gation was  set  on  foot  by  the  German  Gesellschaft  f  iir  Kinderheilkunde 
to  determine  the  average  fatality  following  intubation. 

"In  1893  von  Ranke  reported  to  the  society  that  1445  cases  of 
diphtheria  with  laryngeal  stenosis  treated  by  intubation  gave  a  fatality 
of  62.5  per  cent.  This  result  was  interpreted  in  favor  of  intubation  as 
opposed  to  tracheotomy.  There  is  a  difference  of  33.6  per  cent,  between 
this  percentage  and  that  obtained  from  our  342  intubation  cases  treated 
with  antitoxin.  This  difference  is  so  great  that,  after  making  all  pos- 
sible allowance  for  diflPerences  in  the  series  of  cases  entering  into  the  two 
groups  of  statistics,  it  seems  impossible  to  explain  it  otherwise  than  as  a 
powerful  additional  support  of  the  arguments  already  presented  in  favor 
of  the  claims  of  antitoxin.  Here  certainly  the  objection  that  the  cases 
treated  by  antitoxin  were  light  ones  cannot  be  made. 

"  During  the  enforced  two  months'  (August  and  September)  interrup- 
tion of  the  serum  treatment  in  Baginsky's  service  there  were  116  cases 
of  laryngo-stenosis,  with  a  fatality  of  62.2  per  cent.,  as  opposed  to  a 
fatality  of  37.8  per  cent,  in  the  serum  periods  which  preceded  and  fol- 
lowed the  pause.  The  percentage  of  operations  rose  to  55.2  as  opposed 
to  18.1  per  cent,  during  the  periods  of  serum  treatment,  and  this  without 
any  change  in  the  general  character  of  the  cases  admitted. 

"  During  the  serum  periods  there  were  more  intubations  than  trache- 


ANTITOXIS  IN  THE  TREATMILXT  OF  DII'IITIIERIA.  699 

otoniii's,  whorcns  (lining   ilic  j):iii.-c'  tlici'c  were  40  traclieotomics  and  19 
intubations,  V.\  ol'  the  latter  i'c'(|uirini::  secondary  traelieotoiny." 

Tlie  following-  statistics,  showino-  the  results  of  treatment  with  anti- 
toxin in  24,768  cases,  as  contrasted  with  those  not  receiving  antitoxin, 
liave  been  furnislicd  nie  by  Dr.  Girade.  They  have  been  compiled 
without  the  least  attempt  to  favor  antitoxin.  They  comjirise  all  the 
cases  given  in  the  journals  l)y  observers  reporting  over  10  cases: 

Table  I.  Mortality  in  iJijjIitJieria  treated  icith  Antitoxin  and  Previous 
Mortality  icithout  Antitoxin. 

Cases.  Deaths.  ifortality,    Previous  mortality, 

per  cent.  per  cent. 

Hospital  cases     ....    15,o60  3009  19.0 

Private  ctises 9,208  995  10.1  

Total 24,768  4004  16.0  30  to  40 

(Cases  moribund  at  the  time  or  dying  mthin  twenty-four  hours  after 
are  included  in  these  statistics.) 

Table  II.  Mortality  of  Diphtheria  treated  With  and  Without  Antitoxin 
at  the  Same  Time  or  during  the  Same  Period. 

cases.  Deaths.  ^pl-taUty. 

Hospital  with  antitoxin 7986  1754  21.0 

"          ^vithout  antitoxin      9039  3309  36.4 

Private  with  antitoxin 3161  412  13.0 

"        without  antitoxin       4255  1717  40.0 

Total  with  antitoxin 11,147  2161  19.1 

"     without  antitoxin 13,294  5026  37.8 

(The  antitoxin  cases  were  often  severe  cases  taken  as  tests.) 

Table  III.  Mortality  of  Operative  and  Nonoperative  Cases  of  Diph- 
theria treated  with  Antitoxin,  and  Previous  Mortality  of  Operative 
Cases  ivithout  Antitoxin. 

Cases.  Deaths.  Mortality,    Previous  mor- 

per  cent,    tahty,  per  cent. 

Nonoperative  cases  ....    12,066  1491  13.5 

Operative  cases 3,082  1135  .36.7  65 

Total 15,148  2626  16.6 

Tracheotomy 1355  569  42.0  70 

Intubation  "      1173  361  30.8  51.5 

Intubation  and  second  tra- 


cheotORiv 


52  37  71.0 


Intubation  or  tracheotomy.          502                   168  .33.2 

Table  IV.  Mortality  of  Diphtheria  rvith  Antitoxin,  arranged  according 

to  Age. 

cases.               Deaths.  ^p^-tality. 

0-2vears 1494                  469  31.4 

2-5  vears 3678                  762  20.7 

5-10  years 3184                  473  14.8 

Over  10  years 1444                99  6.9 

Total 9800                1803  1^4  (chiefly  hospital). 


700  DIPHTHERIA. 

Table  V.  Mortality  of  Diphtheria  with  Antitoxin,  arranged  according 
to  Day  of  Disease  on  which  Treatment  was  Commenced. 

cases.  Deaths.  Mortality, 

First  and  second  day 4,232  267  6.3 

Third  and  fourth  day 3,870  656  17.2 

After  fourth  day  .    ." 1,984  605  34.6 

Day  unknown   " 339               44  13.0 

"  Total 10,425  1672  16.0 

(Cases  moribund  or  dying  within  twenty-four  hours  inchided.) 

Leaving  statistics,  let  us  look  more  closely  at  the  results  noticed  in 
individual  cases. 

Beneficial  Results  of  Antitoxin. —  Upon  the  Local  Process. — In  the 
cases  in  w^hich  I  have  made  or  seen  an  injection  made  within  the  first 
twenty-four  hours  of  the  disease  the  results  have  been  so  remarkable  that 
I  have  attributed  them  to  the  antitoxin.  Following  are  the  histories 
of  two  typical  cases : 

Case  I.  A  boy  eleven  years  old  had  had  for  twelve  hours  malaise,  with 
pain  on  swallowing.  Inspection  showed  the  tonsils  and  portions  of  the 
palate  to  be  covered  with  a  soft,  slightly  adherent  exudate.  The  boy 
was  injected  with  1000  units,  and  twelve  hours  later  his  throat  was  clear 
and  temperature  normal.  I  do  not  believe  this  Avould  have  been  a  severe 
case  without  antitoxin,  but  the  effect  seemed  magical. 

Case  II.  The  second  case  was  a  baby  one  year  old,  with  a  slight 
croupy  cough  for  twenty-four  hours,  and  stenosis  just  beginning.  Tem- 
perature 102  ;  patient  restless  and  without  desire  for  food.  Injected  600 
units,  and  found  the  baby  on  the  following  morning  practically  well. 

When  the  disease  has  progressed  several  days — and  these  cases  are 
the  ones  seen  in  the  hospital — the  benefit  is  not  so  apparent.  I  believe, 
however,  that  a  marked  effect  is  still  produced.  There  have  been  very 
few  cases,  indeed,  of  pharyngeal  or  tonsillar  diphtheria  in  w^hich  the 
membrane  has  increased  after  admission.  I  believe  that  the  same  result 
has  taken  place  in  laryngeal  diphtheria.  Even  in  well  developed  cases 
the  pseudo-membrane  itself  has  seemed  to  me  to  separate  somewhat  more 
quickly  than  formerly,  there  being  usually  seen  after  thirty-six  to  forty- 
eight  hours  a  line  of  demarkation  separating  the  membrane  and  making 
it  look  like  a  slough  ready  to  be  cast  off.  The  swelling  of  the  throat 
tissues  and  of  the  glands  of  the  neck  also  appears  to  me  to  begin  to  abate 
earlier.  The  ulcerated  surface  left  in  some  cases  after  the  separation  of 
the  membrane  is  covered  with  a  soft  exudate  until  healing  occurs  some 
days  later.  In  laryngeal  diphtheria,  if  the  intubation  could  be  put  off 
for  eighteen  hours,  it  was,  with  very  few  exceptions,  avoided  altogether. 
The  time  during  which  the  cases  remained  intubated  seemed  to  me  to  be 
shorter  than  before  the  use  of  antitoxin.  Many  children  coughed  up 
their  tubes  in  from  twenty-four  to  forty-eight  hours,  and  quite  a  number 
were  able  to  do  without  them  afterward.  Others  required  the  tube  from 
three  to  eight  days.  Exceptional  cases  occurred,  as  previous  to  the  use 
of  antitoxin,  when  the  tube  had  to  be  worn  for  weeks.  The  general 
condition  of  patients  was  beneficially  influenced.  The  loss  of  appetite 
and  the  apathetic  condition  are  less  apt  to  occur,  and  when  present  seem 


ANTITOXiy   IS    Till-:   TIIKATMENT  OF  J)IPHTHERIA.  701 

more  quickly  rclicvcil.  In  cases  iu  wliicli  treutiiicnt  wus  begun  very  late, 
us  a  rule  no  good  effects  were  noted. 

///  Kff'ccfs  of  Aitfifo.vin  Scrum. — A  small  jierccntagc  of  the  cases  have 
a  slight  rise  of"  temperature  inunediately  after  an  injection.  In  a  very 
few  cases  abscesses  develop  at  the  seat  of  the  injection.  This  is  a  pre- 
ventable accident. 

Mcushes. — These  are  peculiar  to  the  serum  injections.  They  are  iiii- 
doubtedlv  partly  due  to  the  horse  serum,  not  altogether  to  the  antitoxin. 
Thev  occur  in  from  5  to  20  per  cent,  of  the  cases  according  to  the  cha- 
racteristics of  the  serum.  The  eruption  may  be  limited  to  the  point  of 
injection,  or  may  more  or  less  com])letely  cover  the  whole  body.  It  most 
often  appears  as  an  urticaria,  but  may  very  closely  resemljle  scarlet  fever 
or  more  rarely  measles.  It  usually  develops  between  the  tenth  and  fif- 
teenth days.  In  some  cases  all  the  forms  may  be  united  in  one  person. 
Following  the  eruption,  desquamation  may  occur.  In  al)OUt  one  fifth  of 
the  cases  there  is  a  rise  in  temperature  of  2°-4°  F.  This  lasts  from  one 
to  three  days.  In  a  small  percentage  of  cases  there  is  accompanying  the 
rash  great  tenderness  over  the  joints  of  the  extremities.  These  i)ains  last, 
as  a  rule,  one  to  four  days.  In  one  case  in  the  hospital  the  joint  affection 
was  more  serious.  The  child,  aged  fifteen  months,  was  admitted  on  April 
25th  with  severe  stenosis.  The  temperature  was  101°  F.  The  child 
was  intubated  and  did  well.  It  received  two  injections  of  1200  units 
each.  On  the  27th  there  was  a  macular  eruption  over  the  body ;  twenty- 
four  hours  later  the  joints  of  the  hands  and  feet  became  intensely  painful. 
The  child  dreaded  the  least  handling.  The  knees  and  the  two  joints  of 
the  left  thumb  became  more  swollen,  and  appeared  like  acute  articular 
rheumatism.  Before  the  eruption  developed  the  child's  condition  was 
rendered  more  serious  by  the  appearance  of  a  broncho-pneumonia,  which 
continued  gradually  to  increase  until  death,  two  weeks  later.  There  have 
been,  in  New  York,  four  cases  reported  in  which  the  joint  lesions  per- 
sisted for  several  weeks.  These  all  finally  recovered.  The  urticaria  and 
erythema  which  at  times  accompany  the  rise  in  temperature  are  in  certain 
cases  very  distressing,  and  in  a  person  already  prostrated  might  not  be 
wholly  without  danger  to  the  patient. 

I  iiave  seen  in  watching  over  1500  cases  no  serious  effects  upon  the 
heart,  kidney,  or  nervous  system  which  I  attribute  to  antitoxin,  with  the 
possible  exception  of  two  cases  of  scarlatina  complicated  with  diphtheria. 
In  these  two  there  was  an  almost  complete  suppression  of  the  urine. 
This  was  probably  due  to  the  scarlet  fever  and  diphtheria,  and  not  to 
the  antitoxin. 

Since  it  has  been  suggested  by  some  that  injections  of  antitoxin  with 
the  accompanying  horse  serum  have  a  disintegrating  effect  upon  the  red 
cells  of  the  blood,  we  investigated  the  matter  very  carefully  in  the 
laboratory  of  the  New  York  Health  Department. 

J.  S.  Billings,  Jr.,  one  of  the  assistant  bacteriologists  of  the  depart- 
ment, examined  very  carefidly  the  blood  in  15  babies  after  they  had 
received  doses  of  antitoxin  for  immunization.  The  children  received 
from  200  to  400  units  each.  No  alteration  was  discovered  in  charac- 
ter of  the  red  or  white  blood  cells.  The  number  of  the  Avhite  cells 
practically  remained  unchanged.  The  number  of  the  red  cells  showed, 
however,   in    half   of   the    cases,   a  very   interesting    change :    in   7   of 


702  DIPHTHERIA. 

the  15  a  gradual  diminution  in  their  number  took  place  from  day  to 
day  until  by  the  sixth  day  there  was  a  loss  of  from  200,000  to  600,000 
in  each  5,000,000  of  their  cells.  After  this  date  the  number  rapidly 
increased,  imtil  upon  the  fourteenth  day  the  numbers  had  returned  to 
the  normal.  In  adults  receiving  1200  units  the  same  result  took 
place.  From  6,000,000  the  count  dropped  to  5,400,000,  and  then  re- 
turned to  the  normal  at  the  end  of  ten  days.  None  of  these  persons 
showed  any  evidences  of  anaemia  except  in  the  examination  of  the  blood. 
The  cells  contained  their  normal  amount  of  haemoglobin.  The  blood 
of  a  series  of  cases  of  diphtheria  treated  with  antitoxin  was  compared 
with  that  in  a  number  in  which  no  antitoxin  was  used.  The  diminution 
in  the  number  of  the  red  blood  cells  was  greater  in  those  not  receiving 
the  antitoxin.  No  marked  effect  was  noticed  upon  the  number  of  the 
white  cells. 

Limitations  of  Antitoxin. — Diphtheria  antitoxin,  so  far  as  is  known, 
has  no  action  upon  the  cells  in  causing  them  to  resist  any  poisons  other 
than  those  produced  by  the  diphtheria  bacilli.  Here  we  see  at  once  a 
limitation  in  the  cure  of  the  complex  disease  called  diphtheria,  for  it  is 
as  correct  to  class  some  of  the  cases  met  with  as  pneumonia  complicated 
with  diphtheria  as  to  call  them  diphtheria  complicated  with  pneumonia. 
Upon  the  pneumonia,  so  far  as  it  is  not  due  to  the  diphtheria  bacillus, 
one  cannot  hope  that  the  antitoxin  will  have  any  curative  effect. 
Another  limitation  is  suggested  by  the  results  of  experiments  upon 
animals.  It  is  known  that  after  the  infection  has  proceeded  to  a 
moderate  degree  it  cannot  be  arrested  by  antitoxin.  Experience  shows 
that  in  human  beings  also  the  cells  no  longer  react  to  antitoxin  after  a 
certain  degree  of  poisoning  has  taken  place,  and  this  point  in  some  cases 
seems  to  occur  very  early.  I  doubt  if  we  are  justified  in  saying  that  in 
these  the  actual  lesions  have  progressed  so  far  that  without  any  further 
poisoning  life  has  become  impossible.  I  believe  it  may  be  possible  that 
even  after  the  administration  of  antitoxin  the  poison  goes  on  producing 
further  lesions,  the  cells  already  affected  by  the  toxin  not  responding  to 
the  antitoxin.  There  are  exceptional  cases  in  which  even  when  the 
antitoxin  is  given  early  it  apparently  fails  to  fortify  the  cells  against 
the  diphtheria  poison. 

In  the  hospital  the  effects  of  antitoxin  upon  laryngeal  diphtheria, 
though  in  one  way  striking,  are  in  another  disappointing.  More  children 
live  than  formerly,  but  it  seems  as  though  still  more  should  live.  Many 
survive  the  acute  infection  only  to  die  later  of  the  complicating  broncho- 
pneumonia. It  has  occurred  in  cases  of  diphtheria  treated  with  antitoxin, 
just  as  in  cases  not  so  treated,  that  a  relapse  may  take  place  four  or  five 
weeks  after  recovery  from  the  disease.  Pneumonia  is  much  less  frequent 
in  private  practice,  and  seems  to  be  less  frequent  under  hospital  treatment 
abroad.     Special  hospital  conditions  were  probably  accountable  for  it. 

The  following  case  illustrates  a  class  which  end  fatally,  and  yet, 
although  the  disease  is  thoroughly  established  and  the  patients  are  under 
the  influence  of  the  toxin,  one  cannot  help  feeling  disappointment  when, 
although  they  respond  to  the  antitoxin  partially,  they  finally  die. 

Case  III.  Alice  M ,  aged  sixteen  years,  a  girl  strong  and  well 

nourished,  was  admitted  to  the  hospital  on  the  third  day  of  her  illness ;  the 
glands  of  her  neck,  both  tonsils,  and  the  peritonsillar  tissues  were  greatly 


USE  OF  AyriTOXIX  IX  I'llEVENTING   DIPHTHERIA.  703 

swollen.  rho  whole  area  extending  hack  into  the  pharynx  was  covered 
by  a  thielv  dirty  white  adherent  membrane;  her  nostrils  were  partially 
obstructed  ;  temperature  99°  F. ;  pulse  108.  Her  intellect  was  clear. 
1000  units  of  antitoxin  were  injected;  same  amount  was  injected 
twenty-four  hours  later.  Thirty  hours  after  her  admission  the  swelling 
and  infiltration  were  much  less;  the  membrane  had  lessened  and  was  of 
more  benign  character.  Pier  heart  was  irregular,  but  she  felt  better ; 
the  temperature  was  99°  F.  and  the  pulse  110.  Four  days  after  her 
admission  her  heart  action  became  much  more  irregular,  and  her  pulse 
was  but  (36,  falling  the  next  day  to  34.  The  patient  had  repeated  attacks 
of  heart  failure  ;  all  nourisiiment  was  vomited,  so  that  stimulants  had 
to  be  given  by  rectum.  The  patient  died  on  the  fifth  day  of  her  stay 
in  the  hospital.  Autopsy  showed  extreme  fatty  degeneration  of  the 
heart  and  extensive  degeneration  of  the  other  organs. 

Use  of  Diphtheria  Antitoxin  in  Preventing-  by  Immunization 
the  Development  of  Diphtheria. — The  results  obtained  under  my 
observation  in  a  number  of  children's  asylums  and  hospitals  and  in 
the  crowded  tenements  of  New  York  have  been  so  very  favorable  that 
they  encourage  the  hope  that  a  general  use  of  antitoxin  for  immuniza- 
tion will  to  a  large  extent  limit  the  spread  of  diphtheria.  At  the  Mt. 
Vernon  branch  of  the  New  York  Infant  Asylum  a  case  of  diphtheria 
developed  on  February  18,  1894.  Cases  continued  to  develop  from 
time  to  time,  so  that  in  September  alone  14  cases  occurred.  From 
that  time  until  January  14th  there  was  hardly  a  day  in  which  a  case 
did  not  develop.  On  January  16th  and  17th,  221  children  were  each 
injected  with  from  100  to  200  units  of  von  Behring's  serum.  No  bad 
effects  were  seen,  and  during  the  next  month  but  1  case  of  diphtheria 
developed ;  this  was  on  the  fourteenth  day.  From  February  22d  to 
27th,  5  cases  appeared,  and  the  children  were  again  immunized.  This 
time  they  each  received  from  125  to  225  units  of  von  Behring's  standard 
of  a  serum  prepared  under  the  direction  of  the  New  York  City  Health 
Department. 

No  cases  appeared  after  the  second  immunization  for  a  period  of  five 
weeks.  Cultures  made  from  the  throats  of  those  in  the  neighborhood 
of  this  case  showed  diphtheria  bacilli  in  the  throats  of  6  of  the  children. 
These  6  were  given  200  units  each  on  March  30th.  One  of  these  chil- 
dren developed  a  small  patch  two  weeks  later,  but  had  no  constitutional 
symptoms.  A  case  developed  on  May  3d,  and  one  on  May  27th,  in 
the  children  immunized  on  February  27th.  The  hospital  has  remained 
since  then  free  of  diphtheria,  so  that  no  third  general  immunization  has 
been    thought  necessary. 

At  the  Nursery  and  Child's  Hospital  in  New  York  in  the  three 
weeks  preceding  April  18,  1895,  there  were  15  cases  of  diphtheria. 
Upon  that  day  136  children,  varying  in  age  from  three  weeks  to  four 
years,  were  immunized  by  receiving  from  50  to  200  units  each.  The 
children  showed  no  bad  effects  from  the  injections.  A  temporarv  rise 
in  temperature  occurred  in  one  fourth  of  them,  which  lasted  for  six  to 
twelve  honrs.  From  the  day  of  the  injections  to  the  present  time  no 
diphtheria  has  developed  in  the  hospital,  with  two  very  interesting 
exceptions — a  physician  and  a  nurse  who  had  not  been  immunized. 
Since  then  the  hospital  has  been  free  from  diphtheria. 


704 


DIPHTHERIA. 


At  the  House  of  Reception  of  the  New  York  Catholic  Protectory 
2  cases  of  diphtheria  developed  on  July  7,  and  3  cases  on  July  8th 
and  9th,  1895.  On  July  9th  and  10th  the  remaining  67  children  were 
injected  with  150  to  600  units  each.  (The  children's  ages  varied  be- 
tween two  and  a  half  and  fifteen  years.)  No  diphtheria  developed  after 
the  injections  in  any  of  these  children.  In  August  a  new  set  of  chil- 
dren were  received,  and  August  5th  a  case  of  diphtheria  developed  among 
these,  and  on  August  10th  a  second.  On  this  day  the  37  children  who 
comprised  the  new  lot  were  injected  with  from  200  to  600  units  of  the 
Health  Department's  serum.     No  more  diphtheria  developed. 

The  dosage  was  graded  as  follows  : 

2  years 1  case 200  units. 

3  "      1     "       250     " 

6  "      1     "       350     " 

7  to  12  years     .    .    •    ...  20  cases 400  to  500  units. 

13  to  20      "        14     "       500  to  600     " 

The  injection  having  been  made  in  the  forenoon,  most  of  the  children 
showed  temperatures  of  from  99°  to  99.5°  F.  the  same  evening,  two  or 
three  reaching  100°,  and  one  100.6°  F.  During  the  two  days  on  which 
observations  were  made  most  of  the  temperatures  subsided  to  normal,  a 
few  remaining  at  99°  F.  No  cases  except  those  mentioned  later  showed 
any  constitutional  symptoms  after  the  injections.  In  only  2  cases  was 
there  any  local  irritation.  In  1  of  these  the  symptoms  promptly  sub- 
sided without  treatment ;  the  other,  unfoi'tunately,  developed  an  abscess. 
In  the  last  group  of  cases,  37  in  number,  specimens  of  urine  were 
obtained  before  the  injections  to  compare  with  those  taken  after  the 
administration  of  the  serum.  The  results  of  the  examinations  are  as 
follows : 


Before  immunization, 
August  9tli. 

After  immunization, 
Aug.  lltli.                         Aug.  13th. 

Sp.  gr. 

Albumin. 

Sp.  gr. 

Albumin. 

Albumin. 

Case  1 

"    2 

"     3 

"     4 

'•     5 

"     6 

10.22 
10.24 

Trace. 

Negative. 

30  per  cent,  in  vol. 
Negative. 

10.30 

Negative. 
Trace. 

60  per  cent. 
16  per  cent. 

Negative. 

One  child  showed  30  per  cent,  in  volume  of  albumin  (the  urine,  after 
boiling  and  the  addition  of  nitric  acid,  was  allowed  to  stand  for  twenty- 
four  hours,  and  the  deposit  was  then  estimated)  in  the  urine  before  treat- 
ment, and  after  the  injection  there  was  about  60  per  cent,  in  volume. 
The  urine  from  the  sister  of  this  child  showed  no  albumin  before  the 
injection,  and  gave  not  the  slightest  evidence  of  illness  other  than  the 
albuminuria  at  any  time,  and  neither  showed  any  temperature  reaction. 
In  both  of  these  cases,  as  in  all  the  others,  the  albumin  had  entirely 
disappeared  two  days  later. 

Nine  days  after  the  injections  1  case  developed  an  urticaria  which 
lasted  for  twenty-four  hours.  No  other  cases  showing  the  skin  rashes 
were  observed.     At  the  Reception  House  of  the  Juvenile  Asylum  in 


USE   OF  AXTITOXIX   IS   ritEVENTIXG   DIPHTHERIA.  705 

New  York  4  cases  of  diplitlieria  developed  during  the  week  ending 
April  1 1,  l^i05.  On  tlie  Titli  the  children  (to  the  number  of  about  70) 
were  injected  with  from  200  to  400  units. 

No  cjises  occurred  afterward,  except  that  the  boys'  attendant  and  an 
engineer  who  handle(l  tlio  clothes  from  the  diphtheria  cliildren,  and  who 
hail  received  immunizing  injections,  develoj)ed  diphtheria. 

To  nu'  these  results  seem  conehisive  as  to  the  immunizing  power  of 
injections  of  from   100  units  of  antitoxin   upward. 

Although  in  these  institutions  it  was  impossible  to  say  that  any 
special  child  would  develop  diphtheria,  still  it  was  an  absolute  certainty 
that  in  each  of  these  institutions  more  cases  would  have  developed  unless 
in  some  wav  the  children  could  l)e  immunized. 

About  one  sixth  of  the  children  had  slight  albuminuria,  and  a  much 
smaller  jiercentage  developed  it  to  a  greater  extent.  In  none,  however. 
Mere  there  any  other  symptoms  pointing  to  any  deleterious  action  on  the 
kidneys,  and  in  none  was  the  albuminuria  more  than  transitory. 

In  the  blood  there  was  noticed,  as  before  stated,  a  slight  temporary 
diminution  in  the  number  of  the  red  blood  colls  ;  no  other  changes  were 
observed. 

Iiiiiiiunizatloii  by  Xcw  YorJ:  Health  Department  In.spedors  In  Infected 
Familiefi. — For  some  months  past  in  families  in  which  diphtheria  has 
occurred,  and  in  which  there  were  other  children  exposed  to  infection, 
the  Health  Department  inspectors,  a<:'ting  on  their  own  judgment  as  to 
the  necessity,  have  immunized  some  of  these  exposed  persons.  Most 
of  these  cases  have  been  among  the  tenement-house  population.  A  few 
cases  taken  at  random  from  the  reports  of  the  inspectors  illustrate  the 
method  : 

Fainilji  1. — Five  children  in  family  ;  2  cases  of  diphtheria  ;  the  other 
o  children,  aged  nine,  eleven,  and  thirteen  years,  were  immunized  ;  no 
further  cases  occurred. 

Fa  mill/  2. — Three  children  in  family;  1  case  of  diphtheria  ;  2  other 
children,  aged  eight  and  sixteen  years,  immunized  ;  1  child  had  diph- 
theria bacilli  in  the  throat  at  the  time.     Xo  further  cases  of  diphtheria 

Family  S. — Three  children  in  family  ;  1  case  of  diphtheria,  1  of  the 
remaining  2  children  immunized  ;  second  child,  aged  sixteen,  not  im- 
munized. This  child  developed  diphtheria  three  weeks  later,  and  was 
successfully  treated  with  the  antitoxin. 

Cases  like  the  foregoing  might  be  repeated  almost  indefinitely.  232 
persons  had  been  immunized  in  this  way  up  to  October  1,  1895,  and  of 
these  at  least  93  (many  of  the  others  were  not  examined  bacteriologically 
before  being  immunized)  had  diphtheria  bacilli  present  in  their  throats 
when  treated.  The  cases  were  kept  under  observation  until  the  premises 
had  been  disinfected,  and  this  was  done  until  the  throats  of  all  were  free 
from  bacilli. 

Among  the  232  persons  immunized  by  the  inspectors  3  developed' mem- 
branous croup  within  twenty-four  hours  of  the  time  when  they  were 
treated,  who  in  fact  had  diphtheria  before  l)eing  injected,  but  all  recov- 
ered. Three  others  had  mild  pharyngeal  diphtheria — developing  1  on 
the  nineteenth,  1  on  the  thirtieth,  and  1  on  the  thirty-first  day  after 
injection,  and  1   developed  a  fatal  diphtheria  on  the  fifty-fifth  day. 

The  cases  detailed  number  altogether  1043;  224  of  these  were  im- 

YoL.  I. — 45 


706 


DIPHTHERIA. 


munized  once  with  von  Behring's  sernm,  and  the  second  time  with  the 
New  York  Health  Department  serum.  In  a  large  percentage  of  the 
whole  number  diphtheria  bacilli  were  present  in  the  throat  when  the 
serum  was  administered,  and  all  had  been  exposed  to  diphtheria  under 
conditions  more  or  less  favorable  for  the  transmission  of  the  disease. 
Among  those  immunized  3  cases  of  diphtheria  occurred  between  one 
and  thirty  days  after  the  treatment ;  i.  e.  1  on  the  twelfth,  1  on  the 
seventeenth,  and  1  on  the  nineteenth  day,  respectively. 

Twelve  cases  developed  diphtheria  later  as  follows  :  On  the  thirtieth 
day,  2  ;  thirty-first  day,  1  ;  thirty-third  day,  1  ;  thirty-seventh  day,  1  ; 
thirty-ninth  day,  1  ;  fortieth  day,  2  ;  forty-second  day,  1  ;  fifty-second 
day,  1 ;  fifty-fifth  day,  1  ;  sixty-sixth  day,  1  ;  ninetieth  day,  1 .  The 
4  cases  that  developed  croup  within  twenty-four  hours  of  the  injection 
undoubtedly  had  the  disease  at  the  time  of  injection. 

Table  showing  the  Number  of  Cases  Immunized  in  New  York  City,  and 

the  Results. 


c 

=e   COr- 

•gSi 

li   '         fi^ 

■o 

'S 

■gj  3 

j:  2 

£o    '          £.ai 

'3 

S  bcS 

s 

c 

^S-i^ 

p.^ 

!§•  c              ~  =  'S 

s 

c3 

'■3% 
o 

'm 

QD    U 

i,  b'''?,  ^ 

«  so 

to                         r      -M 

i^S. 

o  p  g  ce 

<E    C 

Oi  .«                               3J  E  CO  ^ 

c3 

am 

e  'B.'"  "^ 

S'P. 

m   o                              X   o  C  -^ 

ce  £*                      ^  o  c  c 

t> 

^"a 

=^.25§ 

o  ®                       ^  c  —  ^ 

o 

oS 

O  >  5 

of;                      'o  ri  S  c 

o 

o^ 

6^.§i 

V  o 

d  -a                     ;  ~  X  •= 

IZi 

!2i 

;zi 

•^ 

;z;                 a 

New  York  Infant  Asylum  (1st  im- 
munization). 
New  York  Infant  Asylum  (2d  im- 

224 

100  to  200 

1  mild  on  the 

19th  day. 
1  mild  on  the 

0 

6      107  cases  in  108  days. 

245  125  to  225 

0 

4      6  cases  in  12  davs. 

munization). 

] 

12th  day. 

Nursery  and  Child's  Hospital  .   . 

136  j    50  to  200 

0 

0 

0      46  cases  in  90  days  ; 
15  cases  in  15  days. 

New  York  Juvenile  Asylum  .   .  . 

81  150  to  250 

0 

0 

0      12  cases  ;  3  cases  in 
2  days. 

New  York  Catholic  Protectory  .   . 

114,  150  to  600 

0 

1 

0      5  cases  in  3  days. 

Bellevue  Hospital 

11'  175  to  225 

0 

0 

0      2  cases  in  10  days. 
(1  :  30  One  or  more  cases  in 
3-^  1  :  31:    more  than  90  fam- 
U  :  55'    ilies. 

Health  Department  Inspectors  .  . 

232  150  to  250 

1  mild  on  the 
19th  day. 

3 
4 

Total 

1043         .    . 

3 

18      i 

Altogether,  therefore,  excluding  these,  16  cases  of  diphtheria  occurred 
among  1014  persons — 3  in  from  one  to  thirty  days,  and  13  in  from 
thirty  to  one  hundred  and  ten  days  after  immunization.  These  cases 
were  all  mild,  excepting  2,  1  of  which  proved  fatal  from  diphtheria,  and 
in  the  other  death  seemed  to  be  due  to  broncho-pneumonia  complicated 
by  a  mild  diphtheria.  During  ninety  days  preceding  immunization, 
under  practically  the  same  conditions,  it  may  be  said  that  more  than 
225  cases  of  diphtheria  occurred.  By  the  use  of  antitoxin  it  has  been 
possible  to  stamp  out  completely  diphtheria  in  four  great  institutions  for 
the  care  of  children  in  which  it  was  prevailing  in  more  or  less  epidemic 
form.  In  no  instance  have  there  been,  so  far  as  can  be  determined,  any 
serious  results  from  the  administration  of  the  remedy  for  this  purpose. 
The  duration  of  immunity  in  many  cases  is  apparently  not  more  than 
thirty  days,  but  it  may  be  for  a  much  longer  time.  The  doses  required 
to  confer  immunity  are  probably  between  50  and  300  antitoxin  units,, 
according  to  the  age  of  the  individual  treated. 


PSEUDn-nirnriiJUHA.  707 

A  siiiiiinary  ol"  I'liscs  ivpurlcd  in  the  joiiriKils  is  as  lollctws: 

Iimiuinlzdfion  />;/  Aiifito.vin. 

Total  I'ast's  iiiimiini/A'il         li),o7(). 

Antitoxin  units  iiijivti'd ")0  to  1000  fusnally  150- 200). 

Attai'kod  witliin  ;{("l  (lays 129  niild,  all  ri'covi'ivd. 

Attac-ked  after  30  days 20  mild,  all  recovered. 

(No  serious  after-effects  observed  wliicli  could  be  ascribed  to  the 
antitoxin  injected.) 

Conclusion  on  Diphtheria  Antitoxin. — Diphtlicria  antitoxin 
lias  a  marked  curative  effect  in  diphtlieria.  The  results  are  very  strik- 
ing when  the  injections  are  used  early  in  the  disease,  and  when  the 
diphtheria  is  nn(!oniplicated  with  pneumonia  or  sepsis.  In  Avell  devel- 
oped cases  and  in  those  having  complications  its  benefit  is  less  marked. 
In  cases  already  profoundly  under  the  influence  of  the  diphtheria  toxin 
and  in  a  dying  condition  it  is  useless. 

The  total  amount  required  in  the  treatment  of  a  case  varies  from 
1000  to  0000  units  of  von  Behring's  standard,  and  is  determined  b}^  the 
severity  and  duration  of  the  disease  and  the  weight  of  the  patient.  An 
injection  of  100  to  300  units  of  antitoxin  in  a  person  will  give  an 
almost  certain  immunity  from  diphtheria  for  four  weeks.  If  security  is 
desired  for  a  longer  period,  the  injection  must  be  repeated. 

Diphtheria  antitoxin  will  not  cure  all  cases  of  diphtheria  in  which 
the  element  of  mixed  infection  is  marked,  even  if  given  early  in  the 
disease.  It  does  not  destroy  the  diphtheria  bacilli.  It  is  desirable 
with  the  antitoxin  to  use  other  treatment,  both  local  and  constitu- 
tional. The  injection  of  diphtheria  antitoxin  Math  its  accompanviug 
horse  serum  is  attended  in  a  moderate  percentage  of  the  cases  with 
disagreeable  results,  but  in  very  few  if  any  with  serious  ones.  Xo 
cases  have  been  observed  in  which  the  kidneys  showed  any  evidence 
of  being  seriously  affected.  It  does  not  appear  to  have  any  deleterious 
effects  on  the  blood,  other  than  to  cause  a  moderate  temporary  diminu- 
tion in  the  number  of  red  blood  cells,  and  even  this  is  more  than  coun- 
terbalanced by  its  lessening  the  action  of  the  diphtheria  poison. 

Large  injections  in  persons  not  having  diphtheria  are  more  apt  to 
cause  unpleasant  and  even  somewhat  serious  after-effects,  than  in  those 
affected  by  the  disease.  It  is  well,  therefore,  to  be  fairly  sure  of  the 
diagnosis  in  adults,  in  whom,  as  a  rule,  but  little  danger  exists,  before 
giving  a  full  injection. 

PSEUDO-DIPHTHERIA,  INCLUDING  NON-DIPHTHERITIC 
MEMBRANOUS  LARYNGITIS,  OR  CROUP. 

Pseudo-diphtheria  is  not  a  distinct  disease  like  diphtheria.  The 
name  is  used  to  cover  all  inflammations  of  the  upper  air  pasisao-es  not 
due  to  the  diphtheria  bacilli  which  simulate  the  less  characteristic  cases 
of  di])htheria.  The  bacteriology  of  pseudo-diphtheria  has  been  already 
considered  in  the  earlier  part  of  this  article.  (See  page  670.)  Manv  oif 
the  varieties  of  pseudo-diphtheria  are  considered  imder  other  headings, 
such  as  tonsillitis,  the  throat  lesions  complicating  scarlet  fever,  acute 


708  DIPHTHERIA. 

laryngitis,  etc.      These   will  be,   however,  grouped  together  here,  and 
briefly  considered  in  connection  with  a  few  illustrative  cases. 

Clinical  Divisions. — 1.  Extensive  pseudo-membranes,  mostly  con- 
fined to  tonsils,  soft  palate,  and  pharynx  :  a,  uncomplicated  ;  b,  compli- 
cating infectious  diseases.  2.  Pseudo-membranes  involving  the  larynx. 
3.  Pseudo-membranes  and  exudates  confined  to  the  tonsils. 

1.  Illustrative  Cases. — Extensive  Fseudo-membranes,  confined  Chiefiy 
to  the  Tonsils,  Soft  Palate,  and  Pharynx. — Case  I.  Feb.  5th.  Female 
aged  eight.  Clinical  history  :  Tonsils  covered  by  large,  irregular,  ad- 
herent, whitish  patches.  Fauces  and  tonsils  swollen  and  livid  in  color. 
Temperature,  104°  F. ;  pulse,  40 ;  respiration,  20. 

February  6th.  Tonsils,  sides  and  tip  of  uvula,  and  faucial  pillars  cov- 
ered by  a  thin,  friable,  grayish  pseudo-membrane,  which  leaves  a  bleeding 
surface  on  removal.  The  appearance  is  as  if  on  a  mucous  membrane 
denuded  of  its  superficial  epithelium  a  thick  paint  had  been  applied. 

February  7th.  Tonsils  and  faucial  pillars  clear  of  membrane; 
superficial  ulceration  on  pillars,  and  adherent  membrane  to  uvula. 
Temperature  remains  between  102°  and  104°  F. ;  pulse,  118  to  130; 
respiration,  24  to  30. 

February  16th.  Ulceration  on  uvula  nearly  healed.  Temperature 
normal.     No  albumin  in  urine  at  any  time.     No  great  prostration. 

Case  II.  February  27th.  Female,  aged  nineteen.  Clinical  history  : 
Both  tonsils  and  adjacent  surfaces  of  uvula  covered  by  a  thin  gray  mem- 
brane. Tonsils  much  swollen  and  painful.  Great  hypersemia  of  pharynx. 
Temperature,  99.6°  F.  ;  pulse,  100.     No  albumin  in  urine. 

February  29th.  All  symptoms  abated.  Membrane  disappeared. 
No  swelling  of  glands. 

Case  III.  February  3d.  Female,  aged  sixteen  months.  Clinical 
history  :  Thin,  adherent,  semi-translucent  membrane  on  tonsils  and  ad- 
jacent surfaces  of  uvula.  Nostrils  occluded,  but  no  membrane  visible. 
Croupy  voice  and  breathing.  Slight  swelling  of  glands  of  neck.  Tem- 
perature, 100.2°  F. ;  pulse,  136;  respiration,  34. 

February  4th.     Membrane  nearly  disappeared.     Child  nearly  well. 

February  6th.  Throat  perfectly  clean.  Child  is  well.  Evening 
temperature,  100°  F.  ;  pulse,  118  ;  respiration,  28. 

Case  TV.  February  3d.  Jennie  K ,  aged  eighteen.  Clinical  his- 
tory :  Thin  adherent  pseudo-membrane  on  sides  and  tip  of  uvula.  Some 
hyperemia  of  pharynx.  Temperature,  101.4°  F. ;  pulse,  100.  Mem- 
brane remained  four  days.  After  the  first  day  temperature  and  pulse 
sank  to  the  normal,  and  patient  did  not  appear  sick.  No  albumin  in 
urine.     Discharged  on  the  sixth  day. 

In  these  cases  there  is  first  a  redness  and  swelling  of  the  mucous 
membrane  of  the  pharynx,  tonsils,  and  fauces,  with  later  a  thin  purulent 
discharge.  Cultures  at  this  time  reveal  very  abundant  colonies  of  strep- 
tococci. The  epithelium  of  the  inflamed  mucous  membrane,  where  the 
irritation  is  intensified  by  the  contact  and  friction  of  adjacent  surfaces, 
becomes  necrotic,  and  the  denuded  surface  becomes  covered  by  a  thin 
pseudo-membrane,  composed  mostly  of  streptococci  held  together  by  a 
small  amount  of  fibrin.  The  streptococci  may  also  penetrate  into  the 
denuded  mucous  membrane. 

If  one  looks  at  a  well  marked  case,  having  the  patient  open  the  mouth 


rsKri)<)-i>ii'iiriii:i:i.\.  VOf> 

sligljtly,  :uk1  ik'pivsst's  tlic  li>nt2,iu' Jiist  a  lilllc,  (Ik-  iiillaincd  uvula  is  seen 
lying  botweon  and  against  the  swollen  tonsils.  On  the  portions  of  the 
uvula  thus  irritated  by  contact,  on  the  f'aueial  pillars  lying  against  the 
tonsils,  and,  in  extreme  cases,  on  the  lateral  walls  of  the  ]>harynx  and  on 
the  soft  palate  spreading  up  from  the  sides  of  the  uvula,  one  finds  the 
pseudo-membrane,  which  is  always  light  grayish  in  color,  thin,  an<l  fri- 
able. On  removal  a  bleeding  surface  is  disclosed.  When  astringent 
applications  are  not  used  the  membrane  usually  disappears  gradually, 
and  does  not  scale  otf  in  firm  pieces  of  considerable  size,  as  in  niany  eases 
of  true  diphtheria. 

In  none  of  these  cases  is  there  a})t  to  be  a  fatal  result,  nor  great  pros- 
tration, after-emaciation,  or  paralysis.  Except  that  these  cases  were  not 
complicated  by  suppuration  of  the  cervical  glands  and  diifuse  cellulitis, 
they  otherwise  appear  to  be  the  same  as  the  pseudo-membranous  inflam- 
mations complicating  scarlet  fever,  the  greater  severity  in  the  latter  being 
probably  due  to  the  influence  of  the  scarlet  fever  poison.  The  temper- 
ature curve  varies  greatly  in  different  cases.  The  bacteriological  diag- 
nosis is  of  great  value  in  prognosis. 

Pseudo-membranous  Inflammations  Gomplieating  Scarlatina . — C^on- 
fined  (ihiefly  to  tonsils,  soft  palate,  and  pharynx.  Except  for  compli- 
cations these  give  exactly  the  same  clinical  appearances  as  those  not 
complicating  infectious  diseases. 

The  complicating  pseudo-membranous  inflammation  occurring  early 
adds  greatly  to  the  severity  of  the  case;  thus  in  10  cases  of  scarlet  fever 
observed  by  me,  in  which  a  severe  complicating  croupous  inflammation 
appeared  early,  6  died.  Of  the  7  in  which  it  appeared  late,  all  recovered. 
Of  the  6  fatal  cases,  2  had  extensive  gangrenous  cellulitis,  beginning  in 
the  neck,  spreading  over  the  chest,  and  causing  the  sloughing  of  an  ex- 
tensive portion  of  skin.  A  third  had  diifuse  suppuration  in  and  al)out 
the  cervical  glands. 

2.  Pseudo-membranes  Involving  the  Larynx  caused  by  Streptoeocvl . — 
Case  I.  February  1 3th.  Female,  aged  five.  Recovered.  Clinical  history  : 
On  admission  to  the  hospital  cyanotic  from  laryngeal  obstruction  ;  intu- 
bated, relieved  ;  very  slight,  adherent,  thin,  pearl-gray  patches  on  uvula. 
Temperature,  100°  F. ;  pulse,  102 ;  respiration,  22. 

February  17th.  Patient  never  seemed  sick  ;  exudation  on  uvula  dis- 
appeared ;  no  albumin  in  urine  ;  tube  remained  in  five  days. 

Case  II.  March  18th.  Female,  aged  one.  Recovered.  Clinical  his- 
tory :  A^ery  small  white  patch,  slightly  adherent  to  right  tonsil ;  laryngeal 
dyspnoea ;  made  to  vomit,  and  fumigated  with  calomel,  but  without  relief; 
intubated  five  hours  after  arrival  in  hospital.  Temperature,  99.6°  F. ; 
pulse,  120;  respiration,  30. 

March  20th.  Seems  about  well ;  tube  still  retained  ;  some  albumin 
in  urine, 

March  26th.     Tube  removed  ;  temperature  never  above  100°  F. 

Bacterial  examination  :  Cultures  gave  abundant  colonies  of  the  long- 
chained  streptococcus. 

Case  III.  March  19th.  Male,  aged  four.  Died.  Clinical  history  : 
Intubated  before  admission  to  hospital.  Temperature,  100°  F. ;  pulse, 
130;  respiration,  32.  No  membrane  visible  in  throat;  some  white,  flaky 
membrane  coughed  up  ;  large  amount  of  albumin  in  urine. 


710  DIPHTHERIA. 

March  22d.  Chest  full  of  rales  ;  child  drowsy  and  cyanotic,  although 
there  is  no  laryngeal  obstruction.  Temperature,  102°  F. ;  pulse,  150; 
respiration,  42.     Swallows  with  difficulty.     Died  on  23d. 

Case  IV.  March  21st.  Female,  aged  four.  Clinical  history  :  Marked 
laryngeal  dyspnrea  on  arrival,  intubated  one  half  hour  later ;  large  piece 
of  thin,  crumbling  membrane  coughed  up  through  tube ;  swollen  tonsils, 
with  small  whitish  patches.  Temperature,  99.4°  F. ;  pulse,  104  ;  respira- 
tion, 26. 

March  24th.  Tube  removed  ;  seems  well;  highest  temperature,  101° 
F.     Xo  albumin  in  urine. 

Case  A".  April  27th.  Male,  aged  forty-three.  Died.  On  admis- 
sion the  history  is  obtained  from  friends  that  he  has  been  three  days 
sick.  He  is  weak,  slightly  delirious,  and  appears  as  if  suifering  from 
some  severe  infectious  disease.  The  whole  uvula  and  the  portions  of 
soft  palate  adjacent  to  it  are  covered  by  a  very  thin,  dirty  covering 
which  can  hardly  be  called  a  pseudo-membrane.  The  whole  pharynx 
and  palate  are  extremely  hypersemic.  Patient  is  hoarse,  and  has  some 
laryngeal  dyspnoea.  Temperature,  103°  F. ;  pulse,  128  ;  respiration,  26. 
Patient  became  violently  delirious,  and  died  the  next  day.     Xo  autopsy. 

This  case  is  interesting,  as  it  is  the  only  fatal  one  in  adults.  It  is 
probable  that  the  croupous  inflammation  was  only  a  complication  of 
some  one  of  the  infectious  diseases. 

Swmmary. — These  typical  cases  prove  that  membranous  croup  is 
at  times  an  independent  disease,  having  no  connection  with  true  diph- 
theria. In  only  2  out  of  16  investigated  by  me  was  any  connection 
with  scarlet  fever  or  measles  discovered.  A  diagnosis  from  the  clinical 
history  and  appearance  is  impossible.    Of  the  1 6  cases  there  were  6  deaths. 

In  the  majority  of  the  10  cases  that  recovered  the  course  of  the 
disease  was  mild.  After  intubation  had  relieved  the  dyspnoea  the 
patients  never  appeared  dangerously  ill.  By  the  third  day  they  were 
sitting  up  in  their  beds  and  playing  with  their  toys.  The  temperature 
averaged  somewhat  higher  during  the  first  days  than  in  the  cases  of 
laryngeal  diphtheria,  and  rose  to  103°  and  104°  F.  when  the  lungs 
became  involved. 

In  2  of  the  children  a  pretty  clear  history  of  direct  infection  from 
other  cases  was  obtained.  In  non-diphtheritic  croup  the  magical  effect 
of  intubation  is  seen,  for  without  tracheotomy  or  intubation  the  majority 
would  certainly  have  died.  The  percentage  of  recovery  was  71^  per 
cent,  in  the  cases  not  complicated  by  scarlet  fever.  Broncho-pneumonia 
was  the  most  frequent  cause  of  death. 

3.  Pseudo-membranes  confined  to  the  Tonsils  caused  by  Streptococci. — 
Case  I.  March  3,  1892.  Female,  aged  six.  Clinical  history :  From 
an  asylum  with  3  other  cases.  Right  tonsil  is  swollen  and  covered 
by  a  thick,  adherent,  gray-colored,  fibrinous  pseudo-membrane.  Cer- 
vical glands  considerably  swollen  on  right  side  ;  slight  pain  and  tender- 
ness.    Temperature,  101°  F. 

March  5th.  Still  thick  membrane  on  tonsil,  nowhere  else.  Feels 
well. 

March  7th.     Tonsil  clean.     Is  slightly  croupy. 

March  9th.     Perfectly  well. 

Case  II.     Male,  aged  four.     From  same  asylum.     Clinical  history  : 


]'Sicri>()-i)fi'iiTi{i':iiLi.  71 1 

Pseiulo-incmhraiic  on  upper  portion  of  led  toii-il  and  adjacent  surface 
of  anterior  and   jiosterior  i)illars.      Well  on   tliird  day.     No  fever. 

Cash  III.  March  5,  189:2.  Female,  a^ed  twenty-one.  Clinical 
liistorv  :  Both  tonsils  are  nearly  covered  hy  irrefi;nlar,  senii-adlierent 
pseiulo-menibranons  patches.  (Considerable  swellinii;  and  liypenemia. 
No  swelling  of  glands.  Not  nuicli  })ain  ;  slight  constitutional  symptoms. 
Temiierature,  101°  F. 

>Iareh  7tli.     Tonsils  nearly  clean.     Feels  well. 

March  Stii.      Perfectly  well. 

In  adults  thick  croupous  patches,  adherent  or  non-adherent,  if  con- 
fined to  the  tonsils  after  twenty-four  hours,  very  rarely  have  anything 
to  do  with  true  diphtheria.  The  same  bacteria  (the  streptococci)  which 
under  certain  influences  cause  an  inflamed  throat  or  a  follicular  tonsil- 
litis, under  others  seem  to  produce  a  croupous  tonsillitis.  Two  n)eml)ers 
of  a  family  may  be  affected,  one  with  the  former,  the  other  with  the 
latter  disease.  In  a  few  cases  a  very  complete  history  of  direct  trans- 
mission of  the  contagium  is  obtained.  The  croupous  deposit  or  pseudo- 
membrane  lasts  from  two  to  seven  days.  All  cases  recover  without 
complications. 

The  intimate  connection  of  some  cases  of  croupous  tonsillitis  with 
scarlet  fever  is  brought  out  in  the  following  example  : 

Female,  aged  twenty-one,  was  admitted  to  the  hospital  with  marked 
croupous  tonsillitis,  with  constitutional  and  local  symptoms,  on  May  20th. 
The  three  previous  days  she  had  taken  care  of  a  child  sick  with  scarlet 
fever,  and  on  the  last  day  also  of  the  mother,  who  was  attacked  with 
croupous  tonsillitis.  Both  she  and  the  mother  had  come  in  frequent 
direct  contact  with  the  child. 

Two  physicians  attended  a  gentleman  sick  with  malignant  scarlet 
fever  and  croupous  tonsillitis.  Both  were  attacked  with  croupous  tonsil- 
litis, and  one  w'ith  scarlet  fever  also. 

Proc4Xosis. — With  the  exception  of  cases  in  which  the  larynx  is 
involved  uncomplicated  cases  of  psendo-diphtheria  are  not  dangerous  to 
life.  Although  non-diphtheritic  croupous  laryngitis  is  less  dangerous 
than  diphtheritic,  still  the  danger  of  suffocation  without  operative 
relief  and  of  complicationg  pnemnonia  is  ever  present,  and  the  mor- 
tality is  considerable. 

Pseudo-diphtheria  complicating  infectious  diseases  during  their  early 
stages  adds  somewhat  to  the  danger  of  the  disease,  and  is  usually  an 
indication  of  a  severe  infection. 

Teeatmext. — The  treatment  of  pseudo-diphtheria  is  similar  to  that 
of  equally  severe  cases  of  diphtheria,  with  the  exception  of  the  anti- 
toxin. 

In  cases  not  involving  the  larynx  the  temperature,  general  pains, 
and  local  soreness  can  be  somewhat  alleviated  by  giving  internally  salol 
gr.  V  every  three  to  six  hours  or  phenacetiu  gr.  v  every  six  to  eight 
hours  in  adults,  gr,  iii  in  children.  Antipyrine,  antifebrin,  and  salicylate 
of  soda  are  also  employed  with  good  effect  in  the  tonsillar  cases. 


PERTUSSIS. 

By  J.  P.  CROZER  GRIFFITH,  M.  D. 


Synonyms. — Whooping  cough  ;  Tussis  convulsiva. 

Definition. — An  infectious  disease,  occurring  principally  in  chil- 
dren, and  characterized  by  a  cough  of  a  peculiar  paroxysmal  nature  and 
by  more  or  less  bronchial,  laryngeal,  and  nasal  catarrh. 

Etiology. — Age. — Among  the  most  powerful  predisposing  causes 
of  whooping  cough  age  would  seem  to  hold  a  prominent  place.  The 
great  majority  of  cases  occur  before  the  sixth  year,  and  over  half  of 
these  before  the  fourth  year,  according  to  the  estimates  of  West.  Be- 
fore the  age  of  six  months  the  disease  is  not  so  common,  although  less 
unusual  at  that  period  of  life  than  are  scarlet  fever,  measles,  and  some 
of  the  other  infectious  diseases  of  childhood.  In  a  few  reported  cases  it 
seems  to  have  developed  before  birth.  It  does  not  often  occur  after  the 
age  of  ten  years,  although  adults  sometimes  are  attacked  by  it.  The 
chief  cause  for  this  immunity  of  adults  doubtless  is  that  the  majority 
of  them  suffered  from  the  disease  during  childhood.  There  is,  however, 
probably  a  lessened  susceptibility  to  it  with  advancing  years. 

Sex  does  not  appear  to  exert  any  decided  etiological  influence.  It 
has  often  been  stated  that  pertussis  is  more  common  in  girls  than  in 
boys,  but  the  truth  of  this  does  not  seem  to  be  entirely  confirmed  by 
statistics,  which  are  not  at  one  upon  this  point.  The  extensive  statistics 
of  Vladimiroff  favor  the  greater  frequency  in  girls. 

The  state  of  the  previous  health  is  important.  It  is  the  general 
opinion  that  weakly,  delicate,  or  sickly  children  acquire  whooping  cough 
more  easily  than  do  those  who  are  well.  An  attack  of  measles  is  often 
followed  by  one  of  pertussis.  This  association  is  especially  well  illus- 
trated in  epidemics  of  the  two  disorders.  Indeed,  the  statement  is  often 
made  that  an  epidemic  of  measles  predisposes  to  the  development  of  one 
of  whooping  cough.  It  does  not  seem  clear,  hoAvever,  whether  the  asso- 
ciation is  only  accidental  or  whether  it  is  actually  etiological.  Whatever 
causal  relation  other  diseases  may  have  to  whooping  cough,  it  appears 
certain  that  its  development  is  not  at  all  hindered  by  their  existence. 

Climate,  season,  and  geographical  jjosition  do  not  seem  to  exert  any 
real,  influence.  The  disease,  it  is  true,  is  more  prevalent  in  the  civilized 
parts  of  the  world,  but  this  depends  merely  on  the  foct  that  it  has  not 
yet  been  carried  to  other  regions  or  has  not  yet  become  firmly  established 
there.  There  are  contradictory  statistics  regarding  the  frequencv  of 
the  disease  at  any  one  period  of  the  year,  which  show  that  season  cer- 
tainly has  but  little  bearing. 

The  station  in  life  is  likewise  without  much  influence.     The  poor  are 

713 


714  PERTUSSIS. 

perhaps  more  subject  to  it,  on  account  of  the  greater  ease  of  its  diffu- 
sion which  their  unhygienic  method  of  living  occasions. 

The  exciting  cause  of  whooping  cough  is  infection.  Consequently, 
the  disease  occurs  in  epidemics,  although  in  the  larger  cities  it  is  practi- 
cally endemic.  The  epidemics  seem  to  have  a  disposition  to  appear  at 
intervals  of  about  two  years.  The  virulence  of  the  infectious  principle 
is  so  great  that  nearly  all  children  exposed  to  it  will  contract  the  dis- 
ease. -The  infection  is  transmitted  by  the  breath  and  by  the  secretions 
from  the  respiratory  tract.  Comparatively  close  contact  is  required, 
although  this  need  be  of  but  very  short  duration.  Probably  the  poison 
enters  "by  way  of  the  respiratory  tract,  but  it  is  not  certain  that  this  is  in- 
variablv  the  case.  It  is  possible  for  the  disease  to  be  carried  by  a  third 
person  from  the  sick  to  the  well  by  means  of  handkerchiefs,  clothing, 
and  the  like  ;  but  this  is  certainly  of  very  rare  occurrence.  The  infec- 
tiousness of  whooping  cough  is  present  during  the  whole  of  the  attack, 
but  especially  in  the  paroxysmal  stage. 

Pathology. — The  nature  of  the  infection,  as  indeed  the  nature 
of  the  disease  itself,  is  not  definitely  understood.  It  is  not  even  ad- 
mitted by  all  writers  that  the  disease  is  of  an  infectious  nature.  De 
Mussy  claimed  that  it  is  due  to  the  irritating  pressure  of  enlarged 
bronchial  glands  upon  the  terminal  filaments  of  the  pneumogastric 
nerve.  Other  writers  have  advanced  the  theory  that  it  is  of  the  nature 
of  a  pure  neurosis,  the  result  of  some  functional  disturbance  of  the 
pneumogastric,  recurrent  laryngeal,  phrenic,  or  sympathetic  nerves,  or 
of  the  medulla.  Still  others  have  thought  it  to  be  a  simple  bronchial 
catarrh  associated  with  a  neurotic  condition.  The  whole  analogy  of  the 
affection  to  diseases  of  the  infectious  class  indicates,  almost  beyond  ques- 
tion, that  it  too  belongs  to  this  class.  Various  organisms  have  been 
supposed  to  be  the  cause.  The  larva  of  insects  were  assigned  as  the 
active  agents  by  Linnseus.  Bacteria  were  described  by  Poulet  and 
by  Letzerich,  and  a  protozoon  was  found  in  the  sputum  by  Deichler. 
The  observations  which  have  been  the  most  promising  are  those  of 
Afanassiew,  who  isolated  a  short  bacillus  from  the  sputum  of  pertussis 
patients  which  he  named  the  bacillus  tussis  convulsivw.  He  was  able  to 
obtain  pure  cultures  of  this  which,  inoculated  upon  the  respiratory  mu- 
cous membrane  of  animals,  produced  some  of  the  symptoms  of  whoop- 
ing cough,  with  a  catarrhal  state  of  the  respiratory  tract  and  a  tendency 
to  broncho-pneumonia.  Moncorvo  has  also  described  a  bacillus  found 
in  the  sputum,  and  more  recently  Ritter  has  found  a  small  coccus  which 
he  believes  to  be  the  germ.  It  is  evident  that  further  research  is  greatly 
needed  in  this  direction. 

The  manner  in  which  the  germs  of  the  disease,  whatever  they  may 
be,  produce  the  symptoms  is  also  by  no  means  clear.  It  is  possible,  on 
the  one  hand,  that  they  act  primarily  upon  the  respiratory  tract,  occa- 
sioning a  catarrhal  inflammation,  or,  on  the  other  hand,  that  the  nervous 
system  is  primarily  affected.  There  is  no  question  that  a  catarrhal  con- 
dition of  the  respiratory  tract  is  present  in  ^^hooping  cough.  Some 
writers  have  claimed  that  this  is  most  marked  in  the  nose,  others  hold 
that  it  is  predominant  in  the  bronchi.  It  would  seem  from  the  obser- 
vations of  Meyer-Huni  and  of  Von  Herff  that  the  mucous  membrane  of 
the  nose,  larynx,  and  trachea  down  to  the  bifurcation  is  the  region  of  the 


SYMPTO.VS.  715 

res})iratoi'v  tract  most  att'ccteil.  Of"  this  tlu'  part  whicli  is  prc-eniiiu'iitly 
involved  is  the  "  cough  region  " — /.  e.  the  posterior  wall  of  the  larynx 
in  the  intorarytenoid  space.  If  we  accept  the  view  that  the  infection  is 
<>hieflv  local,  with  a  secondary  involvement  of  the  nervous  system,  it 
would  seem  likely  that  a  small  (|uantity  of  mucus,  rising  from  l)elow, 
lands  upon  the  cough  region  and  sets  up  a  jiowerful  irritation  of  the 
hvpersensitive  filaments  of  the  superior  laryngeal  nerve.  This  occasions, 
through  reHex  action,  a  series  of  repeated  expiratory  efforts  which  con- 
tinue until  the  mucus  is  expelled.  A  long-drawn,  crowing  inspiration 
follows,  due  to  a  spasm  of  the  glottis,  itself  de])endent  upon  an  irritation 
of  the  convulsive  centres  in  the  medulla.  It  seems  very  much  mcjre 
probable,  however,  that  whooping  cough  is  actually  an  infectious  dis- 
ease of  the  nervous  system,  Avith  a  secondary  localization  of  the  process 
upon  the  respiratory  mucous  membrane,  exactly  similar  to  the  relation 
between  measles  and  its  respiratory  symptoms.  According  to  this 
view,  some  poison  in  the  i^lood,  produced  by  the  infectious  germs, 
occasions  a  great  excitability  of  the  superior  laryngeal  nerve  oi*  its 
centres  in  the  medulla,  and  of  other  portions  of  the  central  and  periph- 
eral nervous  apparatus  which  control  respiration  and  cough.  There 
are  various  grounds  for  this  hypothesis.  In  the  first  place,  the  even 
occasional  occurrence  of  pertussis  shortly  after  birth  as  a  result  of 
foetal  infection  indicates  that  the  microbes  must  be  in  the  general  circu- 
lation. Then,  too,  paroxysms  are  brought  on  quite  independently  of  the 
presence  of  mucus  on  the  cough  region.  Thus  excitement  of  any  sort, 
drinking,  crying,  or  sudden  change  of  air  will  occasion  them,  all  acting 
rather  through  the  nervous  system  than  in  other  ways.  The  greater 
frequency  of  paroxysms  at  night  probably  indicates  the  diminished 
degree  of  resistance  of  the  respiratory  centre  in  the  medulla  at  this  time, 
as  a  result  of  which  convulsive  respiratory  efforts  become  more  frequent. 
Of  course,  with  this  central  excitability  of  the  respiratory  nervous 
system  dependent  on  the  infection,  any  local  excitation,  such  as  mucous 
-or  other  irritant  to  the  respiratory  mucous  membrane,  will  produce 
cough.  The  presence  of  pathogenic  microbes  on  the  respiratory  mucous 
membrane  might  only  indicate  that  this  was  the  seat  of  entrance  and 
chief  seat  of  growth,  and  the  disease  would  be  in  this  respect  exactly 
analogous  to  typhoid  fever. 

There  are  no  characteristic  post-mortem  lesions.  Emphysema  is 
quite  commonly  found  in  bad  cases,  alone  or  combined  with  other  pul- 
monary complications,  especially  broncho-pneumonia.  Enlargement  of 
the  bronchial  glands  has  been  noted,  but  is  not  characteristic.  Atelec- 
tasis is  a  common  condition. 

Symptoms. — The  attack  is  ordinarily  divided  into  four  periods  :  (1) 
incubation  ;  (2)  invasion,  or  the  catarrhal  or  premonitory  stage  ;  (3)  the 
paroxysmal  or  whooping  stage ;  and  (4)  the  terminal  stage  or  stage  of 
decline.  There  is  no  very  sharp  division  between  these,  since  they  pass 
gradually  into  each  other. 

(1)  Incubation. — During  this  period  no  symptoms  of  the  disease  pre- 
sent themselves.  Statistics  are  at  variance  res^arding  its  lenp:th,  and  the  fact 
that  the  invasion  takes  place  so  insidiously  makes  the  determination  of 
the  exact  duration  of  the  incubation  difficult  in  most  cases.  It  probably 
lasts  from  two  to  seven  days,  with  an  average  of  three  to  four  days. 


716  PERTUSSIS. 

(2)  Catarrhal  Stage. — At  the  beginning  of  this  period  there  are  pres- 
ent the  evidences  of  a  severe  cold,  such  as  slight  hoarseness,  obstruction  to 
breathing  through  the  nose,  sneezing,  tickling  in  the  throat,  a  dry  cough, 
and  malaise.  Although  there  is  often  some  slight  fever,  especially  in 
the  evening,  it  is  disputed  whether  this  is  merely  the  result  of  the 
catarrhal  condition  or  whether  it  should  be  considered  as  the  direct 
result  of  the  action  of  the  infectious  poison  on  the  nerve  centres. 
Treatment  may  produce  temporary  amelioration  in  some  cases,  yet  the 
tendency  is  for  the  symptoms  to  grow  gradually  worse  in  spite  of  it. 
This  is  especially  true  of  the  cough,  which  becomes  more  frequent, 
occurs  in  longer  paroxysms,  and  is  decidedly  worse  at  night.  Examina- 
tion of  the  chest  at  this  period  shows  either  an  entire  absence  of  r^les, 
or  a.  number  of  them  too  insignificant  to  account  for  the  severity  of  the 
cough.  In  a  smaller  number  of  cases  there  is  a  decided  bronchitis  dur- 
ing the  premonitory  stage,  with  numerous  rales  and  considerable  fever, 
but  this  is  to  be  regarded  rather  as  a  complication.  The  premonitory 
stage  lasts  during  a  time  w^hich  varies  with  different  cases  and  whose 
exact  length  is  difficult  to  determine,  owing  both  to  the  insidiousness 
of  its  onset  and  the  fact  of  its  merging  into  the  next  stage.  In  some 
cases  it  continues  but  two  or  three  days,  while  in  others  the  whoop- 
ing stage  never  comes  on.  The  younger  the  child,  the  less  in  many 
cases  is  the  length  of  the  invasion.  It  may  be  said  to  average  about 
two  weeks. 

(3)  The  Paroxysmal  Stage. — The  typical  and  fully  developed  paroxys- 
mal cough  of  pertussis  is  marked  by  the  occurrence  of  the  "  whoop,"  and 
it  is  customary  to  date  the  beginning  of  the  paroxysmal  stage  from  the 
time  when  this  symptom  first  appears.  A  typical  paroxysm  of  whoop- 
ing cough,  or  a  "  kink,"  is  very  characteristic.  Often  it  comes  on  very 
suddenly  without  any  w^arning.  In  other  cases  some  sensation  just 
before  the  paroxysm  warns  the  child  that  one  is  about  to  begin.  This 
sensation  varies  with  different  children.  It  may  be  a  tickling  in  the 
nose  or  larynx,  or  a  strong  inclination  to  cough,  or  a  pain  in  the  region 
of  the  sternum.  If  the  child  has  been  lying  down,  it  sits  up  quickly 
and  perhaps  grasps  at  the  side  of  the  bed.  If  it  has  been  playing  about 
the  room,  it  drops  its  toys  and  runs  to  its  nurse  or  seizes  upon  any  object 
near  it  for  support.  The  cough  then  begins,  and  consists  of  a  series  of 
rapidily  repeated,  short,  explosive  expiratory  efforts,  follow^ed  by  a  long- 
drawn  crowing  inspiration.  The  short  coughs  are,  as  stated,  little  more 
than  efforts  at  expiration,  for  auscultation  reveals  almost  no  sound  of 
breatliing,  and  only  a  series  of  impulses  against  the  ear  can  be  perceived. 
The  expiratory  efforts,  wdthout  inspiration  between  them,  continue  for 
a  few  seconds,  during  which  time  the  face  becomes  swollen  and  cyanotic,, 
the  eyes  are  prominent,  congested,  and  watering,  the  tongue  is  protruded 
and  driven  against  the  teeth,  saliva  flows  from  the  mouth,  and  the  pulse 
grows  rapid.  The  whoop  which  follows  is  the  result  of  a  spasm  of  the 
glottis.  The  ear  against  the  chest  wall  at  this  moment  hears  at  most  a 
very  feeble  inspiration  or  none  at  all.  Immediately  after  the  whoop 
another  series  of  expiratory  efforts  usually  begins,  and  this  alternation 
of  expirations  and  whoop  may  be  repeated  several  times.  The  whole 
attack  lasts,  as  a  rule,  from  a  few  seconds  up  to  one  or  two  minutes,  but 
exceptionally  it  may  continue  for  from   ten  to   thirty   or    even    more 


SYMPTOAfS.  7 1 7 

iiiimitL'>.  In  such  a  case,  and  often  in  tlie  slinrter  attacks,  momentary 
periods  oi'  rest  occur,  and  then  the  coughing  returns.  In  the  hitter 
])art  of  a  paroxysm  ro]w  mucus  may  flow  in  abundance  from  the  moutli, 
and  vomiting  is  very  a])t  to  follow.  In  bad  cases  the  paroxysms  may 
be  attended  by  hemorrhage  from  the  nose  or  mouth  or  beneath  the 
conjuneti\'a\,  or  even  in  the  brain  or  elsewhere.  The  urine  and  fteccs 
may  be  expelled  by  the  violence  of  the  coughing,  yometimes  a  whoop 
immediately  precedes  the  lirst  of  a  series  of  expiratory  efforts.  .Vfter 
an  attack  is  over  the  child  may  be  left  pale  and  exhausted  for  a  short 
time,  but  soon  resumes  its  play  if  it  is  strong.  Some  degree  of  swelling 
of  the  face,  cyanosis,  puffiness  of  the  eyes,  and  blueness  of  the  tongue 
persists  betw(,'en  the  paroxysms  and  gives  the  child  a  very  character- 
istic ap})earance. 

The  paroxysms  are  nearly  always  most  numerous  in  the  night.  The 
number  of  paroxysms  which  occur  in  twenty-four  hours  varies  greatly 
in  different  children.  In  the  mildest  cases  there  may  be  only  six  or 
eight,  and  these  may  occur  almost  entirely  at  night,  leaving  the  child 
but  little  disturbed  during  the  day.  In  severe  cases,  however,  they 
may  number  forty  or  eighty,  or  even  more,  in  twenty-four  hours.  A 
paroxysm  is  brought  on  by  excitement  of  any  kind,  crying,  singing, 
swallowing,  exercise,  the  use  of  a  tongue-depressor,  a  sudden  change  in 
the  temperature  of  the  air  inhaled,  the  breathing  of  air  vitiated  by  car- 
bon dioxide,  and  so  on. 

Examination  of  the  chest  during  the  paroxysmal  stage  shows  freedom 
from  bronchitis,  except  perhaps  of  the  slightest  grade.  Fever  is  absent 
or  only  occasionally  present.  If  constantly  present,  some  complication 
must  be  suspected.  In  mild  cases  the  general  condition  of  the  child  is 
unaffected,  but  in  severe  ones  the  nutrition  and  strength  may  suffer 
greatly  from  the  frequent  vomiting  of  the  food  taken  and  from  the  loss 
of  sleep.  The  continuance  of  the  paroxysmal  stage  is  characterized  by 
the  occurrence  of  the  paroxysms  with  unabated  severity.  Its  actual 
duration  is  difficult  to  determine,  and  is  very  variable.  It  averages  from 
three  to  six  weeks,  but  may  greatly  exceed  this. 

(4)  The  Stage  of  Decline. — This  is  reckoned  from  the  time  when  a  dis- 
tinct diminution  in  the  severity  of  the  disease  can  be  observed.  The 
preceding  stage  merges  so  gradually  into  it  tliat  its  exact  commencement 
can  scarcely  be  determined.  The  paroxysms  grow  steadily  less  frequent 
and  less  severe.  The  cough  has  a  much  looser  quality,  and  finally, 
although  slowly,  loses  its  paroxysmal  character  almost  entirely,  while 
the  whoop  becomes  more  and  more  infrequent.  There  is  a  muco-puru- 
lent  bronchial  secretion,  and  moist  rales  are  heard  in  greater  numbers  in 
the  chest.  Hemorrhage  and  vomiting  no  longer  occur.  Finally,  all 
whooping  ceases  and  the  disease  changes  into  a  simple  bronchitis  or  the 
cough  stops  entirely. 

The  duration  of  this  stage  is  even  more  variable  than  that  of  the 
two  preceding  ones.  It  ranges  from  ten  days  to  several  months. 
Should  the  winter  season  be  approaching,  occasional  paroxysms  with 
whooping  may  continue  until  spring,  sometimes  after  all  persistent 
cough  has  ceased.  It  not  seldom  happens  that  all  cough  disappears 
for  some  time,  but  returns  again,  even  with  whooping.  Such  a  return 
cannot  with  reason  be  called  a  continuation  of  the  third  staee.     It  is 


718  PERTUSSIS. 

often  found  that  cough  with  whoop  occurs  at  intervals  for  months  or 
even  during  a  year  after  the  original  attack  began,  being  brought  on  even 
by  slight  bronchitis.  The  terminal  stage  may  safely  be  said  to  have 
ceased  when  once  cough  has  disappeared  if  only  for  a  brief  period,  for 
whooping  occurring  after  this  is  rather  a  habit  than  anything  else,  and 
is  to  be  considered  a  pure  neurosis  without  any  infectious  element. 

Complications  and  Sequels. — Complications  connected  Avith  the 
respiratory  apparatus  are  the  most  frequent.  Bronchitis  is  very  com- 
mon, and  when  it  develops  early  it  may  at  first  greatly  obscure  the  diag- 
nosis of  the  case.  One  of  the  most  dangerous  complications  is  broncho- 
pneumonia. This  is  most  apt  to  occur  in  feeble  or  rickety  children  or 
in  those  who  have  been  subjected  to  exposure  to  cold  or  to  improper 
hygiene  of  any  sort.  It  is  very  prone  to  develop  where  measles  has 
immediately  preceded  the  attack  of  pertussis,  but  its  most  frequent 
cause  is  the  occurrence  of  atelectasis.  Atelectasis  alone  is  a  frequent 
complication  in  young  children,  especially  in  those  who  are  weakly  or 
rhachitic.  It  may  be  widespread  or  may  be  localized  in  a  small  area. 
Its  onset  is  indicated  by  the  ordinary  symptoms  of  this  disease,  com- 
bined with  a  diminution  or  disappearance  of  the  paroxysmal  nature  of 
the  cough.  Emphysema  is  a  common  complication,  but  is  usually  only 
temporary,  although  this  is  not  always  the  case.  Empyema,  croupous 
pneumonia,  and  pleural  effusion  are  of  less  frequent  occurrence.  (Ede- 
ma of  the  glottis  is  not  common.  Hemorrhage  from  the  nose  is  ob- 
served almost  too  often  to  be  regarded  as  a  complication.  The  same  is 
true  of  hemorrhage  from  the  mouth,  but  true  hgematemesis,  in  which 
the  blood  comes  originally  from  the  stomach  and  is  not  first  swallowed 
and  then  vomited,  is  unusual.  Hemorrhage  under  the  conjunctivae  is 
frequent,  but  that  from  the  ear  or  lungs  or  under  the  skin  is  rare. 
Meningeal  hemorrhage  is  not  at  all  uncommon,  and  is  the  cause  of 
many  instances  of  convulsions  and  cerebral  palsy. 

A  superficial  ulceration  on  and  at  each  side  of  the  froenulum  linguce  is 
so  common  that  it  can  almost  be  called  a  symptom.  It  is  probably  pro- 
duced by  the  forcible  driving  of  the  tongue  against  the  lower  incisor 
teeth  during  coughing.  It  cannot  be  said  to  be  diagnostic  of  whooping 
cough,  for  it  may  be  seen  in  cases  of  severe  cough  from  other  causes. 
Loss  of  appetite,  diarrhoea,  and  indigestion  are  frequent  complications. 
The  looseness  of  the  bowels  tends  to  be  somewhat  chronic,  and  the  pas- 
sages contain  considerable  mucus.  Prolapse  of  the  rectum,  hernia,  or 
involuntary  evacuation  of  fseces  may  be  produced  by  the  violence  of 
the  cough.  Convulsions  constitute  a  not  infrequent  and  a  dangerous 
complication,  often,  as  stated,  the  result  of  cerebral  hemorrhage.  General 
oedema  of  the  skin  and  subcutaneous  emphysema  are  very  unusual  oc- 
currences. Hemiplegia,  paralysis  of  other  forms,  persistent  spasm  of 
the  glottis,  aphasia,  and  sudden  blindness  are  occasional  complications. 
Albuminuria  is  quite  frequent,  and  acute  nephritis  has  repeatedly  been 
observed.     Sugar  is  sometimes  found  in  the  urine. 

Other  distinct  diseases  may  accompany  whooping  cough  oi"  develop 
as  sequelse.  Thus  diphtheria,  varicella,  or  other  infectious  disease  may 
occur  with  it,  but  measles  is  especially  likely  to  do  so  or  still  oftener  to  pre- 
cede it.  Rhachitis,  ansemia,  or  other  constitutional  disease  may  be  either 
a  sequel  or  a  complication.     Tuberculosis  is  one  of  the  sequelse  most  apt 


RECUR llKSrE  A.\l>    lti:LAPSK—I)IA(;S()SlS.  719 

to  (lovoloj)  and  most  to  be  dreaded.  It  is  liable  to  come  on  ehielly  in 
cliildrcn  \\\\o  iia\'e  had  pertussis  very  badly  or  whose  general  nutrition 
is  much  below  normal  from  other  canses.  Its  favorite  seats,  from  whieh 
a  more  or  less  general  alleetion  may  extend,  are  the  bronchial  and  intes- 
tinal glands  and  patches  of  broncho-pneumonia.  Various  paralyses, 
blindness,  deafness  from  rupture  of  the  membrana  tympani,  epilepsy, 
aphasia,  and  disseminated  sclerosis  are  among  the  numerous  sequelae 
whieh  have  occasionally  been  reported. 

Uecukrence  and  Relapse. — Pertussis  has  a  remarkable  tendency 
to  what  appear  to  be  relapses,  yet  which  are  not  to  be  considered  as  such 
in  reality.  As  has  been  pointed  out,  the  return  of  whooping  after  the 
disease  has  apparently  ceased  is  rather  a  neurosis  than  an  evidence  of  a 
return  of  the  disorder,  since  it  is  no  longer  infectious  at  this  stage. 

Recurrence  of  pertussis  is  extremely  rare.  Le  Gendre  was  able  to 
collect  only  8  cases  in  addition  to  1  seen  by  himself. 

Diagnosis. — In  the  early  stages  the  diagnosis  of  whooping  cough 
is  difficult  or  impossible.  The  existence  of  a  cough  which  becomes 
more  and  more  paroxysmal  as  time  passes,  in  spite  of  treatment  directed 
to  a  possible  bronchitis,  renders  the  existence  of  pertussis  very  suspi- 
cious, especially,  too,  if  physical  examination  does  not  reveal  a  bronchitis 
which  is  at  all  commensurate  in  severity  with  the  intensity  of  the  cough. 
Vomiting  occurring  after  the  paroxysms  of  coughing  and  the  greater 
frequency  of  the  attacks  at  night  are  also  diagnostic  points.  Of  course 
the  prevalence  of  an  epidemic  of  the  disease  or  the  existence  of  other 
cases  in  the  family  are  additional  confirmatory  signs.  The  development 
of  the  whoop  will  settle  the  matter  finally,  except  in  those  cases  where 
the  disease  never  passes  the  catarrhal  stage.  In  these  cases  the  occur- 
rence of  vomiting,  the  congestion  of  the  eyes,  and  the  character  of  the 
cough  are  often  sufficient  to  render  a  diagnosis  possible  ;  but  it  is  especi- 
ally in  such  cases  that  the  prevalence  of  the  disease  as  an  epidemic  or 
its  existence  in  other  members  of  the  family  renders  the  most  valuable 
service  in  determining  the  nature  of  the  attack. 

Sometimes  a  severe  acute  bronchitis  with  an  unusually  spasmodic 
cough  greatly  resembles  pertussis,  but  the  existence  of  decided  fever, 
shortness  of  breath,  and  numerous  rales  in  the  chest  generally  serves  to 
distinguish  it.  The  difficulty  is  especially  great  at  the  close  of  an  attack 
of  measles.  Here  we  have,  on  the  one  hand,  the  existence  of  a  severe 
bronchitis  which  may  appear  to  account  for  the  severity  of  the  cough, 
and,  on  the  other  hand,  the  tendency  w^hich  pertussis  has  to  appear  after 
an  attack  of  rubeola.  Broncho-pneumonia  is  most  liable  to  develop  in 
the  later  stages  of  pertussis.  When  it  occurs  during  the  catarrhal  stage 
it  may  alter  the  character  of  the  cough  and  even  prevent  entirely  the 
development  of  the  whoop,  making  the  diagnosis  difficult.  A  pro- 
longed terminal  stage  of  pertussis  may  simulate  tuberculosis  of  the  lungs. 
Only  continued  observation  of  the  case  will  render  it  possible  to  deter- 
mine whether  this  disease  is  actually  developing.  Tuberculosis  of  the 
bronchial  glands  may  occasionally  be  the  cause  of  a  paroxysmal  cough 
Avhich  greatly  resembles  that  of  pertussis.  The  long  continuance  of  the 
affection,  the  absence  of  distinct  stages,  of  vomiting,  and  of  very  cha- 
racteristic whooping,  and  the  history  of  previous  wasting  and  of  fever, 
serve  to  distinguish  it. 


720  PEBTUSSIS. 

Prognosis. — The  danger  of  whooping  cough  is  far  greater  than  is  com- 
monly supposed.  Statistics  show  that  a  very  large  number  of  children 
die  of  it.  For  instance,  J.  Lewis  Smith  states  that  4840  deaths  from  it 
occurred  in  New  York  City  during  a  period  of  fifty  years,  this  equalling 
1  out  of  every  79  deaths  from  all  causes.  W.  W.  Johnston  says  that 
an  estimate  based  on  the  census  of  1880  shows  that  over  100,000  chil- 
dren died  of  whooping  cough  in  the  United  States  during  ten  years : 
120,000  persons  fell  victims  to  it  in  England  and  Wales  between  1858 
and  1867,  and  85,000  in  Prussia  between  1875  and  1880.  Not  only  is 
the  actual  number  of  deaths  large,  but  the  proportion  of  fatal  cases  to 
the  whole  number  of  cases  is  very  considerable.  Statistics  ^vould  indi- 
cate that  the  relative  mortality  is  from  3  to  15  per  cent.,  and  occasionally 
higher.  The  mild  cases  of  course  recover,  and  it  is  upon  the  complica- 
tions that  the  mortality  largely  depends,  although  in  severe  uncompli- 
cated cases  death  may  be  caused  by  the  great  exhaustion  produced  or  by 
other  ways.  The  younger  the  child  the  greater  is  the  danger  to  life. 
After  the  age  of  five  years  few  succumb,  while  under  that  of  two  or 
three  years  the  death  rate  is  at  its  highest.  Rather  more  females  die 
than  males,  probably  the  result  of  a  less  degree  of  strength  of  constitu- 
tion and  of  resistance  possessed  by  them.  Badly  nourished  children 
raised  amongst  unfavorable  hygienic  surroundings  naturally  sufPer  the 
most.  Any  constitutional  disease,  such  as  rickets,  increases  the  danger. 
The  previous  occurrence  of  measles  just  before  the  development  of 
pertussis  renders  the  prognosis  much  graver.  Both  the  summer  and  the 
winter  seasons  bring  their  dangers  with  them.  In  the  first  the  occur- 
rence of  intestinal  complications  and  the  debilitating  influence  of  hot 
Aveather  add  to  the  danger,  -while  in  the  latter  the  liability  to  the 
development  of  respiratory  disorders  distinctly  increases  the  risk. 
Broncho-pneumonia  complicating  pertussis  makes  the  prognosis  most 
grave  and  is  a  common  cause  of  death.  Convulsions,  too,  constitute  a 
common  fatal  ending.  Tuberculosis  occurring  as  a  sequel  adds  greatly 
to  the  death  rate. 

Treatment. — Prophylaxis. — In  the  light  of  the  danger  and  the 
great  infectiousness  of  pertussis  every  effort  should  be  made  to  guard 
children  from  the  disease.  The  custom  so  prevalent  of  allowing  children 
suffering  with  it  to  play  freely  W'ith  others  in  the  streets  or  parks  cannot 
be  too  strongly  condemned.  Children  should  be  strictly  kept  from  the 
slighest  contact  with  those  who  are  even  suspected  of  having  whoop- 
ing cough,  since  it  is  infectious  in  the  catarrhal  stage  as  well  as  later. 
Unfortunately,  the  difficulty  of  recognizing  the  malady  at  this  period 
renders  the  task  almost  herculean.  AVhere  an  epidemic  is  prevailing  it 
is  better  to  remove  unaifected  children  entirely  from  the  locality.  This 
is  especially  true  in  the  case  of  weakly  or  very  young  subjects. 

It  is  impossible  to  determine  exactly  how  long  infectiousness  con- 
tinues. It  grows  less  during  the  last  stage,  and  it  may  ordinarily  be 
assumed  to  have  ceased  entirely  by  the  end  of  two  months  after  the 
onset  of  the  disease.  Quarantine  may  be  discontinued  after  the  child  has 
ceased  to  cough  for  a  few  days,  even  though  coughing  return,  with  or 
without  the  whoop,  afterward.  As  has  previously  been  remarked,  this 
later  coughing  is  rather  a  neurosis  or  of  a  purely  catarrhal  nature  than 
in  any  Avay  partaking  of  the  original  infectious  character.     Both  in  the 


TREATMENT.  721 

eases  in  which  the  (Xiuo:h  roturns  :it  intervals  for  months  and  in  tiiose 
in  which  one  or  two  paroxysms  daily  persist  for  an  indefinite  time  it 
wouhl  be  as  clearly  entirely  impraetieable  to  continue  quarantine  as  it 
would  be  unnecessiiry.  In  such  cases  isolation  may  cease  two  or  at  most 
three  months  after  the  onset.  Since  there  is  a  possibility,  althouirh  a 
remote  one,  of  ti'ansmittinjj:  the  infection  by  the  bed-  or  body-linen,  disin- 
fection of  this  should  be  carried  out,  as  well  as  of  the  room,  after  the 
disease  is  over.  , 

Treatment  of  the  Attack. — In  the  treatment  of  pertussis  the  physician 
often  encounters  a  problem  which  taxes  his  resources  and  ingenuity  to 
the  utmost.  The  mildest  cases  require  only  careful  supervision  or  are 
easily  relieved  to  a  very  satisfactory  extent  by  medication.  In  the 
severe  cases,  on  the  other  hand,  the  condition  is  far  different.  Here  we 
must  be  ready  to  employ  one  plan  of  treatment  after  another  until  some- 
thing of  benefit  is  found,  for  there  is  no  disease  of  which  it  is  truer 
than  of  pertussis  that  the  treatment  which  has  acted  like  a  charm  in  one 
case  or  series  of  cases  may  fail  utterly  in  another  series  or  individual. 
Even  in  one  family  one  child  may  be  greatly  relieved  by  one  drug  and 
another  only  by  another.  Then,  too,  we  must  not  fail  to  employ  our 
remedies  in  sufiticiently  large  dose  before  decrying  them  as  useless.  So 
also  it  is  only  early  in  or  at  the  height  of  the  disease  that  we  can  come 
to  any  conclusion  regarding  the  virtue  of  any  plan  of  treatment,  for 
almost  anything  will  seem  to  benefit  when  the  attack  is  about  to  undergo 
its  natural  decline. 

Treatment  maybe  conveniently  divided  into — (1)  hygienic;  (2)  lo- 
cal ;  (3)  general. 

1.  Hygienic  treatment  is  of  great  importance.  Children  who  are  not 
suffering  from  any  respiratory  complication  should  be  kept  in  the  fresh 
air  as  much  as  possible.  There  is  no  doubt  that  air  vitiated  by  carbon 
dioxide  increases  the  number  and  intensity  of  the  paroxysms.  On  the 
other  hand,  they  must  not  be  recklessly  exposed,  since  the  tendenev 
to  respiratory  complications  is  so  great.  Damp  and  windy  weather 
must  be  avoided  and  the  children  confined  in  airy  rooms.  It  is  an 
excellent  plan  to  have  two  large  rooms — one  for  the  day  and  the  other 
for  the  night — and  to  air  each  thoroughly  before  it  is  used.  The  num- 
ber of  paroxysms  at  night  is  often  considerably  diminished  in  this  ^\■ay. 
Clothing  must  be  sufficiently  warm,  and  food  should  be  nutritious  and 
easily  digestible,  and  given  frequently  in  small  quantities  in  eases  where 
the  tendency  to  vomiting  is  troublesome.  Nutrient  enemata  may  be 
required  in  some  of  these  cases.  Change  of  climate  often  works 
wonders,  especially  in  the  stage  of  decline.  It  should,  however,  never 
be  employed  at  the  expense  of  unaffected  children. 

2.  Local  treatment  has  been  largely  employed.  It  may  be  di\"ided 
into  (a)  insufflation  of  powders  into  the  nose  or  larynx ;  (6)  applications 
of  solutions  by  the  spray  or  brush  or  by  irrigation;  (e)  inhalation  of 
volatile  substances  and  of  gases. 

(a)  Quinine  by  insufflation  has  been  one  of  the  most  popular  methods 
of  local  treatment.  The  formula  first  recommended  by  Letzerieh  con- 
sisted of  a  mixture  of  this  drug,  bicarbonate  of  soda,  and  powdered  acacia. 
With  this  insufflations  were  made  into  the  larynx  three  times  a  day. 
Very  excellent  results  with  quinine  have  been  obtained  by  a  numV)er  of 
Vol.  I.— 46 


722  PERTUSSIS. 

physicians.  Laryngeal  insufflations  are  not  easy  to  employ  in  the  case  of 
young  children,  and  it  is  quite  certain  that  in  the  hands  of  any  one  not 
especiallv  skilled  in  the  manipulation  the  greater  number  of  them  never 
reach  the  larvnx  at  all.  On  this  account  nasal  insufflations  of  quinine 
are  to  be  preferred.  Among  the  other  powders  which  have  been  recom- 
mended for  insufflation  into  the  nose  or  larvnx  are  resorcin,  boric  acid, 
benzoin,  iodoform,  salicylic  acid,  borate  of  soda,  antipyrine,  and  tannin. 
Of  these  benzoin  appears  to  hold  the  most  prominent  place  and  to  have 
most  authority  in  its  favor.  Boric  acid  is  also  serviceable  in  many 
cases.  I  have  found  it  useful  by  nasal  insufflation,  but  the  results  were 
not  so  good  as  those  obtained  by  internal  medication.  Eesorcin  is  also 
highlv  praised.  Guttmann  recommends  sodium  sozoiodol  for  nasal 
insufflations.  Various  combinations  of  powdered  drugs  for  insufflation 
have  been  recommended  by  different  writers.  Thus,  boric  acid  and 
powdered  coffee  are  praised  liy  Guerder,  and  benzoin,  salicylate  of  bis- 
muth, and  quinine  by  Moizard. 

(6)  One  of  the  earliest  methods  of  local  treatment  for  pertussis  was 
the  application  of  a  weak  solution  of  nitrate  of  silver  to  the  larynx, 
recommended  by  Watson  in  1849.  Some  later  observers  have  obtained 
good  results  with  it.  A  solution  of  cocaine  of  a  strength  of  from  2  to 
15  per  cent,  has  been  used  as  an  application  to  the  pharynx  by  the 
brush  or  sprav.  It  can  undoubtedly  do  good,  but  the  effect  is  liable  to 
be  only  transitory  and  the  remedy  is  not  devoid  of  danger.  Alarming 
svmptoms  produced  by  the  application  have  been  reported.  Among 
tiie  other  drugs  in  solution  which  have  been  used  locally  as  a  spray 
or  on  the  brush  are  peroxide  of  hydrogen,  morphine,  resorcin,  bromide 
of  potassium,  chloride  of  ammonium,  alum,  tannic  acid,  and  salicylic 
acid.  Resorcin  is  one  of  the  best  of  these.  It  has  been  especially 
recommended  by  Moncorvo,  who  applies  it  in  2  per  cent,  solution  with 
a  brush  to  the  larynx  once  daily.  Irrigation  of  the  nares  is  advocated 
by  numerous  writers.  For  this  purpose  we  may  use  peroxide  of  hydro- 
gen, a  saturated  solution  of  boric  acid,  sulphate  of  iron  in  the  strength 
of  1  grain  to  the  ounce  of  water,  bichloride  of  mercury,  1  :  6000,  and 
salicvlic  acid,  1  :  1000.  The  procedure  is  very  unpleasant  to  the  child, 
is  not  devoid  of  danger  to  the  Eustachian  tubes,  and  is  not  in  any  way 
superior  to  insufflation  or  atomization. 

(c)  Desmartes  in  1859  first  recommended  the  inhalation  of  the  air 
from  the  purifying  rooms  of  gas-works,  and  since  then  the  value  of 
the  treatment  has  often  been  urged.  Later  studies  have  not  sustained 
the  claims  which  have  been  made.  Among  the  numerous  other  sub- 
stances recommended  for  inhalation  are  carbolic  acid,  creasote,  eucalyp- 
tus, turpentine,  terebene,  tar,  petroleum,  thymol,  pumilene,  benzine, 
camphor,  ozone,  naphtluilin,  nitrite  of  amyl,  and  compressed  air.  Of 
these  the  one  which  would  seem  to  be  most  generally  esteemed  is  car- 
bolic acid.  This  may  be  vaporized  from  a  saturated  solution  in  a  croup- 
kettle  or  steam  atomizer  or  from  sponges  or  cloths  wet  with  it  and  hung 
about  the  room,  or  it  may  be  inhaled  from  a  respirator  placed  over  the 
mouth  and  nose.  It  may  also  be  volatilized  by  placing  a  few  crystals 
upon  hot  iron.  The  fumigation  of  the  room  with  burning  sulphur 
was  strongly  advocated  by  ^Slohn,  and  his  experience  has  been  confirmed 
by  others.   '  The  sulphur  should  be  burned  after  the  child  has  been  re- 


TREATMEyT.  723 

moved  in  the  morning  and  dressed  in  clean  elotlies.  After  five  liours 
the  room  should  he  well  aired,  and  then  slept  in  that  ni<:;ht.  Inhalation 
of  ehloroform  or  ether  has  been  advise<l  for  its  anjesthetie  etfeet. 

3.  General  Treatnwni. — Inasnuieh  as  the  disease  appears  to  be  due 
to  a  disordered  condition  of  the  nervous  system  dependent  upon  a 
systemic  infection,  nuich  is  to  be  expected  from  internal  medication — 
more,  I  think,  than  from  local  treatment.  Tiie  method  to  be  followed 
depends  somewhat  upon  the  stage  of  the  disease.  Early  in  the  attack, 
before  the  paroxysmal  character  of  the  cough  develoj)s,  remedies  useful 
in  bronchitis  may  be  selected.  Late  in  the  attack,  when  secretion 
becomes  more  abundant,  expectorants  may  be  indicated,  or,  if  the  secre- 
tion is  very  profuse,  medicines  to  hold  this  in  check  to  some  degree. 
Throughout  the  whole  course  of  the  disease,  however,  the  neurotic 
nature  of  the  couffh  arenerallv  makes  it  necessarv  to  use  remedies  chosen 
for  their  quieting  effect  upon  the  nervous  system.  In  the  mildest  cases, 
in  which  the  paroxysms  do  not  exceed  four  or  six  in  twenty-four  hours, 
are  not  very  severe,  and  have  no  influence  upon  the  general  health,  it  is 
often  just  as  well  to  refrain  from  any  medication  or  to  use  only  such  as 
will  aid  in  procuring  quiet  nights. 

So  many  remedies  have  been  proposed  that  it  is  impossible  to  review 
all  of  them  ;  only  those  Mhich  seem  to  have  oftenest  been  of  avail  can 
be  discussed.  The  testimony  of  many  investigators  shows  that  antipyrine 
is  one  of  the  drugs  upon  which  most  reliance  can  be  placed.  It  was 
first  recommended  for  this  disease  by  Sonnenberger.  It  must  be  given 
in  sufficiently  large  doses  and  its  use  must  be  persisted  in  ;  and  it  may 
be  said  in  this  connection  that  children  take  it  in  proportionately  larger 
doses  than  adults  do.  Beginning  with  a  small  amount,  this  should  be 
rapidly  increased  until  a  child  of  two  years  is  taking  2  or  3  grains  every 
three  hours.  In  afebrile  states  it  is  never  depressant  unless  some 
idiosyn(!rasy  exists.  In  many  cases  its  action  is  little  short  of  marvel- 
lous, but  in  the  majority  all  we  can  expect  is  a  decided  lessening  of  the 
number  and  severity  of  the  paroxysms.  Phenacetin,  acetanilid,  and 
other  remedies  of  this  class  may  be  used  in  place  of  it,  but  the  effects 
do  not  seem,  as  a  rule,  to  be  so  good.  Sometimes  one  drug  of  this  class 
will  be  of  service  wdien  another  has  failed. 

Bromoform,  recommended  by  Stepp,  has  proved  of  value  in  the 
hands  of  many  observers.  It  may  be  given  in  doses  of  from  2  to  4 
drops  three  or  four  times  a  day  at  three  to  six  years  of  age.  It  is  most 
conveniently  administered  on  moistened  sugar  or  in  a  mixture  with  alcohol, 
in  which  it  is  soluble.  My  own  results  have  been  favorable  in  many 
instances,  although  not  as  often  so  as  with  antipyrine.  Sometimes 
bromoform  makes  the  child  sleepy  and  stupid  without  affecting  the 
severity  of  the  disease,  and  in  a  few  instances  it  has  seemed  to  be  dan- 
gerous. Belladonna  has  been  used  for  years,  and  is  of  undoubted  service 
in  many  instances.  It  often  needs  to  be  given  in  large  doses.  A  child 
of  two  years  should  begin  Avith  2  minims  of  the  tincture  or  -^  grain 
of  the  extract  three  or  four  times  a  day,  and  have  this  increased  until 
the  limit  of  tolerance  is  reached.  Quinine  is  another  drug  whose  value 
has  been  proven  beyond  doubt.  Large  doses  are  required  :  1  grain  or 
more  may  be  given  every  two  to  four  hours  at  two  years  of  age.  Its 
taste  may  be  partially  disguised  by  syrup  of  liquorice  or  of  yerba  santa. 


724  PERTUSSIS. 

or  it  may  be  given  by  suppository.  If  it  disturbs  the  digestion,  it.-?  use 
should  be  discontinued.  Opium  is  one  of  the  most  valuable  of  drugs  in 
many  instances.  In  light  cases  it  is  often  very  servicable  in  small  doses 
given  during  the  day.  In  severe  cases  it  is  sometimes  unequalled  in  full 
doses,  given  at  night  to  produce  sleep  and  allay  the  cough.  Bromide  of 
potassium  is  often  very  serviceable  in  doses  of  2  to  5  grains  at  two  years 
of  age,  repeated  as  needed.  It  may  be  advantageously  combined  with 
antipyrine  or  belladonna.  Chloral  is  another  drug  Vv'hich  is  frequently 
of  value,  especially  for  procuring  sleep  at  night.  The  dose  at  two  years 
should  be  from  1  to  3  grains.  That  it  is  a  cardiac  depressant  must  not 
be  forgotten.  Alum  has  long  been  a  favorite ;  it  is  especially  useful  to 
cheek  excessive  secretion  in  the  later  stages,  or  when  the  presence  of 
the  mucus  seems  to  excite  the  paroxysms  :  2  grains  may  be  given  every 
three  or  four  hours  at  two  years  of  age.  Among  other  drugs  \vliich 
have  been  recommended,  and  for  the  value  of  which  there  ap])ears  to  l)e 
distinctly  favorable  evidence,  are  cannabis  indica,  castanea,  drosera, 
asafoetida,  quebracho,  carbolic  acid,  creasote,  peroxide  of  hydrogen, 
ouabaine,  terpene  hydrate,  wild  thyme,  grindelia,  pilocarpine,  resorcin, 
camphor,  hyoscine,  turpentine,  benzol,  carbonate  of  iron,  and  conium. 
The  use  of  the  galvanic  current  has  also  been  recommended.  Several 
observers  have  made  the  statement  that  vaccination  modifies  greatly  the 
course  of  whooping  cough.  In  some  of  the  cases  coincidence  may  have 
much  to  do  with  the  apparent  action  of  the  vaccine  infection.  In  others 
it  is  readily  possible  that  one  disease  may  have  modified  the  course  of 
the  other.     Further  studies  upon  the  question  are  needed. 


EPIDEMIC  PAROTIDITIS. 

By  J.   P.   CROZER    GRIFFITH,   M.  D. 


Synonyms. — Parotitis ;  Mumps. 

Definition. — Epidemic  parotiditis  is  an  acute  infectious  disease, 
characterized  bv  inflammation  of  the  parotid  gland,  sometimes  with 
involvement  of  the  other  salivary  glands,  and  occasionally  of  the  testicle, 
the  mammary  gland,  and  the  female  genital  organs. 

Etioloc4Y. — Mumps  is  rare  in  children  under  two  years  of  age,  and 
is  commonest  in  those  between  five  and  fifteen  years.  Young  adults  are 
also  strongly  predisposed  to  it.  Old  age  is  almost  always  exempt.  It 
is  generally  considered  that  sex  exercises  a  powerfully  predisposing  in- 
fluence, and  that  males  are  much  oftener  attacked  than  females. 

The  season  of  the  year  is  an  influential  factor.  The  statistics  of 
Hirsch  have  been  confirmed  by  later  experience,  and  show  that  it  is  the 
colder  months  in  which  mumps  especially  prevails.  Climate  appears  to 
possess  little  etiological  power,  and  the  same  is  true  of  geographical 
regions.  It  is  true  that  certain  localities  may  suffer  from  epidemics  of 
mumps  year  after  year,  while  others  remain  free,  and  that  the  latter  may 
suddenly  and  without  apparent  reason  become  subject  to  it.  The  disease 
is  of  a  decidedly  epidemic  nature.  The  epidemics  are  oftenest  limited 
to  a  house  or  street,  or  consist  of  outbreaks  in  barracks  or  camps,  but 
sometimes  they  are  widespread  over  a  city  or  even  a  district  of  countr}^ 
In  such  cases  it  has  frequently  been  observed  that  the  disease  spreads 
very  slowly  from  house  to  house.  It  does  not  become  prevalent  over  a 
large  district  at  once.  An  epidemic  may  last  for  months  or  may  be 
short-lived  and  attack  but  few  individuals. 

As  with  other  diseases  of  a  similar  nature,  however,  the  sole  real 
producer  is  infection,  the  contagious  principle  being  transmitted  from 
the  sick  to  the  well.  In  just  what  Avay  the  infection  takes  place  is 
uncertain.  The  frequent  limitation  of  the  disease  within  narrow  con- 
fines indicates  that  the  poison  cannot  be  one  which  is  easily  disseminated, 
and  tiiat  it  probably  can  be  communicated  only  by  close  contact  with  an 
infected  person,  it  being  transmitted  either  in  the  breath  as  expired  or 
in  the  secretions  from  the  mouth,  and  being  taken  in  through  the  mouth 
of  the  person  acquiring  the  disease.  It  would  also  seem  very  probable 
that  it  can  be  carried  in  the  clothing  of  a  third  person.  The  infectious- 
ness is  certainly  present  during  the  actual  existence  of  symptoms,  and 
even  after  these  have  disappeared.  There  are  numbers  of  reported 
cases  also  which  indicate  that  the  disease  can  be  transmitted  even  during 
the  stage  of  incubation.  The  degree  of  infectiousness  seems  to  depend 
largely  upon  the  closeness   and  the  frequency  of  the  contact.     Thus 

725 


726  EPIDEMIC  PAROTIDITIS. 

ill  outbreaks  in  barracks  or  other  public  institutions  the  disease  is  liable 
to  attack  a  large  proportion  of  those  exposed. 

Pathology. — The  true  nature  of  the  malady  is  far  from  being 
understood.  It  is  not  even  decided  whether  it  is  to  be  considered  a 
local  infection  upon  which  the  fever  and  other  symptoms  depend,  or  a 
general  blood  infection  with  a  secondary  localization  upon  the  salivary 
glands.  Analogy  to  other  infectious?  diseases  would  indicate  that  the  last 
hypothesis  is  the  correct  one.  The  occasional  involvement  of  other 
more  remote  glands,  as  the  testicle,  also  certainly  favors  this  view,  as 
does  the  existence  of  a  period  of  incubation,  although  it  is  possible  that 
the  germs  may  be  lying  dormant  or  developing  in  the  duct  of  Steno 
during  this  time. 

It  is  fair  to  presume  that  some  micro-organism  is  the  active  infectious 
agent  of  mumps,  but  the  nature  of  the  microbe  is  still  a  matter  of 
which  nothing  positive  is  known.  Capitan  and  Charrin,  whose  investi- 
gations have  been  among  the  most  important,  found  bacilli  and  micro- 
cocci in  the  blood  and  saliva  of  a  number  of  patients  with  mumps.  They 
were  able  to  make  cultures  of  these,  but  did  not  find  them  pathogenic 
for  animals  experimented  on.  Ollivier  has  discovered  the  micro-organ- 
isms in  the  saliva,  urine,  and  blood,  and  Bouchard  in  the  saliva  and  urine. 
The  observations  have  been  confirmed  by  Netter,  Vedrenes,  Boinet,  and 
Bordas.  Laveran  and  Catrin  discovered  a  diplococcus  in  67  out  of  92 
cases.  This  was  present  in  the  blood  and  in  the  secretion  from  the 
parotid  gland.  It  was  also  obtained  from  the  testis  in  cases  of  orchitis. 
Inoculation  experiments  were  negative  in  their  results.  Whether  the 
various  micro-organisms  described  by  these  different  observers  have  any 
etiological  significance  cannot  yet  be  determined. 

The  pathological  anatomy  of  mumps  is  little  understood.  The  fact 
that  the  course  of  the  disease  is  always  benign  or  that  fatal  cases  are 
complicated  interferes  with  satisfactory  post-mortem  examinations.  The 
swelling  is  situated  in  the  parotid  glands  in  most  cases,  but  sometimes  in 
other  salivary  glands  as  well  or  alone,  or  in  the  testicles  alone.  Cases 
have  been  reported  in  which  the  submaxillary  glands  were  first  affected, 
and  then  the  testicles,  while  the  parotid  glands  were  at  no  time  attacked. 
The  periglandular  tissue  is  also  involved.  Virchow  described  the  pro- 
cess as  a  catarrh  of  the  epithelium  of  the  salivary  passages  in  the  gland. 
Others  have  considered  the  swelling  to  be  the  result  of  exudation  of 
serum  into  the  gland  or  the  periglandular  tissue.  Bamberger  found  an 
inflammatory  exudate  in  the  interacinous  connective  tissue. 

Symptoms. — Incubation. — The  period  of  incubation  is  a  somewhat 
variable  one,  and  different  estimates  of  its  length  are  given.  In  general 
it  would  seem  to  vary  between  one  and  three  weeks,  with  an  average  of 
about  two  weeks.  Nicholson  reports  an  instance  of  the  incubation  last- 
ing six  weeks,  and  periods  as  short  as  three  or  four  days  have  also  been 
known  (Leitzen).     There  are,  as  a  rule,  no  symptoms  during  this  time. 

Initial  Stage. — In  the  majority  of  cases  prodromal  symptoms  are  not 
present  or  are  overlooked,  and  the  enlargement  of  the  gland  is  among 
the  first  symptoms.  In  other  cases,  however,  there  is  a  distinct  period 
of  invasion.  The  frequency  of  the  occurrence  of  prodromal  symptoms 
seems  to  vary  with  different  epidemics.  Young  children  exhibit  them 
much  oftener  than  adults  do.     These  symptoms  when  well  developed 


SYMl'TUMS.  727 

consist  of"  malaise,  cliilliiu'ss,  licadaclic,  uciicral  iiciiral«:i<'  |)aiii,  (listiirl)c(l 
sl('('|)  or  soinnolc'iu'o,  loss  (tC  appetite,  and  moderate  lever.  In  some 
epidemics  tliere  arc  also  vomilini:,',  diai'rli<ea,  and,  in  yoimjr  snhjects, 
I'onvnlsions.  Not  all  of  the  prodromal  symptoms  will  ap[»ear  in  any 
one  case.  Ivilliet  and  Bartlie/,  state  that  prodromes  weic  j)resent  in 
1  ont  of  .'>  cases  oocnrrini*-  sporadically  in  tlicii-  hospital  j)raetice.  The 
j)n)dromal  svmptoms  last  a  few  honrs  to  perhaps  two  days.  In  excep- 
tional cases  they  may  continne  four  to  eight  days. 

Stage  of  Swelling. — Generally  by  the  second  or  third  day  after  the 
beirinnino-  of  symptoms  evidences  of  involvement  of  the  parotid  ^land 
apj)ear — if,  indeed,  as  stated,  they  are  not  the  first  signs  of  the  disease. 
A  dnll,  aching',  continnons  pain  beg'ins  in  the  region  of  the  ear  and 
cheek  on  one  side.  It  is  made  worse  l)y  pressnre  and  by  every  move- 
ment of  the  jaw  for  eating  or  speaking.  It  hinders  to  a  considerable 
extent  the  opening  of  the  mouth,  and  often  renders  it  impossible.  Pain 
in  the  ear  is  not  uncommon.  Swallowing  and  the  movement  of  the 
head  are  often  painful.  The  degree  of  pain,  slight  at  first,  increases 
gradually  during  several  days,  coincidently  with  the  increase  of  swell- 
ing. Its  intensity  varies  with  the  case.  Sometimes  it  is  but  slight, 
and  may  even  be  almost  wanting,  except  upon  movement  of  the  jaws, 
while  in  other  cases  it  is  constantly  severe.  Rilliet  and  Barthez  have 
described  three  especially  painfnl  points  as  being  very  frequently  pres- 
ent— viz.  on  the  mastoid  process,  on  the  temporo-maxillary  articulation, 
and  over  the  submaxillary  gland.  Swelling  commences  a  few  hours 
after  the  first  development  of  pain  and  increases  rapidly,  reaching  its 
height  by  the  second  to  the  fourth  day,  or  sometimes  not  until  the  sixth 
day.  It  begins  in  the  region  of  the  parotid  gland,  between  the  descend- 
ing portion  of  the  lower  jaw  and  the  mastoid  process.  Although  it 
may  remain  confined  to  this  area,  it  often  spreads  backward,  forward, 
and  downward  owing  to  the  involvement  of  the  submaxillary  and  sub- 
lingual glands,  the  connective  tissue  of  the  face  and  neck,  and  the  cervi- 
cal lymphatic  glands.  The  ear  seems  lifted  up  and  pressed  outward, 
and,  in  cases  of  extensive  swelling  the  outline  of  the  lower  jaw  dis- 
appears and  the  whole  side  of  the  face  and  neck  seems  much  swollen. 
The  skin  over  the  swelling  usually  is  pale  and  shining.  Only  seldom 
is  it  reddened.  Pressure  with  the  finger  generally  meets  with  an  elastic 
resistance,  but  when  there  is  much  cedematous  infiltration  of  the  skin 
pressure  is  very  painful  and  leaves  an  indentation.  In  cases  of  very 
extensive  swelling  the  oedema  may  extend  even  to  the  upper  part  of 
the  chest.  After  the  swelling  has  reached  its  height  the  diminution  in 
size  begins.  The  rapidity  with  which  this  occurs  is  very  variable. 
Generally  no  trace  of  it  remains  by  the  seventh  or  eighth  day  after  its 
first  appearance,  although  it  occasionally  persists  a  longer  time. 

In  the  majority  of  cases  both  parotids  are  attacked,  but  it  is  only^ 
exceptionally  that  the  swelling  in  them  comes  on  simultaneously.  Ac- 
cording to  some  writers,  the  gland  of  the  left  side  is  usually  the  one  first 
swollen.  The  second  parotid  is  involved  one  or  tw^o  days  after  the  first 
begins  to  enlarge.  Sometimes  the  interval  is  longer,  and  it  may  ha])pen 
that  the  disease  has  nearly  disappeared  from  the  first  side  before  it  shows 
itself  on  the  second.  Almost  always  the  second  swelling  is  less  pro- 
nounced than  the  first. 


728  EPIDEMIC  PAROTIDITIS. 

Fever  of  varying  degree,  mentioned  among  the  prodromal  symptoms, 
continues  during  the  stage  of  swelling,  its  height  depending  largely 
upon  the  severity  of  the  attack.  As  a  rule,  it  is  slight,  with  morning 
remissions  and  evening  exacerbations,  and  it  gradually  rises  until  it 
reaches  its  height,  generally  not  much  more  tlian  102°  F.,  Avith  the  maxi- 
mum of  the  swelling.  Then  it  falls  rapidly  to  normal.  Occasionally, 
especially  in  severe  cases,  the  temperature  rises  higher  than  this,  and 
may  continue  in  the  neighborhood  of  104°  F.  for  several  days.  The 
pulse  and  respiration  maintain  their  normal  ratio  to  the  temperature. 

Some  degree  of  malaise  and  prostration  may  be  present.  Redness 
of  the  fauces  and  lining  of  the  cheeks  and  severe  tonsillitis  are  some- 
times observed.  Ringing  in  the  ears  and  some  deafness  are  not  uncom- 
mon during  the  height  of  the  disease.  The  secretion  of  saliva  is 
sometimes  increased,  but  is  oftener  diminished.  Gerhardt  found  by 
introducing  a  cannula  into  the  duct  of  Steno  that  the  saliva  from  the 
affected  gland  came  more  slowly  than  normal,  but  exhibited  no  material 
changes  in  character.  The  pressure  of  the  swollen  glands  narrows  the 
fauces  and  increases  the  difficulty  in  swallowing,  makes  the  voice  nasal, 
and  may  cause  dyspnoea  by  pressure  on  the  larynx,  CEdema  of  the 
larynx  is  sometimes  produced.  Vomiting,  diarrhoea,  and  epistaxis  are 
occasionally  seen.  In  the  form  of  the  disease  sometimes  called  the  tv- 
phoid  type  there  is  a  prominence  of  threatening  nervous  symptoms, 
such  as  delirium,  restlessness,  adynamic  state,  and  involuntary  evacua- 
tions.    Enlargement  of  the  spleen  often  accompanies  the  severe  cases. 

One  of  the  most  interesting  of  the  symptoms  of  mumps — too  inte- 
gral a  part  of  it  to  be  called  a  complication — is  the  involvement  of  the 
genital  apparatus,  especially  the  testicle.  This  was  once  considered 
to  be  the  result  of  metastasis,  the  transmission  to  the  testicle  of  some 
poisonous  substance  produced  in  the  parotid  gland.  The  fact  that  occa- 
sionally the  testicle  is  the  first  to  be  affected  or,  as  in  the  cases  reported 
by  Kovacs  and  others,  is  alone  involved,  proves  that  this  theory  is  in- 
correct and  that  orchitis  is  simply  a  localization  of  the  specific  poison 
upon  the  testicle.  The  severity  of  the  parotiditis  seems  to  have  no 
influence  on  the  tendency  to  orchitis.  The  involvement  of  the  testicle 
is  very  rare  in  children.  It  is  oftenest  seen  in  youths  and  young  adults, 
but  here,  too,  its  frequency  varies  greatly  with  different  epidemics. 
Laveran  reports  it  as  occurring  in  1  out  of  every  3  cases  among  patients 
in  the  army,  while  the  observations  of  some  others  place  its  frequency  at 
much  less  than  this  :  699  cases  of  mumps  occurring  in  14  different  epi- 
demics, collected  by  Comby,  gave  211  cases  of  orchitis,  a  percentage 
of  30.  As  a  rule,  orchitis  begins  six  to  eight  days  after  the  appearance 
of  the  parotid  swelling.  In  the  majority  of  instances  only  one  testicle 
is  attacked.  In  the  cases  where  both  suffer  the  inflammation  begins 
in  the  second  from  two  to  four  days  after  the  first  is  affected.  The 
process  is  a  true  orchitis,  and  the  epididymis  is  only  occasionally 
involved,  and  then  generally  to  a  less  degree. 

The  symptoms  of  the  testicular  involvement  consists  in  a  renewal 
of  the  fever,  which  had  grown  less  or  disappeared,  but  which  now 
reaches  101°  F.  or  more.  Not  infrequently  severe  or  even  threatening 
symptoms  attend  or  precede  the  process,  such  as  vomiting,  severe  diar- 
rhoea, rapid,  feeble    pulse,   profound  depression  of   strength,   delirium, 


( 'OMPUCA TIONS  AND  SEQ UELyE-I)I.  I CNOSIS.  729 

aiul  tyj»lit>i(l  syinptdiiis.  There  is  dull  oi'  .severe  pain  in  the  testicle 
M'ith  swelling  and  tenderness.  The  skin  of  the  scrotum  is  red  and 
tender  and  sonietinies  (edematous.  The  inflammation  reaches  its  heigiit 
by  the  third  or  ioiirth  day,  continues  severe  from  two  to  three  days, 
and  then  rapidly  g-rows  less.  The  severe  li'eiieral  symptoms  usually 
diminish  i'a[)idly  by  the  time  the  testi<'ular  s\vellin<j  has  aj)peai"ed,  hut 
the  fever  contimies  liiiih  until  the  enlargement  of  the  inland  has  dimin- 
ished,  when  it  descends  by  crisis  or  by  lysis, 

]\Iost  cases  of  orchitis  recover  entirely,  but  atrophy  sometimes  re- 
sults. In  certain  epidemics  the  proportion  of  cases  atroj)hying;  has  been 
very  higii.  Very  excej)tionally  an  analogous  inflannnation  is  seen  in 
females,  aifectino-  the  ovaries,  external  labia,  or  mammary  glands. 

CoJiPLiCATioNs  AND  Sequel.e. — In  vcrv  rare  cases  suppuration 
of  the  parotid  gland  takes  place  or  a  chronic  induration  with  some 
enlargement  may  remain  for  a  long  time.  Suppuration  of  the  testicle 
has  also  occurred.  Swelling  of  the  lachrymal  glands  has  been  reported. 
This  last,  like  swelling  of  the  cervical  and  other  lymphatic  glands,  is 
rather  an  unusual  symptom  than  a  complication,  since  it  is  analogous 
to  the  infectious  orchitis.  Albuminuria  may  be  present  in  grave  cases. 
Stomatitis  is  sometimes  observed.  Deafness  arising  during  the  disease 
has  been  alluded  to.  It  may  persist  after  the  attack  as  a  result  of  affec- 
tion of  the  middle  ear  or  even  of  the  labyrinth.  Influenza  complicating 
mumps  has  been  reported  by  Jackson,  Fiessinger,  and  Currier.  Paraly- 
sis from  peripheral  neuritis  after  mumps  is  recorded  by  Joffroy,  and 
paralysis  of  accommodation  by  Boas.  Insanity  of  various  forms  has 
been  observed.  The  possibility  of  oedema  of  the  larynx  developing 
has  already  been  mentioned.  Among  rare  complications  and  sequelae 
are  nephritis,  uraemia,  hfematuria,  meningitis,  convulsions,  conjunctivitis, 
blepharitis,  and  other  affections  of  the  eye,  coryza,  otorrhoea,  tonsillitis, 
oedema  of  the  brain  from  pressure  on  the  jugular  veins,  cystitis,  vagin- 
itis, urethritis,  endo-  and  pericarditis,  pneumonia,  inflammation  of  the 
joints,  etc. 

Rectrrexce  axd  Relapse. — One  attack  of  mumps  gives  almost 
certain  immunity  against  subsequent  ones.  Very  few  instances  of  two 
attacks  have  been  reported.  Servier  saw  one  case  in  which  a  second 
attack  occurred  five  years  after  the  first.  Relapses  are  sometimes 
seen.  Some  instances  of  so-called  relapse  consist  more  in  what  might 
be  called  an  exacerbation  of  the  disease.  In  such  cases  the  swelling  of 
the  parotid  grows  less  on  the  second  or  third  day,  and  then  returns  a 
day  or  two  later.  In  other  cases  there  is  a  genuine  relapse,  the  swelling 
and  other  symptoms  recommencing  from  one  to  two  weeks  after  the  first 
attack  has  entirely  ceased. 

Diagnosis. — Although  the  diagnosis  of  mumps  is  generally  easy  to 
make,  yet  it  is  possible  for  mistakes  to  arise.  A  secondary  parotiditis, 
developing,  as  it  does,  in  the  course  of  other  affections,  can  be  distin- 
guished by  its  history,  as  well  as  by  its  symptoms.  The  s"\^elling  is  uni- 
lateral, more  painful,  and  probably  finally  becomes  red  and  fluctuating, 
or  it  has  a  decided  tendency  to  go  on  to  suppuration. 

Acute  cervical  adenitis  is  the  condition  most  apt  to  be  confounded 
with  mumps.  When  either  affection  can  be  watched  throughout  its 
course  the  diagnosis  is  easy,  but  when  a  patient  is  seen  for  the  first  time 


730  EPIDEMIC  PAROTIDITIS. 

with  either  disease  already  well  under  way,  to  distinguish  between  the 
two  is  often  very  difficult.  Before  suppuration  has  become  evident  in 
the  inflamed  lymphatic  glands  the  swelling  may  extend  over  the  edge 
of  the  lower  jaw  and  to  the  region  of  the  parotid.  Even  now,  however, 
the  centre  of  the  inflamed  area  seems  to  be  rather  below  the  jaw  than 
over  the  parotid,  and  as  pus  increases  in  amount  and  the  inflammation 
concentrates,  as  it  were,  about  the  lymph  gland,  the  seat  of  the  trouble 
becomes  very  evident.  In  the  rare  cases  in  which  mumps  attacks 
primarily  or  solely  the  submaxillary  gland  the  diagnosis  from  cervical 
lymphadenitis  might  be  impossible  early  in  the  attack.  Chronic  inflam- 
mation of  the  lymphatic  glands  runs  an  entirely  different  course  from 
mumps.  In  addition  to  this  difference,  any  lymphatic  inflammation 
covering  so  large  an  area  is  almost  always  multiple,  and  the  individual 
enlarged  glands  can  be  detected  by  palpation.  Diphtheria  or  scarlatina 
may  be  attended  by  swelling  in  the  neck.  Examination  of  the  throat 
will  reveal  the  local  conditions  there.  Retropharyngeal  abscess  may 
extend  until  it  involves  the  tissues  in  the  neighborhood  of  the  maxil- 
lary articulation.  Digital  examination  of  the  pharynx  will  settle  the 
diagnosis.  Should  mumps  begin  in  or  be  confined  to  the  testicle,  the 
diagnosis  from  a  simple  orchitis  might  be  impossible  unless  the  exist- 
ence of  an  epidemic  of  mumps  was  taken  into  account. 

Prognosis. — The  prognosis  of  mumps  is  nearly  always  favorable,  so 
far  as  life  is  concerned.  Tlie  patient  is,  however,  threatened  by  atrophy 
of  the  testicle,  which  is  not  an  infrequent  sequel  of  orchitis.  There  is, 
too,  the  occasional  danger  of  permanent  deafness  remaining.  Some  of 
the  other  complications  may  in  rare  instances  threaten  life. 

Treatment.  —  Prophylaxis.  —  The  prevention  of  mumps  is  ex- 
ceedingly difficult  if  not  altogether  impossible.  This  is  due  to  the 
fact  already  stated,  that  the  disease  is  probably  infectious  during  the 
period  of  incubation,  and  that  the  infection  can  still  be  transmitted 
after  symptoms  have  disappeared.  It  is  safer,  therefore,  that  patients 
suffering  with  mumps  be  kept  from  contact  wdth  others  for  three  or  four 
weeks  after  the  first  appearance  of  symptoms.  Since  close  contact  is 
required  for  the  transmission  of  the  disease,  the  extreme  precautions  for 
disinfection  necessary  with  some  diseases  are  not  needed. 

Treatment  of  the  'Attach. — In  the  majority  of  cases  little  treatment 
is  required,  although  the  patient  should  be  confined  to  the  house  or  bed. 
For  the  relief  of  pain  hot  fomentations  or  poultices  may  be  applied  or 
the  face  covered  wdth  raw  cotton  or  rested  against  a  hot  water  bag.  The 
bowels  should  be  opened  by  a  mild  laxative,  preferably  a  saline.  Fever 
may  be  combated  by  an  ordinary  febrifuge,  or,  in  case  the  temperature 
is  high,  by  anti])yrine  or  other  drug  of  this  class,  or  by  cold  bathing. 
A  preparation  of  opium  may  be  needed  if  pain  is  severe  and  sleep  much 
disturbed.  Nourishment  must  be  soft,  since  chewing  is  difficult  or  im- 
possible. Adynamic  symptoms  may  demand  stimulants.  The  treat- 
ment of  the  orchitis  does  not  differ  "from  that  proper  for  inflammation 
of  the  testicle  due  to  other  causes. 


TUBERCULOSIS. 

By  WILLIAM  OSLER,  M.  D.> 


I.   GENERAL   ETIOLOGY  AND   MORBID   ANATOMY. 

Definition. — An  infectious  disease  due  to  the  bacillus  tuherculosis, 
characterized  by  the  presence  of  nodular  bodies  called  tubercles  (or 
diifuse  infiltrations)  which  may  undergo  caseation  or  sclerosis,  and  which 
may  finally  ulcerate  or  in  some  situations  become  calcified. 

I.  General  Etiology  and  Morbid  Anatomy. — (1)  Tuberculosis 
in  Animal'<. — In  reptiles  the  disease  is  rare,  though  occasionally,  as  Sibley 
has  shown,  it  is  found  in  them  in  a  state  of  confinement. 

In  birds  the  disease  is  common  in  the  domestic  fowls,  but  there  are 
differences  which  warrant  the  separation  of  avian  from  other  forms  of 
tuberculosis. 

In  Domestic  Animals. — One  of  the  most  important  etiological  facts 
in  connection  with  the  disease  is  its  widespread  occurrence  in  animals 
from  which  man  derives  a  considerable  share  of  his  food.  Bovines  are 
chiefly  affected.  Recent  studies  and  the  improved  methods  of  inspec- 
tion have  demonstrated  the  very  widespread  existence  of  the  disease. 

In  the  United  States  no  compulsory  systematic  inspection  is  made  at 
the  abattoirs,  but  a  good  deal  of  information  has  been  collected  of  late 
years.  Of  5297  cattle  slaughtered  in  Maryland,  159  were  tuberculous 
(A.  W.  Clement),  and  of  15,506  animals  slaughtered  at  the  Brighton 
abattoir,  near  Boston,  29  were  tuberculous  (Burr). 

Careful  inspection  of  herds  has  been  made  in  some  of  the  States, 
and  the  tuberculin  test  employed  to  determine  the  presence  of  the 
disease.  The  New  York  State  Commission  examined  947  animals  and 
condemned  66. 

On  the  continent  of  Europe  much  more  accurate  statistics  are  avail- 
able. Thus  for  the  four  years  (1890-93,  inclusive)  the  percentage  of 
tuberculous  animals  among  132,294  oxen  and  cows  slaughtered  in 
Copenhagen  was  17.7.  At  the  Berlin  abattoir  in  the  year  1892-93, 
21,603  animals  out  of  142,874  showed  evidences  of  tuberculosis.  In 
the  same  year  125  calves  out  of  108,348  showed  signs  of  the  disease. 
In  Great  Britain  there  are  no  satisfactory  records  to  show  the  incidence 
of  the  disease  in  cattle. 

In  sheep  the  disease  is  very  much  less  common.  The  percentage  at 
Berlin  is  about  1.5.  Horses  are  rarely  attacked.  Dogs  and  cats  are  not 
very  liable  to  the  disease.  Cadiat  has  recently  investigated  carefully 
the  subject  of  tuberculosis  in  the  dog.     At  Alfort  there  were  40  cases 

^  I  beg  to  acknowledge  the  valuable  assistance  I  have  received  in  the  preparation  of 
this  article  from  my  assistants,  Dr.  George  Bluraer  and  Dr.  T.  B.  Futcher. 

731 


732  TUBERCULOSIS. 

of  the  disease  among  9000  post-mortems.  The  disease,  he  states,  orig- 
inates usually  in  the  intestines,  and  the  virus  is  probably  transmit- 
ted through  bones  which  have  been  previously  picked  by  tuberculous 
patients  or  the  dogs  have  licked  up  what  has  been  left  on  their  plates. 
When  one  considers  the  very  close  contact  of  the  dog  as  a  domestic  pet, 
it  is  somewhat  remarkable  that  the  disease  is  so  rarely  seen  in  it. 

In  other  animals  kept  as  pets,  such  as  the  rabbit  and  guinea-pig,  the 
disease,  under  natural  conditions,  is  very  rare.  Both  of  these  animals, 
however,  are  very  susceptible  to  the  disease  when  inoculated.  Among 
apes  and  monkeys  kept  in  confinement  tuberculosis  is  the  most  formid- 
able disease  with  which  these  animals  have  to  contend. 

(2)  General  Statistics  of  the  Disease  in  Man. — Tuberculosis  is  the 
most  universal  scourge  of  the  human  race.  It  prevails  more  particularly 
in  the  large  cities  and  wherever  the  population  is  massed  together.  It 
is  estimated  that  in  civilized  countries  one-seventh  of  the  deaths  are  due 
to  this  disease.  In  the  United  States  Census  Report  for  1890,  102,188. 
deaths  were  reported  to  be  due  to  consumption.  It  is  difficult  to  get 
accurate  statistics  as  to  the  number  of  deaths  due  to  other  forms  of  the 
disease,  but  at  a  low  estimate  one  can  say  that  at  least  150,000  persons 
die  annually  in  the  United  States  of  all  forms  of  tuberculosis.  An 
estimation  based  on  the  Census  Report  gives  the  total  number  of  per- 
sons in  this  country  infected  with  tuberculosis  as  1,050,000,  or  1  in 
every  60  of  the  population  (Vaughan). 

The  death  rate  from  tuberculosis  in  the  cities  is  very  much  higher 
than  the  average ;  thus  Hirsch  states  that  while  the  general  death  rate 
is  3  per  thousand,  that  of  Vienna  is  7.7,  and  of  Munich  and  Glasgow  4 
per  thousand. 

Geographical  jjosition  has  very  little  influence.  The  disease  is  per- 
haps more  prevalent  in  the  temperate  regions  than  in  the  tropics,  but 
altitude  is  a  more  potent  factor  than  latitude ;  in  the  high  regions  of  the 
Alps  and  Andes  and  in  the  central  plateau  of  Mexico  the  death  rate 
from  tuberculosis  is  very  low. 

The  influence  of  race,  which  has  been  much  studied,  is  probably  less 
owing  to  any  inherent  differences  than  to  the  conditions  under  which  the 
individuals  live.  The  Indians  of  this  continent  are  very  prone  to  the 
disease.  Matthews  states  that  the  death  rate  in  the  older  reservations 
in  the  East  was  three  times  as  great  as  that  of  the  Indians  still  living 
in  the  Northwest.  In  this  country  the  Irish  and  the  negroes  appear 
specially  prone  to  the  disease  ;  on  the  other  hand,  the  Hebrews  possess 
a  relative  immunity.  For  the  six  years  ending  May  31,  1890,  the 
average  annual  death  rate  from  consumption  in  New  York  City,  per 
100,000  of  population  was — for  the  Irish,  645.73  ;  for  the  colored, 
531.35;  for  the  Germans,  328.80;  for  the  American  whites,  205.14; 
and  for  the  Russian-Polish  Jews,  76.72  (J.  S.  Billings). 

The  interesting  question  arises  as  to  w^hether  tuberculosis  is  on  the 
increase  or  on  the  decrease.  E.  F.  Wells,  who  has  tabulated  an  im- 
mense body  of  statistics  on  this  subject,  states  that  the  evidence  is  in 
favor  of  a  very  positive  decline  in  the  prevalence  of  the  disease.  While 
the  last  decennial  census  of  the  United  States  does  not  show  any  decrease, 
yet  in  many  of  the  larger  cities  there  has  been  a  striking  diminution. 
The   question  has  been  considered  very  carefully  by  James  B.  Russell 


GENERAL   KTIOLOGY  AND  MORIUI)  ANATOMY.  1?>:\ 

of  Glasgow  in  his  Sanitary  Ili.stoi-i/  <ti"  that  city.  One  (ji-  two  of"  the 
sentences  from  his  re|)()rt  may  be  ([noted  with  :i(l\:inta<;'e  :  "  Between 
the  five  years  1870-74  and  the  live  years  1890-04  there  was  a  th-erease 
of  41  per  cent,  in  the  tleatli  rate.  If  we  start  from  the  maxim mn 
period  of  fatality  (1860-()4),  the  decrease  amonnts  to  44  per  cent.  The 
acceptance  of  the  doctrine  tiiat  every  case  of  phthisis  is  the  I'esnlt  of  a 
specific  infection — that,  consecinentiy,  no  one  is  foredoomed  to  have 
phthisis  or  any  other  form  of  tnherculoiis  disease — gives  great  j)r('cision 
to  onr  ideas  of  prevention."  He  attributes  a  good  deal  to  the  diffusion 
of  the  knowledge  that  the  existence  and  distribution  of  the  tubercle 
bacillus  is  the  first  condition  of  infection,  and  also  to  the  successful 
administrative  efforts  in  securing  "  ventilation,  especially  of  houses 
and  byres ;  the  removal  of  dampness  by  subsoil  drainage  and  precau- 
tions adapted  to  the  foundations  and  walls  of  houses ;  the  abolition  of 
dark  spaces  and  enclosures ;  the  dissemination  of  direct  sunlight." 

(3)  The  Bacillus  Tuberculosis. — Although  the  researches  of  many 
workers,  particularly  those  of  Villemin,  in  the  field  of  tuberculosis 
had  left  no  doubt  of  the  infective  nature  of  the  disease,  it  was  not 
until  the  discovery  of  the  bacillus  by  Koch  in  1882  that  the  true  nature 
of  the  parasite  was  known.  In  the  fourteen  years  that  have  elapsed 
much  work  has  been  done  on  the  bacillus  tuberculosis  in  its  various 
relations  and  from  varying  standpoints,  but  the  original  work  of  Koch 
was  so  thorough  and  far-reaching  that  our  increase  of  knowledge  has 
consisted  in  the  elaboration  of  finer  details,  the  essential  facts  remaining 
unchanged. 

The  Morphological  and  Biological  Characters  of  the  Bacillus. — The 
bacillus  of  tuberculosis  is  an  aerobic,  non-motile,  strictly  parasitic 
organism,  capable  under  certain  circumstances  of  growing  without  the 
presence  of  oxygen.  Its  length  varies  a  good  deal,  ranging  from  1  to 
5  mikrons,  or  from  one  fourth  to  almost  the  entire  diameter  of  a 
red  blood  corpuscle.  The  diameter  varies  very  little,  the  average 
being  about  two  tenths  of  a  mikron.  The  organism  may  be  either 
straight  or  more  commonly  slightly  curved,  and  occurs  very  often  in 
groups,  the  bacilli  lying  across  one  another.  To  within  a  comparatively 
recent  period  it  was  supposed  that  the  bacillus  of  mammalian  tubercu- 
losis, in  contradistinction  to  avian  tuberculosis,  did  not  show  those 
peculiarities  known  as  involution  forms,  but  considerable  variations, 
not  only  in  length  and  shape  of  the  organism,  may  occur,  and  even 
branched  varieties  may  be  seen,  similar  to  those  of  the  diphtheria 
bacillus.  The  question  of  spore  formation  cannot  yet  be  said  to  be 
definitely  settled.  The  small,  refractile  areas  so  commonly  seen  in 
stained  specimens  of  the  organism,  and  originally  described  by  Koch  as 
spores,  certainly  have  not  tlie  characteristics  of  the  ordinary  spores,  nor, 
on  the  other  hand,  have  they  the  characteristics  of  mere  vacuoles.  It 
seems  possible  that  these  areas,  though  not  really  spores,  may  be,  at  any 
rate,  particles  in  the  bacillus  which  are  more  resistant  than  the  rest  of 
the  organism,  and  which  under  certain  circumstances  are  capable  of 
developing  into  younger  forms. 

The  Sfaining  Reactions  of  the  Tubercle  Bacillus. — As  Koch  pointed 
out  in  his  original  article,  the  bacillus  tuberculosis  possesses  peculiar 
staining  reactions  which  are  associated  with  it  and  with  hardly  any  other 


734  TUBERCULOSIS. 

organism.  These  consist  in  the  fact  that  the  bacilkis  stained  with  great 
difficulty  with  the  ordinary  dyes,  staining  most  intensely  with  alka- 
line reagents,  and  that  its  resistance  to  decolorization  was  even  greater 
than  its  resistance  to  stain,  Koch  thought  that  this  peculiarity  was  due 
probably  to  the  membrane  which  surrounded  the  bacillus,  which  per- 
mitted the  penetration  of  alkaline  solutions,  but  was  peculiarly  resistant 
to  the  action  of  acids.  Subsequent  researches  have  shown,  however, 
that  the  peculiar  staining  reactions  are  almost  certainly  due,  not  to  any 
properties  of  the  surrounding  membrane,  but  to  peculiarities  in  the 
bacterial  protoplasm  itself.  The  researches  of  Hammerschlag  have 
shown  that  a  substance  exists  in  the  bacterial  protoplasm  which  can  be 
isolated  and  which  has  the  staining  peculiarities  mentioned  above.  After 
the  removal  of  this  substance  the  bacillus  no  longer  retains  its  peculiar 
staining  properties,  and  it  has  also  been  shown  that  this  peculiarity  in 
staining  is  one  more  of  mere  difficulty  in  staining  than  of  any  peculiar 
reaction  to  acids  or  alkalies,  for  it  has  been  shown  that  the  bacillus 
tuberculosis  can  be  stained  by  ordinary  media  without  the  addition  of 
alkalies.  The  leprosy  bacillus  presents  similar  staining  peculiarities, 
but  it  can  also  be  easily  stained  by  the  method  of  Weigert,  a  property 
not  possessed  by  the  tubercle  bacillus.  The  bacillus — or,  more  properly 
speaking,  the  group  of  bacilli — found  in  the  smegma  and  also  certain 
bacilli  found  in  the  cerumen  take  the  same  stain  as  the  tubercle 
bacillus  with  ordinary  methods.  This  peculiarity  of  staining  is  not, 
however,  due  to  peculiarities  in  their  protoplasm,  but  to  the  fact  that 
they  have  grown  in,  and  are  surrounded  by,  substances  containing  large 
amounts  of  fat,  which  act  as  a  protection  against  the  acids  used  as  de- 
colorizing agents.  Beinstock  has  shown  that  this  peculiar  reaction  on 
the  part  of  the  smegna  and  cerumen  bacilli  can  be  entirely  removed  by 
submitting  the  cover-slip  preparations  under  the  action  of  heat  to  a 
solution  of  sodium  in  alcohol,  by  means  of  which  the  fatty  capsule  sur- 
rounding the  bacilli  is  saponified,  when  the  usual  reaction  no  longer 
takes  place. 

For  demonstrating  the  tubercle  bacillus  in  sputum  the  following  is  the 
most  satisfactory  method  :  The  sputum  to  be  examined  is  spread  out  in  a 
thin  layer  upon  a  glass  plate  which  has  been  placed  upon  a  dark  or  black 
background.  The  particles  to  be  examined,  which  are  the  purulent 
specks,  are  picked  out  by  means  of  a  pair  of  sharp-pointed  forceps, 
either  with  the  naked  eye  or  with  the  help  of  a  pocket  lens.  The  mate- 
rial thus  obtained  is  carefully  spread  out  upon  the  perfectly  clean  cover- 
slip  and  dried  in  the  air,  and  then  fixed  by  passing  it  slowly  three  or 
four  times  through  the  flame  of  a  Bunsen  burner.  Special  attention 
must  be  paid  to  the  cleanliness  of  the  cover-slip,  as  it  has  been  shown 
that  in  cover-slips  used  for  a  second  time,  even  after  boiling,  bacilli  were 
still  present  from  the  first  examination.  The  staining  preparation  best 
employed  is  that  of  Ziehl,  w^hich  consists  of — 


Distilled  water, 

100  grammes ; 

Crystalline  carbolic  acid. 

5 

Alcohol, 

10 

Fuchsin, 

1  gramme. 

GENKIIM.   ETIOLOGY  A XI)   MORBID   ANATOMY.  735 

A  \'v\\  drops  of  tlu'  solution  arc  |»1;ic(m1  ii|ioii  the  cover-glass,  which 
is  held  over  the  Hanie  until  steam  arises,  actual  i)oiliii<r  not  Ix'iiij;  neces- 
sarv.  The  lilass  is  then  washed  in  water,  and  a  iew  dro])s  of  the  (xahhet- 
Krnst  solution  are  placetl  upon  the  u;lass  and  allowed  to  remain  for  about 
a  minute.  This  solution  consists  of  \  to  \-  per  cent,  solution  of  methy- 
lene blue  in  25  per  cent,  sulphuric  acid.  The  cover-glass  is  then  washed 
in  water  and  mounted — if  for  tem])orarv  examination,  in  water;  if  for 
permanent  keeijing,  in  balsam.  Tubercle  bacilli  are  stained  red,  while 
the  nuclei  of  the  cells  and  other  bacteria  present  are  stained  blue. 

In  the  examination  of  urine  or  faeces  the  same  process  is  carried 
throuo-h,  the  parts  of  material  used  being  in  urine  the  purulent  sedi- 
ment, and  in  the  fteces  the  small  particles  of  pus  or  muco-pus.  A\Tien 
very  small  numbers  of  the  tubercle  bacilli  are  present,  either  in  the 
sputinn  or  in  the  urine,  the  centrifuge  should  be  used. 

The  most  satisfactory  method  for  staining  tubercle  bacilli  in  sections 
is  the  following  :  The  tissues  are  preferably  hardened  in  absolute  alcohol, 
though  tissues  hardened  in  Midler's  fluid  can  be  used  after  special  prep- 
aration. The  tissue  is  imbedded  in  celloidin,  which  is  removed  after 
the  sections  have  been  cut  either  with  oil  of  cloves  or  "with  equal  parts 
of  absolute  alcohol  and  ether.  From  these  latter  agents  they  may  be 
placed  in  water.  The  dye  to  be  used  is  that  of  Ziehl,  the  formula  of 
which  is  given  al)ove.  The  sections  are  left  for  two  hours  at  a  temper- 
ature of  60°  C,  or  for  six  to  eight  hours  in  the  thermostat,  or  else  for 
twenty-four  hours  at  room  temperature,  the  latter  being  perhaps  prefer- 
able, as  the  heating  is  apt  to  cause  shrinkage  of  the  specimens.  After 
staining  by  the  fuchsin  the  tissues  are  decolorized  in  the  ordinary  acid 
alcohol  of  the  laboratory,  the  1  per  cent,  solution  of  hydrochloric  acid 
in  70  per  cent,  alcohol.  The  tissues  are  removed  from  this  decolorizing 
agent  while  they  still  retain  a  decided  pink  appearance,  and  are  then 
placed  in  the  counter-stain,  a  2  per  cent,  aqueous  solution  of  methylene 
blue.  The  sections  are  then  dehydrated  in  absolute  alcohol,  cleared  in 
oil  of  cloves,  or  preferably  in  xylol,  and  mounted  in  xylol  balsam.  By 
this  method  the  tissues  are  stained  a  delicate  blue  and  the  bacilli  a 
bright  red  color. 

Methods  of  Growth  of  the  Bacillus. — The  tubercle  bacillus  does  not 
grow  upon  the  ordinary  media  found  in  the  laboratory  with  the  ex- 
ception of  potato,  and  on  this  the  growth  is  not  very  satisfactory. 
Special  media  are  necessary,  the  particular  agent  favoring  the  growth 
being  glycerin.  The  difficulty  of  obtaining  the  original  growth  from 
tuberculous  tissue  is  often  great.  This  is  partly  due  to  the  fact  that  the 
number  of  viable  organisms  in  such  material  is,  as  a  rule,  small,  and 
partly  to  the  fact  that,  the  growth  of  the  bacillus  being  extremely  slow, 
any  contaminating  organism  introduced  with  the  original  material 
entirely  overgrows  the  tubercle  bacillus.  After  this  primary  difficulty 
has  been  overcome  the  growth  of  the  organism  becomes  more  and  more 
satisfactory  with  each  subsequent  inoculation.  The  original  growth  is 
best  obtained  upon  solid  media,  preferably  glycerin  agar  or  blood  serum. 
On  this  medium  at  the  end  of  ten  days  or  two  weeks,  at  a  temperature 
of  37°  to  38°  C,  there  are  observed  small  isolated  colonies  of  a  gray 
white  color,  having  a  dry,  scaly,  somewhat  dull  appearance.  The  best 
growth,  however,  of  the  organism  is  obtained  in  liquid  media,  a  peptone 


736  TUBERCULOSIS. 

bouillon  containing  a  certain  proportion  of  glycerin  being  the  most  satis- 
factory. A  colony  from  a  solid  medium  is  allowed  to  float  on  the  sur- 
face of  such  liquid  media,  and  in  from  ten  days  to  two  weeks  a  beauti- 
ful growth  is  usually  apparent.  This  appears  as  a  continuous  thick 
white  membrane,  quite  dry  and  wrinkled  on  the  surface.  Hardly  any 
other  organism  can  be  found  ^-hich  approaches  the  tubercle  bacillus  in 
its  intensity  of  growth  on  this  medium. 

Agents  Deleterious  to  the  Tubercle  JBacillas. — The  agencies  which  are 
capable  of  injuring  the  tubercle  bacillus  are  of  both  physical  and  chem- 
ical nature.  The  action  of  direct  sunlight  is  perhaps  the  most  effective 
of  the  physical  agents — so  eifective,  indeed,  that  it  is  probable  that  all 
tuberculous  sputum  exposed  in  the  open  air  is  fully  sterilized  by  the 
time  that  it  has  become  desiccated  and  capable  of  transmission.  The 
desiccation  of  the  organism  has  much  less  effect,  and  repeated  experi- 
ments have  shown  that  bacilli  in  desiccated  sputum  can  retain  their 
virulence  for  as  long  as  nine  or  ten  months  (De  Toma). 

Heat  acts  upon  the  bacillus  tuberculosis  with  comparative  ease,  and 
complete  boiling  for  a  veiy  short  time  is  all  that  is  necessary  to  destroy 
the  organism  in  fresh  sputum  or  in  foods  containing  it.  Dry  heat  also 
has  a  rapid  effect  on  the  organism.  Freezing  does  not  destroy  the 
bacillus. 

Of  the  chemical  agents,  that  which  is  most  suited  to  disinfection  of 
the  bacillus  is  probably  carbolic  acid.  The  process  of  salting,  by  w^hich 
material  to  be  acted  upon  is  exposed  for  long  periods  of  time  to  solutions 
of  chloride  of  sodium  of  a  greater  ordess  saturation,  has  been  shown  to 
have  ver\-  little  eff'ect  upon  the  virulence  either  of  a  pure  culture  of  the 
bacillus  tuberculosis  (Galtier)  or  on  meat  from  tuberculous  animals 
(Forster).  In  connection  with  chemical  agents  it  is  well  to  mention  the 
action  of  the  gastric  juice  upon  the  tubercle  bacillus,  as  it  has  been 
shown  that  whatever  action  this  secretion  has  is  entirely  due  to  the 
hydrochloric  acid  which  it  contains,  and  not  to  its  digestive  power.  The 
principal  exjoeriments  concerning  the  action  of  the  gastric  juice  upon 
the  tubercle  bacillus  have  been  made  by  Falk  and  AVesener,  and  all  tend 
to  show  that  the  bacillus  is  practically  unaffected  by  the  secretion,  except 
after  very  long  periods  of  exposure,  such  as  could  hardly  obtain  in  the 
human  body. 

The  Distribution  of  the  Tubercle  Bacillus  in  the  Body. — The  tubercle 
bacillus  is  found  in  the  human  body  either  in  persons  suffering  from  the 
various  forms  of  tuberculosis  or  in  normal  individuals.  It  is  to  the 
work  of  Straus  in  particular  that  we  owe  our  knowledge  of  the  fact 
that  the  tubercle  bacillus,  like  the  diphtheria  bacillus  and  certain  other 
pathogenic  organisms,  is  occasionally  found  in  perfectly  healthy  indi- 
viduals. His  experiments  show  that  it  existed  in  a  pure  state  in  the 
nasal  cavities  of  9  out  of  29  hospital  attendants,  in  1  out  of  9  of  the 
attendants  upon  public  libraries,  and  in  1  out  of  7  of  those  habitually 
employed  in  theatres.  Other  than  in  the  nasal  cavity  no  observations 
have  been  made  upon  the  existence  of  the  tubercle  bacillus  in  normal 
individuals.  In  an  individual  suffering  from  tuberculosis  the  bacillus 
is  invariably  present  in  those  lesions  characteristic  of  the  disease. 

As  a  rule,  the  more  acute  the  process  the  more  numerous  the  tubercle 
bacilli,  but  in  certain  chronic  processes  occurring  in  the  lung  the  num- 


GENERAL  ETIOLOGY  AND  MORBID  ANATOMY.  737 

ber  of  bacilli  is  exceptioiuilly  large.  The  bacillus  is  also  found  in  cer- 
tiiin  excreta  from  these  individuals — notably  in  the  sputum.  As  Xut- 
tall  has  shown,  from  one  and  a  half  to  four  and  a  tliird  billions  of 
tubercle  baeilli  arc  daily  thrown  off  l)v  an  individual  with  moderately 
advanced  pulmonary  tuberculosis.  In  the  urine  of  those  sut!"eriiig-  frcjm 
genito-urinary  tuberculosis  and  in  the  stools  of  those  suifering  from  in- 
testinal tuberculosis  the  bacilli  are  also  found,  but  usually  in  rather 
small  numbers,  especially  in  the  stools. 

Verv  few  observations  have  been  made  upon  the  excretion  of  the 
tubercle  bacilli  in  the  milk  of  human  beings  (see  p.  833),  but  there  is 
abundant  experimental  evidence  that  bacilli  may  be  excreted  in  large 
numbers  in  the  milk  of  the  lower  animals,  not  only  in  those  suffering 
from  actual  disease  of  the  mammary  gland,  but  in  those  in  which  such 
disease  is  not  evident  clinically. 

The  semen  of  individuals  suffering  from  genito-urinary  tuberculosis 
may  contain  large  numbers  of  tubercle  bacilli,  and  certain  observers 
have  claimed  that  in  individuals  suffering  from  tuberculosis  in  which 
the  genito-urinary  tract  ^vas  free  from  gross  lesions  tubercle  bacilli 
could  also  be  obtained  in  the  semen,  but  in  very  small  numbers. 

The  sweat  of  tuberculous  individuals  has  been  shown  to  be  free  from 
the  tubercle  bacilli. 

The  Distribution  of  the  Bacillus  Outside  the  Body. — Although  it  has 
been  shown  that  the  bacillus  tuberculosis  is  a  strict  parasite  and  can 
only  multiply  under  parasitic  conditions,  there  is  abundant  evidence  that 
it  can  be  present  and  in  a  virulent  state  outside  of  the  human  or  animal 
body.  Its  presence  under  such  conditions  is  very  widespread,  the  num- 
ber of  bacilli  depending  largely  upon  the  prevalence  of  tuberculosis  in 
the  affected  district.  It  has  been  found  in  the  dust  of  houses,  streets, 
railroad  ears,  theatres,  libraries,  and  various  other  public  institutions. 
Outside  of  the  dust,  the  only  other  source  of  contamination  would 
appear  to  be  in  the  food,  either  in  the  insufficiently  cooked  flesh  of 
tuberculous  animals  or  in  the  various  products  of  such  animals,  as  milk, 
butter,  and  cheese. 

It  has  been  shown  that  the  tubercle  bacillus  can  exist  for  a  consider- 
able length  of  time  in  water,  but  so  far  no  authenticated  instance  of 
infection  from  this  source  has  been  reported.  Since  the  work  of  Theo- 
bald Smith  upon  Texas  fever  in  cattle  we  must  admit  the  possibility  of 
a  conveyance  of  infectious  diseases  by  insects,  and,  although  no  authen- 
ticated instance  of  this  sort  has  been  observed  in  tuberculosis,  it  has 
been  shown  that  the  common  house-fly  may  harbor  the  tubercle  bacilli. 

(4)  Modes  of  Infection. — (a)  Hereditary  Transmission. — The  possibil- 
ity of  the  direct  transmission  of  tuberculosis  has  never  been  open  to 
much  doubt,  but  the  method  of  transmission  and  the  frequency  are  still 
under  discussion.  There  are  two  opposing  schools,  the  one  claiming 
that  the  disease  is  transmitted  by  means  of  germ  infection,  the  other 
claiming  that  the  disease  per  se  is  not  inherited,  but  only  a  tissue  soil 
favoring  its  development. 

The  supporters  of  the  former  view,  headed  by  P.  Baumgarten,  claim 
that  in  inherited  tuberculosis  actual  tubercle  bacilli  have  been  carried 
over  from  the  parent  and  lodged  in  the  tissues  of  the  child,  where 
under  suitable  conditions  they  multiply  and  produce  the  disease.     To 

Vol.  I.— 47 


738  TUBERCULOSIS. 

explain  the  late  appearance  in  many  instances  after  birth  Baumgarten 
and  his  followers  assume  that  the  tubercle  bacilli  can  lie  latent  in  the 
tissues  and  subsequently  develop  when,  for  some  reason  or  other,  the 
individual  resistance  is  lowered.  He  likens  such  cases  of  latent  tuber- 
culosis to  the  late  hereditary  forms  of  syphilis,  and  explains  the  lack  of 
development  of  the  germs  by  the  greater  resisting  power  of  the  tissues 
of  children.  This  question  of  latency  has  recently  been  discussed  fully 
before  the  Royal  Medical  and  Chirurgical  Society  of  Loudon,  and  Kings- 
ton Fowler  expressed  the  sensible  opinion  that  it  was  not  necessary  seri- 
ously to  consider  the  question  of  latency  in  tuberculosis  until  direct 
transmission  from  mother  to  child  was  proved  to  be  of  frequent  occur- 
rence. Baumgarten  bases  his  belief  in  germ  transmission  upon  two 
main  factors — the  great  frequency  of  the  disease  in  early  life  and  the 
localization  of  tuberculous  lesions  in  children. 

In  recent  years  statistics  have  shown  the  mortality  from  tuberculosis 
in  the  first  years  of  life  to  be  relatively  high.  Froebelius  in  his  analysis 
of  16,581  autopsies  in  sucklings  found  it  is  416  ;  some  authors  place  the 
percentage  much  higher,  Bolz,  indeed,  stating  that  in  2576  autopsies 
made  on  children  27.8  per  cent,  who  died  in  the  first  year  were  tuber- 
culous. The  localization  of  tuberculous  lesions  in  children  in  the  bones  or 
joints  is  very  common,  Cnopp's  statistics  showing  that  out  of  298  tuber- 
culous children  of  from  a  few  days  to  twelve  years  of  age,  147  had  bone 
or  joint  tuberculosis,  and  only  8  of  these  showed  evidence  of  visceral 
disease.  Baumgarten  is  of  the  opinion  that  the  accidental  conveyance  of 
tubercle  bacilli  to  these  points  would  not  account  for  such  a  large  pro- 
portion of  cases,  and  expresses  the  view  that  the  bacilli  have  been  pres- 
ent since  birth  and  have  developed  when  favorable  conditions  are  offered. 
The  evidence  in  favor  of  Baumgarten's  view  is  both  clinical  and  ex- 
perimental. 

The  clinical  evidence  exists  in  the  form  of  undoubted  cases  of  con- 
genital tuberculosis,  of  which  there  are  now,  in  man  alone,  some  15  or 
20  examples  in  the  literature;^  besides  these  a  number  of  spontaneous 
cases  of  congenital  tuberculosis  in  the  lower  animals  have  been  reported. 

A  number  of  laboratory  workers  have  been  able  to  show  that  con- 
genital tuberculosis  can  be  produced  experimentally,  the  most  prominent 
of  these  being  Gartner,  who  was  able  to  cause  tuberculosis  in  young  mice 
by  inoculating  the  mother  with  tuberculosis,  either  into  the  peritoneal 
cavity  or  into  the  blood  stream. 

The  clinical  evidence  against  Baumgarten's  theory  lies  in  the  fact 
that  the  percentage  of  cases  of  congenital  tuberculosis  is  extremely 
small.  In  the  great  majority  of  instances  the  organs  of  foeti  born  of 
tuberculous  mothers  give  negative  results  when  inoculated  into  guinea- 
pigs.  Thus  Yignal  inoculated  24  guinea-pigs  with  the  organs  of  11 
children  born  of  tuberculous  mothers  with  entirely  negative  results, 
and  Bolognesi,  who  inoculated  130  animals  either  with  the  placentae  of 
8  tuberculous  women  or  with  the  organs  of  their  offspring,  only 
obtained  two  positive  results  in  the  animals. 

The  mass  of  the  experimental  evidence  is  against  the  theory  of 
germ  transmissiou.  Gartner,  for  example,  who  was  able  to  show  the 
possibility  of  germ  infection,   was    only  able,   by  inoculating  into  the 

1  For  a  review  of  the  cases  to  date  see  Hahn  in  Revue  de  la  Tuberculose,  1895,  t.  iii. 


GENERAL  ETIOLOGY  AND  MORBID  ANATOMY.  739 

pei'itoiK'al  cavitv,  to  cause  2  out  ot"  1)  cauary  l)ir<ls  to  produce  tul)ercu- 
lous  og-g.s,  ami  experiments  by  other  observers  all  tend  to  show  that  the 
animals  inheritino-  tuberculosis  directly  are  in  jjreat  minority. 

The  possible  methods  of  transmission  of  the  germ  in  direct  inherit- 
ance are  three — transmission  by  the  sperm  ;  transmission  by  the  ovum, 
and  transmission  through  the  blood  by  means  of  the  j)lacenta. 

There  is  no  clinical  evidence  to  support  the  view  that  direct  trans- 
mission can  occur  through  the  sperm,  nnless  w'e  consider  the  case  of 
Sarnev  as  such  :  a  woman  of  thirty  was  delivered  of  a  deformed  foetus 
in  whose  spinal  column  was  a  caseous  focus  containing  tubercle  bacilli. 
The  W(»man  was  in  perfect  health,  but  her  husband  {)resented  signs  of 
tuberculosis.  In  order  that  the  disease  could  be  transmitted  In-  the 
sperm  it  would  be  necessary  that  the  tubercle  bacilli  should  lodge  in  the 
individual  spermatozoon  which  fecundated  the  ovum.  The  chances  that 
such  a  thing  could  occur  are  extremely  small,  looking  at  the  subject 
from  a  numerical  point  of  view,  although  we  know  that  tubercle  bacilli 
do  occasionally  exist  in  the  semen ;  they  become  still  smaller  when  we 
consider  that  the  spermatozoon  is  made  up  of  nuclear  material,  which 
the  tubercle  bacillus  is  never  known  to  attack.  Experimentation  is 
all  opposed  to  sperm  transmission,  the  work  of  Gartner  and  others 
showing  that  the  young  of  healthy  female  rabbits  impregnated  by 
tuberculous  males  are  never  tuberculous,  even  though  the  females 
themselves  often  contract  the  disease. 

The  possibility  of  transmission  by  the  ovum  must  be  accepted. 
Baumgarten  has  in  one  instance  been  able  to  detect  the  tubercle  bacillus 
in  the  ovum  of  a  female  rabbit  w^hich  he  had  artificially  fecundated 
with  tuberculous  semen.  The  work  of  Pasteur  on  pebrine  has  shown 
the  possibility  of  this  form  of  transmission  in  the  lower  forms,  though 
the  question  as  to  what  effect  such  inoculation  would  have  upon  the 
human  ovum  cannot  of  course  be  answered. 

Probably  the  almost  constant  method  of  transmission  in  congenital 
tuberculosis  is  through  the  blood  current,  the  tubercle  bacilli  penetrat- 
ing by  way  of  the  placenta.  Certain  authors  hold  that  in  these  cases 
the  placenta  itself  is  invariably  the  seat  of  tuberculosis,  and  tubercles 
indeed  have  been  demonstrated  in  several  cases  ;  but  there  are  undoubted 
instances  in  which,  with  an  apparently  sound  placenta,  both  the  placental 
blood  and  the  foetal  organs  contained  tubercle  bacilli,  notwithstanding 
the  fact  that  the  organs  also  appeared  normal. 

The  opponents  of  the  theory  of  germinal  transmission  hold  that  in 
cases  of  hereditary  tuberculosis  a  special  predisposition  of  the  tissues 
exists  toward  the  tubercle  bacillus,  though  just  what  this  predisposition 
is  cannot  be  explained  in  our  present  state  of  knowledge.  Perhaps  the 
most  important  evidence  in  favor  of  this  hereditary  predisposition,  and 
opposed  to  the  theory  of  germ  inheritance,  is  the  fact  that  individuals  of 
tuberculous  stock  will  often  pass  through  life  without  a  sign  of  the  dis- 
ease when  removed  from  sources  of  direct  infection.  Some  instances 
reported  bvBernheim  are  interesting  in  this  connection.  In  one  family 
which  he  mentions,  consisting  of  five  children  born  of  a  healthy  mother 
to  a  tuberculous  father,  one  child  was  taken  from  home  soon  after  birth 
and  brought  up  by  a  relative.  The  rest  of  the  children  continued  liv- 
ing with  their  parents.    The  child  who  was  removed  from  home  remained 


740  TUBERCULOSIS. 

well  and  strong,  while,  of  the  other  four,  two  died  of  pulmonary  tuber- 
culosis and  two  were  in  advanced  stages  of  the  same  disease.  In 
another  family  of  seven  children,  in  which  both  father  and  mother  were 
tuberculous,  the  second  and  fifth  children  had  never  lived  with  the 
family.  The  children  who  lived  with  their  parents  died  of  tuberculosis  ; 
the  other  two  remained  healthy  and  had  healthy  children  of  their  own. 

The  whole  question  of  heredity  in  tuberculosis  can  be  summed  up  in 
these  statements  :  that  though  cases  of  congenital  tuberculosis  occur, 
they  are  extremely  rare ;  that  in  all  probability  most  cases  of  heredi- 
tary tuberculosis  are  due  to  heredity  of  the  soil,  and  not  to  inheritance 
of  the  germ  ;  that  tuberculosis  is  much  more  frequently  transmitted  in 
the  maternal  than  in  the  paternal  line. 

No  circumstance,  perhaps,  has  contributed  more  to  the  belief  in  the 
hereditary  transmission  of  the  disease  than  the  frequency  with  which 
tuberculosis  is  met  with  in  the  ascendants  of  those  affected.  The  esti- 
mates range  from  10  per  cent,  to  25  per  cent.,  or  even  in  some  instances 
to  50  per  cent.  Some  of  the  statistics  on  this  point  are  worth  quoting ; 
In  1000  cases  Williams  found  48.4  per  cent,  with  family  predisposition, 
12  per  cent,  with  parental,  1  per  cent,  with  grandparental,  and  34.4 
per  cent,  with  collateral  heredity.  Of  250  cases  in  which  Solly  made 
very  careful  inquiries  on  this  point,  there  were  28.8  per  cent,  with 
parental,  7,6  per  cent,  with  grandparental,  and  19.2  per  cent,  with  a 
history  of  collateral  heredity.  Of  427  cases  at  the  Johns  Hopkins 
Hospital,  there  were  53  in  which  the  mother  had  had  tuberculosis,  52 
in  which  the  father  had  been  affected,  and  105  in  which  a  brother  or 
sister  had  had  the  disease. 

As  illustrated  in  the  instances  mentioned  by  Bernheim,  the  question 
of  family  infection  is  the  all-important  one,  and  Hilton  Fagge  very 
wisely  remarks  that  it  is  impossible  to  draw  a  line  between  hereditary 
and  accidental  tuberculosis,  as  naturally  the  children  of  an  affected 
parent  are  more  liable  to  accidental  contamination. 

(6)  Inoculation. — Only  tuberculous  matter  when  inoculated  produces 
tuberculosis.  It  was  the  great  merit  of  Villerain  to  demonstrate  in 
1865  the  infective  nature  of  the  disease.  In  man  transmission  by 
inoculation,  which  is  rare,  is  chiefly  met  with  in  persons  whose  ocicupa- 
tion  brings  them  in  contact  with  dead  bodies  or  with  animal  products. 
Demonstrators  of  morbid  anatomy,  butchers,  and  tanners  are  liable  to  a 
local  tubercle  of  the  skin,  particularly  of  the  hands,  which  forms  a  red- 
dened mass  of  granulation  tissue.  This  has  long  been  known  as  the 
post-mortem  wart — the  verruca  necrogenica  of  Wilks.  The  tuberculous 
nature  of  this  body  is  shown  by  the  existence  of  bacilli  and  by  inocula- 
tion experiments  in  animals.  It  forms  one  of  the  most  interesting 
examples  of  a  local  tuberculous  process,  which  may  exist  for  years 
without  showing  any  tendency  to  spread.  It  should  in  reality  be  classi- 
fied with  lupus,  with  which  in  general  and  histological  character  it 
appears  to  be  identical.  These  tubercles  may  persist  for  years  without 
any  change.  Of  many  scores  which  in  former  years  I  have  had  on  my 
hands,  only  one  lasted  for  more  than  a  twelvemonth.  They  show  no 
tendency  to  spread,  though  occasionally  smaller  ones — colonies — may 
start  up  in  the  neighborhood.  Mr.  Hutchinson  refers  to  a  case  in  which 
the  anatomical  tubercle  had  persisted  for  more  than  forty  years.     I  have 


GENERAL  ETIOLOGY  AND  MORBID  ANATOMY.  741 

never  known  ;iii  iiistiiiice  <il"  infection  of  the  lymph  glands,  though  the 
possihilitv  ol"  this  is  shown  by  ii  ciise  by  (xerber,  who  accidentally  inoc- 
ulated liis  hand  in  perfornung  a  post-mortem  in  a  case  of  phthisis,  Avhich 
was  followed  by  a  "  lichen  "  tubercle,  which,  after  j)ersisting  for  months, 
was  excised.  Shortly  after  this  the  lymph  glands  of  the  axilla,  having 
become  enlarged  and  painful,  were  removed,  and  characteristic  tubercu- 
lous changes  with  bacilli  were  found  in  them.  I  have  seen  it  stated  that 
possiblv  [jaennec  contracted  phthisis  from  this  source,  but  this  seems 
verv  imjn-obable,  as  he  did  not  die  until  twenty  years  after  the  inocula- 
tion, and  in  the  interval  had  no  manifestations  pointing  to  this  as  the 
source  of  the  disease. 

In  the  performance  of  the  rite  of  circumcision  tuberculosis  has  not 
infrequently  been  inoculated,  the  infection  being  due  to  disease  in  the 
operator  and  occurring  in  connection  with  the  habit  of  cleansing  the 
wound  by  suction. 

In  various  other  ways  the  disease  has  been  inoculated.  Local  tubercle 
of  the  ear  has  resulted  from  perforation  of  the  lobe  for  earrings.  The 
bite  of  a  tuberculous  patient  has  been  followed  by  local  disease,  or  inoc- 
ulation has  occurred  from  a  cut  by  a  broken  spit-glass  of  a  consumptive 
patient,  and  instances  of  infection  have  followed  transplantation  of  skin 
(Czernv).  There  is  no  evidence  that  tuberculosis  has  ever  been  trans- 
mitted in  the  operation  of  vaccination.  On  the  other  hand,  it  has  been 
shown  that  the  lymph  from  the  vesicles  of  revaccinated  consumptives  is 
non-infective.     The  possibility  of  it,  however,  cannot  be  denied. 

(e)  Infection  by  Inhalation. — A  belief  in  the  contagiousness  of  pul- 
monary tuberculosis  has  always  been  held  in  the  profession.  The  early 
Greek  physicians  referred  to  it,  and  in  the  Latin  races  it  seems  always 
to  have  prevailed.  Among  the  English-speaking  races  until  recently 
very  little  credence  was  given  to  this  view.  Morton  in  the  Phthisio- 
logla  recognized  it,  and  refers  to  a  young  man  who  married  a  phthisical 
girl  and  became  aiFected  ex  contagio. 

It  is  well  remarked  by  Cornet,  "  The  consumptive  in  himself  is  almost 
harmless,  and  only  becomes  harmful  through  bad  habits."  It  has  been 
fully  shown  that  the  expired  air  of  consumptives  is  not  infective.  The 
virus  is  only  contained  in  the  sputum,  which  when  dry  is  widely  dissem- 
inated in  the  form  of  dust,  and  constitutes  the  great  medium  for  the 
transmission  of  the  disease.  "  In  order  to  be  air-borne  the  sputum  must 
be  dried  and  broken  up  into  dust.  If  discharged  into  a  handkerchief, 
it  speedily  dries,  especially  if  it  is  put  into  the  pocket. or  beneath  the 
pillow.  In  the  last  stages  of  consumption  the  jmtient  becomes  weak, 
the  sputum  is  expelled  imperfectly,  pillows,  sheets,  handkerchiefs  are 
soiled.  If  a  male,  the  beard  or  moustache  is  smeared.  Even  in  the 
hands  of  the  cleanlv,  without  special  precautions,  such  circumstances  all 
tend  to  the  production  around  the  patient  of  a  halo  of  infected  dust 
maintained  by  every  process  of  bedmaking  or  of  cleaning  which  includes 
the  pernicious  process  happily  described  as  '  dusting.'  In  the  hands  of 
the  careless  and  the  dirty  the  infectivity  is,  of  course,  greatly  aggra- 
vated. It  attains  its  maximum  of  intensity  where  the  filthy  habit  of 
spittino;  on  the  floor  prevails,  especially  if  it  is  carpeted "  (James  B. 
Russefl). 

Cornet  has  shown  that  the  dust  of  rooms,  hospital  wards,  and  other 


742  TUBERCULOSIS. 

localities  frequented  by  patients  with  pulmonary  tuberculosis  contains 
the  bacilli  and  is  infective.  The  observations  of  Straus  show  how  these 
bacilli  may  be  found  in  the  air-passages  of  perfectly  healthy  individuals. 
Attached  to  particles  of  dust,  the  bacilli  gain  entrance  to  the  system 
through  the  lungs,  which  may  be  regarded  as  the  great  portal  of  inva- 
sion. The  extraordinary  fi-equency  with  which  local  disease  occurs  in 
these  organs  and  in  the  bronchial  glands  will  be  referred  to  later.  A 
considerable  number  of  persons  dying  by  accident  or  disease  show  that 
at  one  time  or  another  the  bacilli  have  eiFected  a  lodgement  in  these 
parts.  Even  when  the  bronchial  glands  exhibit  no  signs  of  tuberculosis 
the  bacilli  may  be  present  and  prove  infective  (H.  P.  Loomis). 

In  institutions,  such  as  jails,  barracks,  and  convents,  and  particularly 
in  those  in  which  the  occupants  are  greatly  restricted  in  the  important 
element  of  fresh  air,  tuberculosis  is  specially  prevalent.  In  a  review 
of  thirty-eight  cloisters,  embracing  the  average  number  of  4028  resi- 
dents, among  2099  deaths  in  the  course  of  twenty-five  years  1320  (62.88 
per  cent.)  were  from  tuberculosis.  In  some  cloisters  more  than  three 
fourths  of  the  deaths  are  from  this  disease,  and  the  mortality  in  all  the 
residents,  up  to  the  fortieth  year,  is  greatly  above  the  average,  the  increase 
being  due  entirely  to  the  prevalence  of  tuberculosis.  It  has  been  stated 
that  nurses  are  not  more  prone  to  the  disease  than  other  individuals,  but 
Cornet  says  that  of  100  nurses  deceased,  63  died  of  tuberculosis.  The 
more  perfect  the  prophylaxis  and  hygienic  arrangements  of  an  asylum 
or  institution  the  lower  the  mortality  from  tuberculosis.  In  the  Ala- 
bama Insane  Hospital,  during  a  period  of  three  years  and  nine  months, 
of  295  deaths,  28  per  cent,  among  the  whites  and  42  per  cent,  among 
the  negroes  were  caused  by  tuberculosis  (Bondurant).  The  mortality 
in  prisons  has  been  shown  by  Baer  to  be  four  times  as  great  as  outside. 
The  death  rate  from  phthisis  is  estimated  at  15  per  cent,  of  the  total 
mortality,  while  in  prisons  it  constitutes  from  40  to  50  per  cent.,  and  in 
some  countries,  as  Austria,  over  60  per  cent.  In  institutions  of  this 
sort,  in  addition  to  the  presence  of  the  bacilli,  the  lowered  vitality,  and 
in  prisons  the  mental  depression,  must  lower  the  resistance.  In  a  single 
ward  in  the  city  of  Philadelphia  Flick  studied  the  distribution  of  the 
deaths  from  tuberculosis  for  a  period  of  twenty-five  years.  He  found 
that  not  less  than  one  third  of  the  houses  of  the  ward  became  infected 
during  this  period,  and  more  than  one  half  of  all  the  deaths  from  this 
disease  during  the  year  1888  occurred  in  these  infected  houses. 

In  hospitals  and  sanitaria  the  number  of  nurses  and  attendants  who 
are  attacked  is  in  indirect  ratio  to  the  stringency  with  which  proper 
sanitary  precautions  are  carried  out.  It  is  stated  that  in  the  Paris  hos- 
pitals the  attendants  are  decimated  by  tuberculosis.  At  the  Brompton 
Consumption  Hospital  in  London  the  doctors,  nurses,  and  attendants 
are  very  rarely  attacked.  AVith  ordinar}^  care  there  is  no  reason  that 
consumptives  should  infect  the  wards  which  they  occupy.  At  the  Adi- 
rondack Sanitarium,  I.  H.  Hance  has  recently  examined  the  dust  of  the 
buildings,  some  of  which  have  been  inhabited  by  consumptives  for  a 
period  of  ten  years.  Sixteen  out  of  seventeen  buildings  were  free  from 
infectious  material.  The  infected  cottage  was  one  always  occupied  by 
two  patients  in  an  advanced  stage,  one  of  whom  had  complained  that 
his  room-mate  had  been  spitting  about  carelessly. 


GENERAL  ETIOLOGY  AXD  MORBID  AXArOMV.  743 

The  tVeqiiciicv  ot"  marital  int'cetiini  iinlicatcs  the  special  (lunger  when 
the  contact  is  very  intimate.  Of  the  re[)lies  to  a  collective  investio^a- 
tion  on  the  question  of  contagion  in  tuberculosis  (Committee  of  the 
British  Medical  Association),  there  were  2()1  in  the  aHirmative,  of  which 
158  were  supposed  to  be  due  to  infection  through  marriage.  Several  of 
Weber's  cases  are  of  special  interest.  One  patient  lost  four  wives  in 
succession,  one  lost  three,  and  four  lost  two  each.  Of  427  cases  of  ])ul- 
inonarv  tuberculosis  at  the  Johns  Hopkins  Hospital,  in  2o  either  husband 
or  wife  was  atfeeted  with  or  had  died  of  tul)crculosis. 

((/)  Infection  ht/  Mill:. — The  prevalence  of  intestinal  and  mesenteric 
tuberculosis  in  children  suggests  that  the  food  suj)ply  may  i)e  the  source 
of  infection.  It  has  been  shown  experimentally  that  the  disease  may  be 
transmitted  to  young  animals  fed  with  the  milk  of  tuberculous  cows.  It 
is  stated  also  "that  butter  made  from  such  milk  may  prove  infective. 
The  pigs  of  a  tuberculous  sow  have  been  found  with  intestinal  tubercu- 
losis of  the  most  advanced  grade.  The  experiments  of  Gerlach,  Bang, 
Bollinffpr,  and  Ernst  have  proved  how  readily  the  disease  may  be  trans- 
mitted. Ernst  states  that  the  bacilli  may  be  present  and  the  milk  be 
infective  even  Avhen  there  is  no  tuberculous  raammitis ;  but  in  the  work 
of  the  Royal  Commission  on  Tuberculosis,  Martin  could  not  induce  the 
disease  artificially  in  animals  inoculated  or  fed  with  the  milk  of  tuber- 
culous cows  whose  udders  were  healthy.  On  the  other  hand,  he  states 
that  "  the  milk  of  cows  with  tuberculosis  of  the  udder  possesses  a  viru- 
lence which  can  only  be  described  as  extraordinary  ;  all  the  animals 
inoculated  showed  tuberculosis  in  its  most  rapid  form."  The  practice 
of  drinking  cow's  milk  raw  and  of  feeding  the  same  to  children  is  not 
without  danger.  When  there  is  the  slightest  doubt  as  to  the  source  the 
milk  should  be  boiled. 

{e)  Infection  by  Meat. — This  mode  perhaps  plays  a  very  minor  role 
in  the  etiology  of  human  tuberculosis.  It  has  been  shown  that  the  meat 
of  tuberculous  animals  is  not  necessarily  infective.  Martin  suggests 
that  it  may  acquire  this  property  by  accidental  contamination  with  tuber- 
culous matter  during  its  removal.  The  ordinary  process  of  cooking 
destroys  the  virus.  With  reference  to  the  confiscation  of  the  carcasses 
of  tuberculous  animals,  the  Royal  Commission  concludes :  "  Provided 
every  part  that  is  the  seat  of  tuberculous  matter  be  avoided  and 
destroyed,  and  provided  care  be  taken  to  save  from  contamination  by 
such  matter  the  actual  meat  substance  of  a  tuberculous  animal,  a  great 
deal  of  meat  from  animals  affected  by  tuberculosis  may  be  eaten  without 
risk  to  the  consumer."  It  would  be  safer,  however,  to  confiscate  the  flesh 
of  all  tuberculous  animals,  the  State  providing  proper  compensation. 

(5)  Conditions  Infiuencinrj  Infection. — (a)  General. — Environment 
is  an  all-important  predisposing  factor.  Dwellers  in  cities  are 
much  more  prone  to  the  disease  than  residents  of  the  country,  Xot 
only  is  the  liability  to  infection  vers'  much  greater,  but  the  conditions 
of  life  are  such  that  the  powers  of  resistance  are  apt  to  be  weakened. 
As  already  stated,  sunlight  is  one  of  the  most  powerful  agents  in 
destroying  the  tubercle  bacillus,  so  that  in  imperfectly  ventilated  dwell- 
ings and  Avorkshops,  and  in  residences  in  close,  dark  alleys,  and  in  tene- 
ment houses  the  liability  to  infection  is  very  much  increased.  The 
influence  of  environment  was  never  better  demonstrated  than  in  the 


744  TUBERCULOSIS. 

now  well  known  experiment  of  Trudeau,  who  found  that  rabbits  inocu- 
lated with  tuberculosis  if  confined  in  a  dark,  damp  place  without  sun- 
light and  fresh  air  rapidly  succumbed,  while  others  treated  in  the  same 
way,  but  allowed  to  run  wild,  either  recovered  or  showed  very  slight 
lesions.  The.  occupants  of  j^risons,  asylums,  and  poorhouses,  too  often, 
indeed,  in  barracks  and  large  workshops,  are  in  the  position  of  Trudeau's 
rabbits  in  the  cellar,  and  under  conditions  most  favorable  to  foster  the 
development  of  the  bacilli  which  may  have  lodged  in  their  tissues.  The 
frequent  respiration  of  air  already  breathed,  upon  which  MacCormac 
of  JBelfast  laid  so  much  stress,  appears  to  render  the  lungs  less  capable 
of  resisting  infection. 

Soil  and  locality  are  believed  by  many  to  have  a  very  important 
bearing  on  the  development  of  tuberculosis.  The  observations  of 
Henrv  I.  Bowditch  in  this  country  and  of  Buchanan  in  England  show 
that  the  disease  prevails  more  widely  in  the  Avet,  ill-drained  districts — 
an  increase  which  is  associated  with  heightened  A'ulnerability  and  greater 
liabilitv  to  catarrhal  affections  of  all  kinds.  The  influence  of  the  dwell- 
ing has  been  already  referred  to  in  connection  with  Flick's  work.  No 
single  condition  is  of  greater  importance  than  that  which  relates  to  the 
proper  arrangement  and  ventilation  of  the  dwelling-houses.  Here  in 
parallel  columns  is  the  contrast  drawn  by  Dr.  Thorne  Thorne  between 
a  dwelling  which  will  tend  to  promote  and  a  dwelling  which  will  tend 
to  prevent  consumption  : 

"  Conditions  of  Divelling-house  tending  to     "  Conditions  of  Dwelling-house  tenditig  to 
the   Promotion  of    Tuberculous    Con-  the  Prevention   of    Tuberculous  Con- 

sumption, sumption. 

''  1.  A  soil  either  (a)  naturally  damp  "  1.  A  soil  which  is  dry  [a]  naturally, 

and  cold,  or  {b)  subject  to  the  influence  or  (b)  freed  by  artificial  ineans  from  the 

of  the  rise  and  fall  of  a  subsoil  water  injurious  influence  of  dampness  and  of 

lying  within  a  few  feet  of  the  surface.  the  oscillations  of  the  underlying  subsoil 

water. 

"2.    A      dwelling-house     of    which  "2.  A  dwelling-house  so  constructed 

either  the  foundations,  the   area   they  as  to  be  protected  against  dampness  of 

enclose,  or  the  walls  are,  by  reason  of  site,  foundations,  and  walls, 
faulty  construction  or  otherwise,  liable 
to  dampness. 

"3.  Such    immediate    surroundings  "3.  Such  open  space  on  at  least  two 

of  the  dwelling-house  as  tend  to  prevent  opposite  sides  of  the  dwelling-house  as 

the  free  movement  of  air  about  it  and  shall   secure   ample    movement  of   air 

its  ample  exposure  to  the  influence  of  about  it,  together  with  its  free  exposure 

sunlight.  to  the  influence  of  sunlight. 

"  4.  Such  structural  defects  as  would  "  4.  Such  construction  of  the  dwell- 

prevent   the     maintenance   within    all  ing-house  as  will  secure  for  its  habitable 

parts  of  the  dwelling-house  of  ample  rooms  and   throughout  its  interior  free 

movement  of  air  by  day  and  night,  and  movement  of  air  by  day  and  by  night 

free  exposure  of  its  habitable  rooms  to  and  the  free  access  of  daylight." 
daylight." 

(6)  Individual  Predisjwsition. — The  fathers  of  medicine,  more  par- 
ticularly Hippocrates,  Aretseus,  and  Galen,  laid  great  stress  upon  the 
bodily  conformation  of  those  prone  to  consumption.  A  great  deal  was 
written  on  the  so-called  habitus  iMhuicus,  which  Hippocrates  described 
in  the  following  terms  :  "  The  form  of  body  peculiar  to  subjects  of  phthis- 
ical complaints  was  the  smooth,  the  whitish,  that  resembling  the  lentil ; 
the  reddish,  the  blue-eyed,  the  leuco-phlegmatic ;    and  that  with  the 


GENERA  J.  ETIOLOGY  AND  MORBID  ANATOMY.  745 

.scapiihi'  liaviiii;  llic  appcai-aiicc  of  wind's."  Un(l<>ul)to(lly  tho  long, 
narrow,  Hat  chest  witli  depressed  sternum  is  eoninionly  cnonoli  seen 
iu  tnbereulous  patients,  but  tliere  are  only  too  many  individuals  with 
perfectly  well-shaped  chests  who  fall  victims  anmially  to  the  dis- 
ease. The  tuberculous  or  scrofulous  diathesis,  ujion  which  formerly 
so  much  stress  was  laid,  is  now  regarded  simply  as  an  indication  of 
a , type  of  conformation  in  which  the  tissues  are  more  vulnerable  and 
less  capable  of  resisting  infection.  Bencke's  investigations  on  the 
viscera  of  phthisical  patients  indicate  that  the  heart  is  relatively  small, 
the  arteries  projwrtionately  narrow,  and  the  pulmonary  artery  relatively 
wider  than  the  aorta.  He  suggests  that  this  may  lead  to  increase  in  the 
intrapulmonary  blood  pressure,  and  so  favor  catarrhal  processes.  The 
lung  volume  he  found  relatively  greater  in  those  affected  wdth  tubercu- 
losis. A  study  of  the  composite  portraiture  of  pulmonary  tuberculosis 
has  been  made  by  Galton  and  ISIahomed.  In  442  patients  they  sepa- 
rated two  types  of  face — one  ovoid  and  narrow,  the  other  broad  and 
coarse  featured.  This  corresponds  in  an  interesting  way  to  the  diathetic 
states  formerly  recognized — namely,  the  tuberculous,  with  thin  skin, 
bright  eyes,  oval  face,  and  long,  thin  bones ;  and  the  scrofulous,  with 
thick  lips  and  nose,  opaque  skui,  large,  thick  bones,  and  heavy  figure. 
These  conditions,  on  which  so  such  stress  was  formerly  laid,  indicate, 
as  Fagge  states,  nothing  more  than  delicacy  of  constitution,  incomplete 
growth,  and  imperfect  development. 

(e)  IitfJuence  of  Age. — No  age  is  exempt.  The  disease  is  met  with 
in  the  suckling  and  in  the  octogenarian.  Pulmonary  tuberculosis  occurs 
most  frequently,  as  stated  by  Hippocrates,  from  the  eighteenth  to  the 
thirty-fifth  yeaV.  From  the  fifth  to  the  tenth  year  individuals  are  less 
prone  to  the  disease.  At  different  ages  different  organs  are  more  prone 
to  be  involved.  During  the  first  decade  the  bones,  meninges,  and  lymph 
glands  are  more  frequently  affected  than  at  subsequent  periods. 

{d)  Sex. — The  influence  of  sex  is  very  slight.  Women  are  perhaps 
somewhat  more  frequently  attacked  than  men,  due,  possibly,  to  the  fact 
that  in  a  more  sedentary,  in-door  life  they  are  more  liable  to  infection. 
Pregnancy  and  lactation  also  are  two  conditions  which  are  apt  to  lower, 
perhaps,  the  resistance  of  the  organism. 

(e)  Race. — The  negro,  wdio  it  is  stated  is  not  specially  prone  to  the 
•disease  in  Africa,  is  in  America  and  in  the  West  Indies  very  subject  to 
tuberculosis.  The  relative  immunity  of  the  Jews  has  been  mentioned 
(page  730). 

(,/')  Occupation  is  an  important  predisposing  factor.  The  inhalation 
of  impure  air  in  occupations  associated  with  a  very  dusty  atmosphere 
renders  the  lungs  less  capable  of  resisting  infection.  The  incidence  of 
pulmonary  tuberculosis  among  the  workers  in  mills  and  factories  is 
very  high,  and  in  certain  occupations,  such  as  glass-workers,  stone- 
cutters, and  coal-miners,  and  the  whole  group  of  trades  which  lead  to 
pneumonokoniosis,  favors  the  development  of  tuberculosis. 

{[/)  Certain  local  conditiom  influence  infection,  among  which  the  fol- 
lowing are  the  most  important : 

Catarrhal  Bronchitis.  The  influence  of  catarrh  of  the  respiratory 
passages  in  pulmonary  tuberculosis  is  well  recognized.  How'  often  is  a 
neglected  cold  blamed  as  the  starting  point  of  the  disease  !     It  seems  to 


746  TUBERCULOSIS. 

act  by  lowering  the  resistance  and  favoring  the  conditions  which  enable 
the  bacilli  either  to  enter  the  system  or,  when  once  in  it,  to  develop. 
The  liability  of  lymphatic  tuberculosis  in  children  is  probably  asso- 
ciated with  the  common  catarrhal  processes  in  the  tonsils,  throat,  and 
bronchi. 

Certain  of  the  specific  fevers  predispose  to  tuberculosis,  among  which 
measles  and  whooping  cough  stand  pre-eminent.  They  are  often  associ- 
ated with  a  bronchial  catarrh.  In  some  of  the  cases  it  is  probably  not  a 
fresh  infection  which  follows,  but  the  blazing  of  a  smouldering  fire. 
Typhoid  fever  is  thought  by  some  to  predispose  to  tuberculosis,  but  my 
experience  is  opposed  to  this  view.  Of  other  affections,  influenza,  vari- 
ola, and  syphilis  are  all  believed  to  favor  the  development  of  the  dis- 
ease. Diabetes,  as  is  well  known,  very  often,  terminates  in  pulmonary 
tuberculosis,  particularly  in  young  persons. 

Chronic  heart  disease,  arterio-sclerosis,  aneurysm  of  the  aorta,  forms 
of  chronic  nephritis,  cirrhosis  of  the  liver,  and  the  various  forms  of 
cerebro-spinal  sclerosis,  all  are  conditions  which  favor  infection.  It  is 
remarkable  in  how  many  of  the  subjects  of  these  disorders  in  general 
hospital  practice  the  fatal  event  is  a  terminal  acute  tuberculosis,  most 
frequently  of  the  serous  membranes.  Subjects  of  congenital  or  acquired 
contraction  of  the  orifice  of  the  pulmonary  artery  usually  die  of  tuber- 
culosis. On  the  other  hand,  mitral  valve  disease,  particularly  stenosis, 
is  stated  to  antagonize  the  disease  (J.  E.  Graham).  In  children  catar- 
rhal entero-colitis  probably  favors  the  development  of  tabes  mesenterica. 

The  influence  of  hsemoptysis  and  pleurisy  will  be  referred  to  later. 

Trauma.  Surgeons  have  laid  great  stress  upon  this  as  an  etiological 
factor  in  tuberculous  processes.  Experiments  indicate  that  tissues  wdiich 
have  been  bruised,  and  which  would  in  health  have  readily  and  rapidly 
destroyed  organisms,  promote  their  growth  under  the  altered  conditions. 
Probably  in  the  case  of  tuberculosis  following  trauma  the  injured  part 
is  for  a  time  a  locus  minoris  resistentioe,  and  if  bacilli  are  present  they  may 
by  it  receive  a  stimulus  to  growth  or  under  the  altered  conditions  be 
capable  of  multiplying.  Not  only  in  arthritis,  but  in  pulmonary  tuber- 
culosis, traumatism  may  play  a  part.  The  question  has  been  thoroughly 
studied  by  Mendelssohn,  who  reports  nine  cases  in  which,  without  frac- 
ture of  the  rib  or  laceration  of  the  lung,  tuberculosis  developed  shortly 
after  contusion  of  the  chest.  Operation  upon  tuberculous  lesions  may 
be  followed  by  a  general  infection.  Resection  of  a  strumous  joint  is 
occasionally  followed  by  acute  tuberculosis.  Of  837  resections,  225 
ended  fatally,  26  with  acute  tuberculosis  (Wartmann).^ 

The  General,  Morbid  Anatomy  and  Histology  op  Tubercle. 

(1)  The  Distribution  of  Tubercles  in  the  Body. — The  distribution  of 
tubercles  in  the  organs  and  tissues  of  the  body  varies  greatly  according 
to  the  primary  seat  of  the  disease  and  according  to  certain  peculiari- 
ties of  individual  organs  and  tissues ;  the  bacilli  may  find  their  Avay  into 
the  circulation  either  by  the  blood  or  lymph  channels,  and  lead  to  the 
formation  of  scattered  foci  of  tubercles  which  are  found  in  the  internal 

^  A  recent  study  of  the  question  is  to  be  found  in  vol.  ii.  of  Bevue  de  la  Tuberculoses 
by  Depage  and  Gallet. 


GENERAL  ETIOLOGY  AND  MORBID  ANATOMY.  747 

orii'ans.  In  ciiscs  oC  licncral  t  iilxTciildsis,  wlici'c  the  hacilli  arc  carried 
into  llic  hlood  in  lar^c  nnnihcrs,  the  tuhcrck!  nodules  are  evenly  dis- 
tributed throu<;hout  the  organs,  thou<;h  to  inacroscopieal  investij^ation 
they  seem  to  be  nuieh  more  numerous  in  one  organ  than  in  another. 
Miliary  tubercles  in  the  liver  are  often  very  difficult  to  distinguish  mae- 
roseopieally,  whilst,  on  the  other  hand,  those  in  the  sj)leen  and  kidney 
are  usually  easily  made  out.  On  microscopical  examination,  however, 
the  liver,  which  to  the  naked  eye  has  seemed  to  contain  l)ut  few  tuber- 
cles, is  often  found  studded  with  them.  The  great  difficulty  in  making 
out  tubercles  in  certain  organs,  particularly  in  the  pancreas  and  thyroid 
gland,  has  led  to  the  belief  that  these  organs  are  relatively  immune  to 
the  attacks  of  the  bacillus.  This  belief,  as  Chiari  pointed  out,  is  false, 
microscopical  examination  showing  in  most  cases  of  miliary  tubercu- 
losis numbers  of  tubercles  in  both  the  organs  mentioned.  Certain  of  the 
organs  and  tissues  of  the  body,  however,  do  seem  to  be  almost  immune 
against  tuberculosis,  particularly  the  oesophagus,  the  inner  lining  of  the 
larger  arteries,  and  the  voluntary  muscles.  The  fact  that  the  latter  are 
resistant  is  often  strikingly  illustrated  in  cases  in  which  both  layers  of  the 
pleura  are  infiltrated  by  the  tuberculous  process,  which,  however,  stops 
sharply  at  the  subjacent  intercostal  muscles.  The  one  organ  which  is 
almost  always  affected  in  tuberculosis,  as  seen  at  the  autopsy  table,  is 
the  lung,  and  this  is  true  both  of  children  and  adults.  Here  may  be 
mentioned  the  very  frequent  occurrence  of  healed  lung  tuberculosis  in 
all  classes  of  cases,  the  healed  area  generally  appearing  in  the  form 
©ither  of  an  area  of  dense  fibrous  material  or  of  an  encapsulated 
caseous  or  calcareous  nodule.  Apart  from  the  lung,  the  organs  are 
affected  with  tubercle  with  varying  frequency  at  varying  periods  of  life  ; 
in  children  the  lymph  glands,  bones,  and  joints  are  attacked  most  fre- 
quently. 

(2)  Changes  Produced  by  the  Tubercle  Bacilli. — The  Nodular  Tuber- 
cle.— The  most  distinctive  lesion  produced  by  the  bacillus  tuberculosis 
is  the  nodular  tubercle,  accurate  descriptions  of  the  histology  of  which 
we  owe  particularly  to  the  painstaking  researches  of  Baumgarten.  The 
fact  must  never  be  lost  sight  of  that  in  their  early  stages  tubercles  do 
not  present  any  peculiarity  in  their  histological  components  or  arrange- 
ment. Similar  aggregations  of  cells  mav  be  caused  bv  foreien  bodies, 
certain  animal  parasites,  and  the  dead  products  of  the  tubercle  bacilli, 
and  in  certain  stages  the  so-called  lymphomata  of  the  liver,  occurring  in 
typhoid  fever,  are  strikingly  like  young  tubercles.  The  evolution  of  the 
tubercle  following  the  introduction  of  the  tubercle  bacillus  into  the  tis- 
sues may  be  traced  as  follows  : 

(«)  The  MuUiplication  of  the  Tubercle  Bacilli. — This  begins  almost 
immediately  after  the  introduction  of  the  organism.  The  growth  is  quite 
rapid,  and  is  accompanied  by  its  dissemination  into  the  surrounding  tis- 
sues, partly  by  direct  growth,  and  partly  by  mechanical  dissemination 
in  the  lymph  stream.  The  action  of  phagocytes  in  connection  with  the 
dissemination  of  the  bacilli  has  not  been  accepted  by  most  pathologists, 
and  probably  does  not  occur.  From  an  early  date  many  of  the  bacilli 
are  found  in  the  fixed  tissue  cells  of  the  affected  tissue. 

(6)  The  Ilultiplication  of  the  Fixed  Cells. — From  the  fifth  day  after 
the  introduction  of  the  tubercle  bacillus  into  the  tissue  changes  can  be 


748  TUBERCULOSIS. 

made  out  indicative  of  multiplication  of  the  fixed  cells  by  the  indirect 
method  of  subdivision,  as  evidenced  by  the  abundance  of  karyokinetic 
figures  to  be  found  in  the  affected  region.  This  cellular  subdivision 
aifects  not  only  the  fixed  connective  tissue  cells  of  the  part,  and  the 
endothelial  cells,  and  the  lining  of  the  smaller  bloodvessels,  but  the 
cells  of  the  parenchyma  of  the  affected  tissue  can  also  be  seen  to  be  in 
a  state  of  active  subdivision.  As  a  result  we  have  the  production  of 
rounded  or  irregularly  cuboidal  cells  with  vesicular  nuclei,  which  re- 
semble epithelial  cells,  and  are  hence  called  epithelioid  cells.  Almost 
from  the  first  appearance  of  these  cells  tubercle  bacilli  can  be  demon- 
strated in  tlie  interior  of  a  certain  number  of  them.  In  some  only  a 
single  bacillus  can  be  made  out ;  in  others  the  cell  is  closely  packed  with 
a  mass  of  bacilli,  often  having  the  appearance  of  a  typical  "  leprosy  cell." 

(c)  The  Invasion  by  Leucocytes. — Following  the  formation  of  the  epi- 
thelioid cells  other  cells  are  soon  to  be  made  out  in  the  tubercle  which 
are  evidently  of  vascular  origin,  as  they  show  no  signs  of  multiplication, 
the  only  changes  they  undergo  being  of  a  regressive  character.  These 
emigrant  cells  are  of  two  varieties — the  polynuclear  leucocyte,  and  the 
small  mononuclear  element  of  the  blood,  the  so-called  lymphocyte.  The 
polynuclear  leucocytes  appear  much  more  susceptible  to  injury  than  the 
mononuclear  variety,  ancl  undergo  regressive  changes  with  great  rapidity. 
The  mononuclear  variety,  on  the  other  hand,  are  much  more  slowly 
destroyed,  and  as  the  tubercle  increases  in  size  the  leucocytes  represented 
are  in  large  part  these  small  round  elements  which  are  situated  particu- 
larly at  the  periphery  of  the  nodule. 

(d)  The  formation  of  a  Reticulum. — About  the  tenth  or  eleventh  day 
a  fine  network  is  to  be  seen  between  the  cells  composing  the  tubercle  — a 
network  first  pointed  out  by  Wagner,  and  which  is  best  demonstrated  in 
specimens  hardened  in  osmic  acid.  This  reticulum  is  composed,  accord- 
ing to  some  pathologists,  of  the  pre-existing  connective  tissue  elements 
which  have  undergone  a  rarefaction  from  the  pressure  of  the  growing 
tubercle  cells.  It  exists  particularly  at  the  periphery  of  the  tubercle,  and 
the  fibres  composing  it  can  at  times  be  made  out  to  be  directly  continu- 
ous with  the  fibres  of  the  surrounding  connective  tissue.  The  recent 
researches  of  Falk  would  tend  to  show  that  there  is  also  present  in  the 
tubercle  nodule  from  an  early  stage — that  is  to  say,  before  the  existence 
of  degenerative  changes — definite  fibrillary  fibrin,  also  most  abundant  at 
the  periphery  of  the  tubercle,  and  undergoing  destruction  in  the  subse- 
quent degenerative  processes  through  which  the  tubercle  passes. 

(e)  The  Formation  of  Giant  Cells. — In  the  large  majority  of  tubercles 
there  are  present,  besides  the  varieties  of  cells  above  mentioned,  large 
cells  containing  from  four  or  five  to  twenty-five  or  thirty  nuclei — so 
called  giant  cells.  These  are  formed  either  from  the  fusion  of  individual 
cells  or  much  more  probably  from  the  indefinite  multiplication  of  the 
nuclei  in  a  single  cell,  the  protoplasm  failing  to  divide  with  the  nuclei. 
The  character  of  the  nuclei  in  these  cells  is  the  same  as  that  of  the  epi- 
thelioid cells  composing  the  tubercle,  and  the  great  mass  of  evidence 
goes  to  show  that  the  giant  cells  are  epithelioid  cells  whose  nuclei  have 
subdivided  indefinitely,  whilst  their  protoplasm  has  lost  its  power  of 
subdivision,  probably  on  account  of  the  injurious  influence  exerted  upon 
it  by  certain  products  of  the  tubercle  bacillus.     The  giant  cell  is  gen- 


GENERAL  ETIOLOdY  AND  MORBID  ANATOMY.  749 

CM'ally  in('i;iil:ii'ly  round  or  o\al  in  shape.  It  varies  in  diaiueter  from 
two  to  tliree  niiki-ons,  and  often  sliows  at  various  points  on  its  periphery 
distinct  branching  j)roh)ngations.  The  giant  cell  is  not  by  any  means 
characteristic  of  tuberculosis,  but  the  type  of  giant  cell  associated  with 
this  disease — Tjanghans'  giant  cell — is  so  characteristic  and  so  seldom 
found  in  other  conditions  that  it  has  been  called  by  certain  (Jcrman 
writers  the  lingcr-])ost  of  tuberculosis.  The  chief  characteristic  of  the 
tuberculous  giant  cell  which  distinguishes  it  from  most  other  forms  is 
the  peculiar  arrangement  of  its  nuclei,  either  around  the  periphery  of  the 
cell  or  at  one  or  both  of  the  poles.  This  is  due  to  the  fact  that  the 
centre  of  the  giant  cell,  like  the  centre  of  the  tubercle,  in  the  mid-por- 
tion of  which  it  generally  lies,  is  particularly  prone  to  undergo  degener- 
ative changes,  so  that  whilst  at  an  early  stage  in  its  development  nuclei 
exist  throughout  the  protoplasm  of  the  giant  cell,  those  in  the  centre  of 
the  cell  are  soon  destroyed,  the  remaining  one  having  a  mural  or  polar 
arrangement  according  as  the  cell  is  round  or  oval. 

(3)  Tlie  Degeneration  of  Tubercle. — The  ultimate  fate  of  all  tubercles 
is  degeneration.  This  is  not  due,  as  was  formerly  supposed,  to  lack  of 
nutrition,  for  much  larger  areas  than  those  represented  by  a  tubercle 
may  be  nourished  without  a  direct  blood  supply.  The  agents  which  lead 
to  the  degeneration  of  the  tubercle  are  the  tubercle  bacilli  themselves 
and  their  products.  In  order  to  produce  this  degeneration  the  living 
bacilli  themselves  are  not  necessary,  the  researches  of  Prudden,  and 
later  of  Kostenitsch,  having  shown  that  the  dead  bacilli  and  the  bac- 
terial products  are  capable  of  setting  up  exactly  similar  changes.  The 
forms  of  degeneration  which  the  tubercle  may  undergo  are  two — caseous 
and  fibrous. 

(a)  Caseous  Degeneratioii  (Caseation). — This  form  of  degeneration, 
which  is  the  most  common,  may  occur  at  any  stage  in  the  process  of  tu- 
bercle formation.  It  is  often  seen  in  the  very  earliest  stages,  and  in  its 
most  characteristic  form  is  seen  in  tuberculous  glandular  masses  and  in 
certain  forms  of  lung  tuberculosis.  Weigert  pointed  out  that  the  process 
was  one  of  coagulation  necrosis.  The  cells  in  the  centre  of  the  tubercle 
die  slowly,  and  are  transformed  into  coagulated  homogeneous  or  finely 
granular  masses,  showing  absence  of  nuclear  staining  or  at  most  but 
fine  nuclear  fragments  taking  the  stain.  These  masses  subsequently 
undergo  fatty  infiltration  and  take  on  a  white,  opaque  appearance  re- 
sembling cheese ;  hence  the  name  caseation.  In  the  miliary  tubercle 
these  caseous  masses  are  seen  as  the  opaque  yellow  centre  of  the  nodule, 
the  gray,  translucent  periphery  representing  the  non-degenerated  por- 
tion of  the  tubercle.  The  aggregation  of  many  caseous  tubercles  leads 
to  the  formation  of  the  much  larger  masses  so  commonly  seen  in  the 
more  chronic  forms  of  the  disease.  At  the  beginning  of  the  process  the 
tubercle  bacilli  can  still  be  demonstrated  Avith  good  staining  reactions  in 
the  degenerated  mass.  At  a  later  date  many  or  even  all  the  bacilli  may 
lose  their  staining  power,  though  this  a])parently  harmless  material  is 
still  capable  of  setting  up  the  disease  when  inoculated  into  susceptible 
animals.  In  some  instances,  as  in  certain  forms  of  lung  tuberculosis, 
the  caseous  material  everywhere  contains  large  numbers  of  tubercle 
bacilli.  The  cheesy  masses  may  undergo  secondary  changes,  some  of 
which  are  favorable,  others  unfavorable,  to  the  progress  of  the  disease.  In 


750  TUBERCULOSIS. 

some  instances  they  soften  and  break  down  into  a  rather  thick,  grumous 
fluid,  forming  the  so-called  tuberculous  abscess.  The  contents  of  such 
abscesses  do  not,  however,  consist  of  true  pus,  but  mainly  of  broken- 
down  cellular  products,  often  showing  an  extreme  grade  of  fatty  change. 
Another  form  of  softening  with  true  pus  formation  is  seen  where  the 
caseous  focus  becomes  secondarily  infected  with  pus  organisms.  Here, 
besides  the  detritus  above  mentioned,  we  have  all  the  constituents  of 
true  pus.  A  more  conservative  process  may  often  take  place  in  the 
caseous  material,  leading  to  the  production  of  a  dense  fibrous  capsule 
about  the  mass — so-called  encapsulation.  In  these  instances  the  fluid 
element  of  the  caseous  material  may  be  almost  entirely  absorbed,  leaving 
the  encapsulated  substance  as  a  dry  and  friable,  but  still  somewhat 
cheesy-looking,  material.  In  some  other  instances  a  deposit  of  lime 
salts  takes  place  in  the  caseous  area,  Avhich  here,  again,  may  become  sur- 
rounded by  a  fibrous  capsule  and  remain  innocuous  in  the  tissues  for 
years. 

(6)  Sclerosis. — In  many  cases,  particularly  in  individuals  who  possess 
good  powers  of  resistance,  a  more  conservative  process  occurs  in  the 
tubercle — the  so-called  sclerosis  or  fibroid  change.  This  is  seen  most 
frequently  in  the  lungs  and  in  the  peritoneal  cavity,  and  is  the  method 
by  which  the  spontaneous  cure  of  tuberculous  lesions  takes  place.  The 
process  consists  in  the  formation,  sometimes  with,  sometimes  without, 
caseation,  of  fibrous  tissue,  with  the  disappearance  of  the  tubercle  as 
such,  the  final  result  being  its  transformation  into  a  small  nodule  of 
dense  fibrous  tissue.  In  the  case  of  the  already  cheesy  tubercle  the 
fibroid  process  takes  place  from  the  cellular  part  of  the  nodule  surround- 
ing the  caseous  centre,  the  new  cells  originating  from  the  pre-existing 
tubercle  cells.  Where  the  process  tends  to  be  fibroid  from  the  beginning 
the  whole  tubercle  may  lose  its  cellular  structure  at  an  early  period  and 
become  transformed  into  a  small  fibrous  tumor  mass. 

(4)  The  Diffused  Infiltration  Tubercle. — In  many  parts  of  the  body, 
more  particularly  in  the  lungs,  the  tuberculous  process,  except  in  very 
acute  cases,  does  not  manifest  itself  as  discrete  nodules,  but  as  a  more  or 
less  extensive  diifuse  process,  which  results  from  the  fusion  of  many 
small  tuberculous  areas.  As  a  matter  of  fact  the  small  nodule  which 
we  are  accustomed  to  regard  as  the  ultimate  tubercle — the  miliary  tuber- 
cle— is,  as  has  been  pointed  out  by  Virchow,  in  many  instances  not 
single,  but  a  mass  of  very  small  tubercles,  the  true  ultimate  tubercle 
ibeing  submiliary  in  size  and  on  the  limit  of  visibility  so  far  as  the 
naked  eye  is  concerned.  As  seen  in  the  lung  the  areas  of  infiltrated 
tubercle  present  to  the  naked  eye  a  grayish,  translucent  appearance,  and 
often  particularly  in  the  later  stages,  a  caseous  centre.  These  areas 
vary  greatly  in  extent,  some  occupying  only  a  few  lobules,  and  again  a 
Avhole  lobe,  or  even  a  whole  lung,  being  affected.  In  many  instances 
the  course  of  the  smaller  bronchi  is  beautifully  mapped  out  by  the  pro- 
cess, which  occurs  as  a  series  of  peribronchial  tuberculous  masses.  At 
times  a  whole  lobe  is  consolidated,  giving  rise,  after  caseation  has  taken 
place,  to  the  appearance  designated  as  caseous  pneumonia — a  condition 
previously  regarded  as  being  due  to  the  superaddition  of  the  tuberculous 
infection  upon  a  preceding  croupous  pneumonia,  but  which  we  now 
know  to  be  entirely  due  to  the  action  of  the  tubercle  bacillus.     The 


ACUTE  TUBERCULOSIS.  751 

whole  ju'dccss,  tVoin  the  t"i)riii;iti(iii  ol"  the  miliary  tubercle  to  tlie  com- 
plete consolidation  of  a  lari;c  lol)e  of  the  lun«^,  can  he  followed  out  step 
by  step  with   suitable  pre})arations. 

(5)  !SiroH<l(irii  InjIuiiuiKifori/  Proccssci  in  Tahcrca/o.sis. — The  forma- 
tion of  tubercles,  particularly  in  the  lung,  is  associated  with  the  produc- 
tion of  secondary  infiamniatory  processes  of  a  non-specific  character. 
These  are  not  due,  as  a  rule,  to  the  action  of  the  tubercle  bacillus 
itself,  but  to  certain  irritative  jiroducts  whicii  it  j)roduces  and  which 
find  their  way  into  the  surrounding  tissue.  The  irritation  thus  caused 
leads  in  the  lung  to  the  formation  of  areas  of  catarrhal  pneumonia 
immediately  about  the  tubercle,  the  exudate  consisting  of  but  a  small 
amount  of  fibrin,  and,  as  a  rule,  but  few  polynuclear  leucocytes, 
the  chief  element  being  desquamated  and  proliferated  epithelial  cells 
orio'inatiny:  from  the  linino;  membrane  of  the  alveoli.  Associated  with 
this  exudation  is  an  infiamniatory  condition  of  the  alveolar  walls,  with 
proliferation  of  the  connective  tissue  elements — a  process  which  varies 
according  to  the  acuteness  of  the  case,  and  which  in  the  more  chronic  forms 
of  the  disease  may  lead  to  the  production  of  large  amounts  of  fibrous 
tissue  which  shut  off  the  tuberculous  process  and  limit,  to  a  great  degree, 
its  tendency  to  spread.  Whether  the  tubercle  bacillus  can  induce  actual 
.suppuration  is  still  much  discussed.  That  it  is  usually  not  a  pus-pro- 
ducer in  the  strict  sense  is  no  doubt  correct,  the  so-called  tuberculous 
pus  consisting  of  caseous  material  and  cellular  debris.  There  seems  to 
be  no  doubt,  however,  that  the  tubercle  bacillus  can  in  some  instances 
be  a  true  pus-producer,  and  occasionally  cases  are  seen  wdiich  show  true 
pus  in  the  histological  sense  and  in  which  this  organism  is  alone 
concerned. 


11.  ACUTE   TUBERCULOSIS. 
Acute  Miliary  Tuberculosis. 


In  this  form  the  bacilli  are  distributed  throughout  the  body  by  the 
blood,  and  the  clinical  picture  is  that  of  an  acute  infection.  The  an- 
atomical lesions  are  widely  distributed  throughout  the  organs  in  the 
form  of  miliary  granulations,  which  are  found  upon  the  serous  mem- 
branes, in  the  lungs,  liver,  lymph  glands,  kidneys,  spleen,  in  the  endo- 
cardium, in  the  membranes  of  the  brain,  in  the  bone  marrow,  and  occa- 
sionally in  the  choroid  coat  of  the  eyes.  Their  distribution  is  unequal. 
They  may  be  abundant  in  some  organs  and  scanty  in  others.  The 
meninges  of  the  brain  may  be  densely  packed  w^ith  tubercles,  Avhile 
there  are  but  few  in  the  abdominal  and  thoracic  viscera.  On  the  other 
hand,  the  lungs  may  be  stuffed  with  granulations  out  of  all  proportion 
to  those  in  other  organs.  The  appearance  and  structure  of  the  miliary 
granulations  has  already  been  described.  Etiologically,  tM'o  forms  are 
distinguished,  the  primary  and  the  secondary. 

The  existence  of  a  primary  miliary  tuberculosis  rests  upon  the 
occurrence  of  cases  in  which,  after  the  most  scrupulous  and  thorough 
examination  of  all  parts,  no  focus  of  tuberculous  disease  has  been  found. 
In  such  cases  it  has  been  assumed  that  the  blood  infection  has  been 


752  ■  TUBERCULOSIS. 

direct,  though  it  is  difficult  to  see  how  it  could  take  place.  Ou  the 
other  haud,  it  is  to  be  remembered  how  difficult  it  is  to  positively 
exclude  the  presence  of  a  primary  caseous  focus  in  the  body. 

In  an  immense  majority  of  all  the  cases  the  disease  is  secondary,  and 
is  an  auto-infection  arising  from  a  pre-existing  tuberculous  focus,  often 
latent  and  unsuspected.  Among  the  common  sources  of  the  general 
infection  are  local  tuberculous  disease  of  the  lungs  and  of  the  bronchial 
glands — the  latter  particularly  in  children — tuberculosis  of  the  bones 
and  of  the  kidneys  or  of  the  testes,  and  less  frequently  tuberculosis  of 
the  skin.  Sometimes  acute  miliary  tuberculosis  has  followed  operative 
procedures  upon  tuberculous  foci.  By  far  the  most  common  sources  of 
infection  are  small  foci  of  disease  in  the  lungs  and  caseous  masses  in  the 
tracheal  and  bronchial  glands.  The  infection  results,  as  a  rule,  from 
the  direct  invasion  of  a  vein  by  the  tubercle,  or  the  rupture  of  a  softened 
nodule  or  of  a  caseous  bronchial  gland  into  one  of  the  pulmonary  veins. 
The  observations  of  Weigert  have  show^n  how  frequent  is  this  invasion 
of  the  walls  of  the  veins  in  the  neighborhood  of  tuberculous  masses. 
In  other  cases  the  general  infection  may  result  from  invasion  of  the 
lymphatics,  and  there  are  many  instances  now  on  record  in  which  the 
general  infection  has  resulted  from  invasion  of  the  thoracic  duct. 
Doubtless  it  depends  greatly  upon  the  number  of  bacilli  which  enter 
the  circulation  whether  a  general  infection  results.  A  small  num- 
ber may  be  distributed  without  doing  any  harm. 

It  is  often  impossible  to  say  what  has  determined  the  sudden  and 
violent  onset  of  the  disease.  It  would  seem,  indeed,  as  though  special 
conditions  favored  the  production  of  a  local  or  a  general  miliary  tuber- 
culosis. Thus  after  certain  fevers,  particularly  measles  and  whooping 
cough  in  children,  the  disease  is  by  no  means  uncommon,  and  in  adults 
the  weakness  and  debility  following  protracted  fevers  seem  predisjjosing 
factors.  In  Bright's  disease,  chronic  cardio-vascular  affections,  and 
cirrhosis  of  the  liver  the  patients  are  very  frequently  carried  off  by 
terminal  miliary  tuberculosis. 

Symptoms. — For  practical  purposes  we  may  divide  the  cases  into 
those  in  which  the  manifestations  are  general,  and  those  in  which 
they  are  local,  predominating  in  certain  organs,  as  the  lungs,  meninges, 
pleurae,  or  peritoneum. 

1.  General  or  Tyidhokl  Form. — The  picture  is  that  of  an  infectious 
disease  with  few  if  any  local  symptoms,  the  course  and  general  features 
of  which  may  very  closely  resemble  typhoid  fever.  The  patient  generally 
has  shown  signs  of  failing  health  with  loss  of  appetite  for  a  week  or 
two.  There  may  have  been  headache,  chilly  feelings,  slight  cough,  and 
digestive  disturbances.  Even  epistaxis  has  been  noted  in  some  cases, 
so  that  the  period  of  invasion  may  simulate  closely  that  of  typhoid 
fever.  Then  the  patient  becomes  feverish,  the  tongue  is  dry,  the  pulse 
rapid,  the  respirations  increase,  and  there  is  often  cough.  The  early 
bronchitis  may  still  further  complicate  the  picture.  The  pulse  is  seldom 
dicrotic.  The  temperature  does  not  show  the  steady  ascent  of  typhoid 
fever.  From  the  outset  it  is  more  irregular  and  the  remissions  are 
greater.  Sometimes,  indeed,  the  pyrexia  is  intermittent,  and  in  the 
early  morning  hours  the  temperature  may  be  normal  or  subnormal.  In 
a  few  cases  there  has  been  observed  an  inverse  type  in  which  the  tern- 


ACUTE  TUBERCULOSIS.  75^ 

pi-ratiirc  is  hiiilicst  in  the  moniiiii;'.  In  viTv  rare  instances  there  may 
he  little  or  no  lever,  particularly  toward  the  clo.se.  From  Riiiunler's 
clinic  Ixeinliold  has  called  particular  attention  to  tiiese  af'ebrilo  forms  of 
acute  tuberculosis.  In  U  out  of  52  cases  there  was  either  no  fever  or 
only  a  transient  rise.  As  mentioned,  the  delirium  is  usually  early,  and 
tlicri-  may  be  great  restlessness  and  jactitation.  Photophobia  may  be  a 
markeil  feature.  Nervous  twitehings  and  subsultus  are  fre(}uent  symp- 
toms. Cutaneous  hypenesthesia  is  a  prominent  feature  in  some  eases. 
The  resj)irations  are  usually  increased,  particularly  in  the  early  stage; 
there  are  signs  of  diffuse  bronchitis  and  a  slight  cyanosis  is  common. 
The  cheeks  are  nsually  Hushed.  Cheyne-Stokes  breathing  may  develop 
toward  the  close.  As  the  disease  progresses  there  is  much  torpor  and 
dulness,  which  often  deepens  towaird  the  close  into  coma. 

Albuminuria  is  almost  constant,  and  the  diazo  reaction  is  frequently 
observed  in  the  urine. 

Gastric  symptoms  are  common.  There  may  be  early  anorexia. 
Vomiting  is  not  infreqnent,  and  diarrhoea  may  occur,  and  even  hemor- 
rhage if  there  are  tuberculous  nlcers  in  the  bowels.  The  abdomen  may 
be  slightly  distended  and  the  spleen  can  usually  be  felt. 

The  differential  diagnosis  between  this  form  of  miliary  tuberculosis  and 
typhoid  fever  may  be  very  difficult.  If  seen  at  the  onset,  the  irregular- 
ity of  the  temperature  curve  in  the  former  is  a  point  of  great  import- 
ance. In  tuberculosis  the  respirations  are  usually  more  frequent  and 
the  tendency  to  slight  cyanosis  more  marked.  Diarrhoea  is  rare  in  tuber- 
culosis, but  there  are  instances  in  which  the  diagnosis  has  been  still 
further  complicated  by  the  occurrence  of  blood  in  the  stools.  The 
enlargement  of  the  spleen  in  general  tuberculosis  is  neither  so  early  nor 
so  marked  as  in  typhoid  fever,  except  perhaps  in  children.  The  pres- 
ence of  the  diazo  reaction  may  increase  the  confusion.  The  absence  of 
the  characteristic  rash  of  typhoid  fever  is  a  very  important  feature. 
Occasionally  in  acute  tuberculosis  reddish  spots  may  develop  on  the  skin, 
but  they  do  not  come  out  in  crops,  and  they  rarely  have  the  characters 
of  a  true  typhoid  eruption.     Toward  the  close  petechia?  may  appear. 

The  examination  of  the  blood  may  give  important  information.  In 
a  few  instances  tubercle  bacilli  have  been  demonstrated.  The  absence 
of  a  leucocytosis  is  in  favor  of  typhoid  fever.  It  is  only  in  the  very 
acute  cases  of  tuberculosis  without  any  suppurating  foci  that  the  leucocy- 
tosis is  absent.  The  eyes  should  be  carefully  examined  for  choroidal 
tubercles.  In  protracted  eases  cultures  should  be  made  from  the  stools 
and  urine  by  Eisner's  method  in  order  to  determine  the  presence  or 
absence  of  the  bacillus  typhi. 

2,  Local  Forms. — (a)  Puhnonar}/. — The  patient  may  have  had  cough 
for  months  or  years  without  special  impairment  (^f  health,  or  he  may 
have  been  the  subject  of  chronic  pulmonary  tuberculosis.  In  other  cases, 
more  particularly  in  children,  the  affection  is  met  with  as  a  sequence  of 
measles  and  whooping  cough  or  may  follow  influenza.  From  the  very 
outset  the  pulmonary  symptoms  are  marked.  There  is  a  diffuse  bron- 
chitis, W'ith  shortness  of  breath,  cough,  and  the  expectoration  of  muco- 
|)urulent,  occasionally  rusty,  sputa.  Haemoptysis  has  been  noted  in  a 
few  cases.  From  the  start  dyspnoea  is  a  special  feature,  and  may  be  out 
of  all  proportion  to  the  intensity  of  the  physical  signs.     The  cheeks  are 

Vol.  I.— 48 


754  TUBERCULOSIS. 

usually  suifused  and  the  lips  and  nose  and  finger  tips  a  little  cyanotic. 
With  the  exception  of  emphysema  and  the  later  stages  of  severe  pneu- 
monia there  is  no  other  pulmonary  condition  in  which  the  cyanosis  is  so 
pronounced  a  feature.  The  physical  signs  are  those  of  bronchitis.  In 
children  there  may  be  defective  resonance  at  the  bases  from  scattered 
areas  of  broncho-pneumonia,  or,  what  is  equally  suggestive,  areas  of 
hyper-resonance.  Indeed,  the  percussion  note,  particularly  in  the  front 
of  the  chest  in  some  cases  of  miliary  tuberculosis,  is  full  and  clear,  and 
it  will  be  noted  (post-mortem)  that  the  lungs  are  unusually  voluminous. 
This  is  the  result  of  a  more  or  less  widespread  acute  emphysema.  On 
auscultation  the  rales  are  either  sibilant  and  sonorous  or  small,  fine,  and 
crepitant.  There  may  be  fine  crepitation  from  the  occurrence  of  tuber- 
cles on  the  pleura  (Jiirgensen).  In  children  there  may  be  high  pitched 
tubular  breathing  at  the  bases  or  toward  the  root  of  the  lung.  Toward 
the  close  the  rales  may  be  larger  and  more  mucous.  The  temperature 
rises  to  102°  or  103°  F.,  and  may  present  the  inverse  type.  The  pulse  is 
rapid  and  feeble.  In  the  very  acute  cases  the  spleen  is  always  enlarged. 
The  disease  may  prove  fatal  in  ten  or  twelve  days  or  may  be  protracted 
for  weeks  or  even  months. 

The  DIAGNOSIS  of  this  form  is  less  difficult,  and  is  consequently  more 
frequently  made,  than  in  the  general  or  typhoid  form.  The  history  of 
previous  cough,  the  existence  of  tuberculous  foci  elsewhere,  or  the  onset 
of  the  disease  in  children  after  measles  are  among  the  suggestive  fea- 
tures. The  sputa  may  contain  tubercle  bacilli.  In  a  few  cases  choroidal 
tubercles  may  be  found. 

(6)  Acute  Tuberculous  Pleurisy. — This  will  be  considered  in  Tubercu- 
losis of  the  Serous  Membranes  (page  766). 

(e)  Acute  Tuberculous  Peritonitis. — This  will  be  considered  in  the 
same  section  (page  770). 

In  a  few  instances  acute  miliary  tubercalosis  involves  both  pleura 
and  peritoneum  simultaneously.  There  are  cases  also  in  which  with  the 
onset  of  the  disease  the  synovial  membranes  have  been  involved,  so  that 
the  disease  has  been  regarded  as  acute  rheumatism. 

(d)  Meningeal  Tuberculosis;  Acute  Tuberculous  3Ieningitis ;  Acute 
Hydrocephalus  ;  "  Water  on  the  Brain.'^ — Our  first  accurate  knowledge 
of  this  affection  dates  from  the  publication  of  Robert  Whytt's  Observa- 
tions on  the  Dropsy  of  the  Brain,  Edinburgh,  1768.  The  literature  is 
very  fullv  given  in  the  last  edition  of  Barthez  and  Sannee.^ 

Though  Guersant  had  as  early  as  1827  used  the  name  granular  men- 
ingitis for  this  form  of  inflammation  of  the  meninges,  it  was  not  until 
1830  that  Papavoine  demonstrated  the  nature  of  the  granules  and  noted 
their  occurrence  with  tubercles  in  other  parts. 

In  1832  and  1833,  W.  W.  Gerhard  ^  of  Philadelphia  made  a  very 
careful  study  of  the  disease  in  the  Children's  Hospital  at  Paris,  and  his 
publications,  more  than  those  of  any  other  author,  served  to  place  the 
disease  on  a  firm  anatomical  and  clinical  basis." 

^  Maladies  des  Enfants,  1S91. 

^  American  Journal  of  the  Medical  Sciences,  vols,  xiii.,  xiv.,  and  xvii. 

^  The  description  which  he  gives  of  the  10  cases  observed  by  him  at  the  Children's 
Hospital.  Paris,  between  Aug.  1,  1832,  and  Aug.  1,  1833,  is  a  model  clinical  study  which 
should  be  carefully  read  by  those  interested  in  the  subject. 


ACUTE  TUBERCULOSIS.  755 

Meningeal  Tuberculosis. 

Etiology. — Tliis  is  Wy  far  tlic  most  important  of"  all  tlic  acute  mcn- 
iug'C'al  atK'c'tioiis.  It  is  very  much  more  common  in  children  than  in 
adults.  While  rare  during-  the  first  year  of  life,  it  is  most  conuiKju 
hetwccn  the  second  and  the  fifth  years.  It  is,  however,  by  no  means  an 
uncommon  disease  in  adults.  Between  the  years  1884  an<l  188J)  in  the 
canton  of  Zurich  oOO  j)crsons  died  of  tuberculous  menino;itis — 275  males 
and  294  females.  Of  these,  454  were  under  fifteen  years  of  age,  and 
115  from  the  fifteenth  to  the  seventieth  year  (Kraemer). 

In  a  few  instances  the  disease  attacks  individuals  in  perfect  health 
and  living  under  the  most  fjivorable  conditions.  In  a  majority  of  cases, 
however,  there  are  predisposing  factors — previous  ill  health  or  a  pro- 
longed illness,  in  children  particularly  tlie  fevers.  Other  instances  fol- 
low overstrain  at  school  or  prolonged  mental  excitement.  The  heredi- 
tarv  influence  has  probably  been  exaggerated.  Cases  are  more  common 
ill  neuropathic  families,  and  a  special  predisposition  cannot  be  denied,  as 
there  have  been  families  in  which  a  number  of  children  have  been  suc- 
cessively attacked. 

The  disease  is  rarely  primary.  In  an  immense  proportion  of  all  cases 
tuberculous  disease  exists  in  other  organs.  Cases  are  reported  in  which, 
after  the  most  thorough  inspection  of  the  entire  body,  tubercles  have 
been  found  only  in  the  meninges,  but  it  is  very  difficult  to  exclude  the 
presence  of  foci  in  the  bones  or  in  the  bone  marrow.  It  has  been  sug- 
gested that  the  bacilli  may  reach  the  meniges  through  the  cribriform 
plate  of  the  ethmoid  bone,  and  Demme  has  recorded  a  case  of  probable 
infection  from  tuberculous  rhinitis.  In  this  connection  we  may  refer 
again  to  the  demonstration  by  Straus  of  the  presence  of  tubercle  bacilli 
in  the  nostrils  of  healthy  persons.  By  far  the  most  common  source  of 
infection  is  the  lungs,  either  a  local  lesion  which  has  become  latent  or  a 
progressive  caseous  broncho-pneumonia.  Lesions  of  the  lymph  glands 
come  next  in  order,  particularly  those  of  the  bronchi  and  of  the  mesen- 
tery. In  other  cases  the  disease  follows  tuberculous  lesions  of  the  bones 
or  joints,  pleurisy,  the  cold  tuberculous  abscess,  or  uro-genital  tubercu- 
losis. The  infection  may  be  through  the  lymph  channels,  but  in  the 
majority  of  cases  is  through  the  bloodvessels,  and  in  this  connection  it 
is  interesting  to  note  that  as  early  as  1878  Huguenin  concluded  that 
the  disease  originated,  as  a  rule,  from  embolism. 

Pathological  Anatomy. — On  removing  the  calvarium  and  the 
dura  mater  the  pia  mater  is  usually  reddened,  its  vessels  engorged,  the 
convolutions  of  the  brain  are  flattened  and  the  sulci  somewhat  obliterated. 
It  is  rare  to  see  exudate  in  any  amount  on  the  cortex.  The  meninges  at 
the  base  are  most  involved,  hence  the  term  basilar  meningitis.  The  parts 
about  the  optic  chiasm,  the  Sylvian  fissures,  and  the  interpeduncular  space 
are  affected.  There  may  be  only  slight  turbidity  and  matting  of  the  mem- 
branes, and  a  certain  stickiness  with  serous  infiltration  ;  but  more  com- 
monly there  is  a  turbid  exudate,  fibrino-purulent  in  character,  which 
covers  the  structures  at  the  base,  surrounds  the  nerves,  extends  out  in  the 
Sylvian  fissures,  and  appears  on  the  lateral,  rarely  on  the  upper,  surfaces 
of  the  hemispheres.  The  tubercles  may  be  very  apparent,  particularly 
in  the  Sylvian  fissures,  appearing  as  small  whitish  nodules  on  the  mem- 


756  TUBERCULOSIS. 

branes.  They  vary  much  in  number  and  size  and  may  be  difficult  to 
find.  The  amount  of  exudate  bears  no  definite  relation  to  the  abundance 
of  tubercles.  The  arteries  of  the  anterior  and  posterior  perforated 
spaces  should  be  carefully  withdrawn  and  searched,  as  upon  them 
nodular  tubercles  may  be  found  when  not  present  elsewhere.  In  doubt- 
ful cases  the  middle  cerebral  arteries  should  be  very  carefully  removed, 
spread  on  a  glass  plate  with  a  black  background,  and  examined  with  a 
low  objective.  The  tubercles  are  then  seen  as  nodular  enlargements  on 
the  smaller  arteries.  The  lateral  ventricles  are  dilated  (acute  hydro- 
cephalus) and  contain  a  turbid  fluid;  the  epenclyma  maybe  softened, 
and  the  septum  lucidum  and  fornix  are  usually  broken  down. 

The  minute  anatomical  changes  have  been  very  thoroughly  studied 
by  many  observers.  In  a  recent  paper  Hektoen^  has  studied  the  subject 
with  great  care,  and  draws  the  following  conclusions : 

1.  "  In  tuberculous  meningitis  there  is  a  tuberculous  endarteritis 
characterized  by  the  formation  of  intimal  tubercles  and  a  diifuse  sub- 
endothelial,  intimal  proliferation  due  to  implantation  of  tubercle  bacilli 
from  the  blood.  From  the  endarteritis  the  infiltration  may  spread  into 
the  muscular  coat  and  the  aclventitia,  and  the  whole  wall  may  undergo 
caseous  and  hyaljne  degeneration, 

2,  "  Tuberculous  proliferation  in  the  adventitia  may  invade  the  media 
and  the  intima,  and  the  whole  wall  of  the  arterial  segment  may  undergo 
degeneration, 

3,  "■  The  veins  are  constantly  the  seat  of  more  or  less  extensive 
infiltration,  which  always  results  from  adjacent  extravascular  or  arterial 
foci. 

4.  "■  The  epithelioid  cells  of  the  subendothelial,  tuberculous  intimal 
proliferation  are  most  likely  derived  from  the  subendothelial  layer  of 
connective  tissue,  and  not  from  the  endothelial  lining." 

In  a  much  larger  proportion  of  cases  than  has  been  supposed  the 
spinal  meninges  are  also  involved,  and  there  are  cases  in  which  the 
symptoms  are  chiefly  spinal.  In  rare  instances  the  spinal  meninges 
may  be  involved  alone.  In  the  case  of  a  sailor  who  was  admitted  to 
the  Montreal  General  Hospital,  who  three  weeks  before  his  death  had 
fallen  on  the  deck,  the  symptoms  were  chiefly  spinal,  and  were  very 
naturally  attributed  to  the  trauma.  The  post-mortem  shoM^ed  an  exten- 
sive eruption  of  miliary  tubercles  with  much  turbid  fibrinous  exudate 
over  the  entire  spinal  pia  mater.  There  was  neither  exudate  nor  tuber- 
cles present  in  the  basilar  meninges.  There  were  small  cheesy  masses 
at  the  apices  of  the  lungs. 

Symptoms. — The  features  of  onset  are  very  variable.  In  a  few 
instances  the  disease  sets  in  abruptly  with  symptoms  of  the  most  intense 
cerebral  excitement  or  mania,  and  proves  rapidly  fatal  within  a  few  days. 
In  this,  the  so-called  apoplectic  form,  the  cerebral  cortex  is  specially 
involved.  In  the  large  proportion  of  all  cases  the  disease  runs  a  more 
subacute  course,  while  in  adults  the  disease  may  be  prolonged  over  a 
period  of  months. 

The  course  of  the  disease  has  been  divided  into  three  or  four  stages, 
which  are  sometimes  clearly  marked,  but  which  are  often  not  well 
defined.     A  prodromal  stage,  a  period  of  excitation,  and  a  period  of 

^  Journal  of  Experimental  Medicine,  vol.  i.  No.  1. 


ACUTE  TUBERCULOSIS.  757 

paralysis  are  recognized  l»y  most  writers.  W'liilc  in  a  few  cases  the  onset 
is  abrupt,  witli  active  and  maniacal  delirinni,  as  a  rule  there  is  a  longer 
or  shorter  period  of  failing  health.  Sometimes  the  sym])tonis  set  in 
after  one  of  the  eruptive  fevers  or  they  follow  a  fall.  The  ciiild  becomes 
irritable  and  restless  and  at  night  sleeps  badly,  and  there  is  loss  of 
appetite,  and  also  a  change  in  the  (lisj)osition.  Headache,  tired  feelings, 
or  actual  pains  in  the  limbs  may  occur.  There  may  be  obstinate  vomit- 
ing and  nausea,  and  constipation.  In  young  children  the  (m.set  may  be 
with  a  convulsion.     There  is  rarely  fever  in  this  prodromal  stage. 

The  onset  is  characterized  by  aggravation  of  the  headache,  vomiting, 
constipation,  and  fever.  The  j)ain  in  the  head  is  often  intense  and 
agonizing.  The  face  is  usually  flushed,  and  at  intervals  when  the  pain 
becomes  very  intense  the  child  utters  a  short,  sudden  cry — the  so-called 
hydrocephalic  cry.  The  headache  is  most  commonly  frontal,  but  in 
many  instances  it  is  general.  It  is  much  exaggerated  by  noise,  by  light, 
and  by  any  movement.  The  child  may  sometimes  scream  continuously 
Avith  the  pain  in  the  head  until  quite  exhausted.  The  screaming  may 
lead  to  error  in  diagnosis.  I  remember  a  young  girl  aged  thirteen  whom 
I  saw  in  West  Philadelphia,  who  for  three  days,  except  when  under  the 
influence  of  strong  sedatives  or  chloroform,  screamed  incessantly  and 
loudly,  so  that  she  could  be  heard  for  the  distance  of  a  square  away. 
At  first  we  suspected  hysteria,  but  ^\'ith  the  onset  of  fever  she  became 
quieter  and  gradually  developed  the  symptoms  of  a  well  marked  basilar 
meningitis. 

Vomiting  is  a  very  common  symptom  and  is  independent  of  the  tak- 
ing of  food.  It  usually  stops  in  a  day  or  two,  but  there  are  cases  in 
Avhich  it  persists  throughout  the  course.  Constipation  is  the  rule,  often 
of  a  most  obstinate  character,  resisting  purgatives  of  great  potency. 
The  fever,  from  the  onset  of  which  we  may  count  the  commencement  of 
the  disease,  is  at  first  moderate,  rarely  reaching  above  102^  F.,  and  pre- 
senting an  evening  exacerbation.  A  very  high  temperature  at  the  onset 
is  rare.  The  pulse  is  at  first  rapid,  ranging  in  an  infant  from  130  to 
160.  The  tongue  is  usually  furred,  the  breath  often  offensive.  The 
abdomen  in  this  stage  may  be  prominent.  As  the  disease  advances  the 
child  does  not  like  to  be  disturbed  ;  the  face  has  a  dull,  fixed  aspect  ; 
the  light  is  irritating,  and  on  attempting  to  move  or  examine  the  child 
it  resists  and  cries.  There  may  be  delirium.  The  pupils  at  this  stage  are 
often  contracted,  and  transient  strabismus  may  be  noted.  The  reflexes 
are  usually  exaggerated,  and  there  may  be  marked  cutaneous  hyperaes- 
thesia.  A  not  uncommon  feature  is  a  blotchy  erythema,  and  there  is 
often  marked  vasomotor  disturbance.  If  the  finger  nail  is  drawn  across 
the  skin  of  any  region,  a  red  line  comes  out  quickly — the  so-called 
tdche  cerebi'cile.  Important  symptoms  of  this  period  are  disturbanees  of 
motility.  In  the  period  of  excitation  there  may  be  recurring  general 
convulsions,  which  sometimes  in  adults  resemble  those  of  epilepsy. 
Local  convulsive  movements  are  common,  and  may  be  unilateral,  of  the 
arm,  face,  and  leg  muscles,  or  the  cortical  irritation  may  be  limited  to 
certain  motor  areas.  In  some  instances  prolonged  tonic  spasms  may 
occur.  When  of  the  neck  and  back  muscles,  there  is  retraction  of  the 
head,  and  when  the  spinal  meninges  are  involved  as  well,  there  may  be 
opisthotonos.     This   period  of  excitation  and    irritation    persists    for  a 


758  TUBERCULOSIS. 

week  or  ten  days.  There  may  be  then  a  very  deceptive  remission  in 
the  general  symptoms ;  the  fever  may  lessen,  and  the  child  may  look 
brighter  and  regain  consciousness. 

In  the  final  period,  or  stage  of  paralysis,  the  fever  is  higher,  the  con- 
vulsive movements  become  perhaps  exaggerated,  and  there  is  a  deepen- 
ing of  the  coma,  so  that  the  child  cannot  be  roused.  Spasmodic  con- 
tractions are  frequent  and  the  retraction  of  the  head  persists.  There 
may  be  much  tremor  and  twitching  of  the  tendons,  and  local  paralyses 
occur.  Ptosis  and  strabismus  are  common ;  the  pupils  are  usually 
dilated.  The  respirations  are  often  much  disturbed,  either  sighing  or 
there  is  well  marked  Cheyne-Stokes  breathing.  The  pulse  becomes 
more  rapid  and  irregular.  The  temperature  often  sinks,  and  may 
become  subnormal.  There  may  be  an  ante-mortem  elevation  of  tem- 
23erature,  the  fever  rising  to  105°  or  106°,  or  even  extreme  hyperpy- 
rexia, 110°  F.  The  sphincters  are  relaxed  and  there  is  incontinence 
of  urine  and  fseces  ;  diarrhoea  usually  occurs.  The  pulse  becomes  very 
rapid  ;  the  skin  is  bathed  in  perspiration  ;  the  extremities  become  cold, 
and  tracheal  rales  announce  the  fatal  event. 

The  ocular  features  of  the  disease  require  special  mention.  In  the 
early  stages  the  pupils  are  usually  contracted ;  at  the  middle  period  of 
the  disease  they  may  be  unequal,  and,  as  a  rule,  with  increase  in  the 
intracranial  pressure  they  become  dilated  and  immobile.  There  may 
be  conjugate  deviation  of  the  head  and  eyes.  The  third  nerve  is  most 
frequently  involved,  causing  ptosis  or  strabismus.  An  exudate  at  the 
inferior  and  internal  part  of  one  crus  may  cause  the  syndrome  of  Weber 
— paralysis  of  the  third  nerve  on  one  side,  with  paralysis  of  the  face, 
limbs,  and  hypoglossal  nerve  on  the  opposite  side.  Of  the  deeper 
changes  in  the  eye,  optic  neuritis  is  the  most  important ;  the  process, 
however,  is  rarely  of  great  intensity.  Tubercles  of  the  choroid  are 
much  less  frequently  seen  during  life  than  post-mortem  figures  would 
indicate.  Litten  found  them  at  autopsy  in  39  of  52  cases.  They  were 
present  in  only  1  of  26  cases  examined  by  Garlick  ;  41  cases  were  exam- 
ined with  negative  results  by  Heinzel. 

The  duration  of  the  disease  is  variable.  Very  acute  cases  may  prove 
fatal  within  a  day  or  two.  It  is  stated  that  Wunderlich  saw  a  fatal  re- 
sult within  thirty  hours.  A  majority  of  the  cases  last  about  three  weeks, 
while  there  are  others,  particularly  in  adults,  which  drag  on  for  ten, 
twelve,  or  even  sixteen  weeks.  Some  of  these  more  chronic  cases  dis- 
play the  symptoms  of  a  cortical  meningitis,  sometimes  with  pronounced 
psychical  symptoms  or  those  of  cerebral  tumor. 

Certain  special  forms  of  tuberculous  meningitis  deserve  brief  mention. 
In  a  few  instances  the  disease  develops  in  the  newborn  or  within  the 
first  months  of  life.  The  symptoms  are  often  obscure ;  the  course  of 
the  disease  is  very  brief,  and  death  may  follow  within  a  few  days  in 
convulsions. 

Tuberculous  meningitis  of  adults  is  seen  most  commonly  in  indi- 
viduals who  present  well  marked  features  of  disease  in  other  parts,  most 
commonly  in  the  lungs.  There  may  be  headache,  increase  in  the  fever, 
or  the  onset  may  be  characterized  by  a  furious  delirium.  Convulsions 
are  by  no  means  uncommon,  and  they  may  be  localized.  Well  marked 
Jacksonian  fits  may  recur  for  weeks.     Remarkable  amelioration  of  the 


ACUTE  TUBERCULOSIS.  759 

general  symptoms  of  tuberculosis  may  ot'cur.  In  other  instances  there 
are  tetanic  s])asms  or  ])ersistent  ri<>i(lity  of  an  extremity. 

Diagnosis. — The  (Ha<i'nosis  of  tuberciildiis  nieninji^itis  is,  as  a  rule, 
easy  in  children.  The  vai>;ue  and  uncertain  features  of  the  j)r()dn»iual 
stao;e  may  sometimes  awaken  one's  sus])ieions,  ])artieularly  in  a  family 
in  Avhich  tuberculosis  has  prevailed.  The  symptoms  of  onset — head- 
ache, fever,  and  vomiting — are  common  enoujj-h  in  many  disorders  of 
childhood,  ])articularly  in  the  initial  stage  of  the  fevers.  A  day  or  two 
usually  suffices  to  clear  u])  the  diagnosis. 

There  arc  three  conditions,  however,  which  demand  s])eeial  notice  : 
First,  the  symptoms  associated  with  otitis  media  in  children.  On  sev- 
eral occasions  I  have  seen  cases  in  which  headache,  vomiting,  and  fever 
were  most  suggestive  of  oncoming  meningitis,  and  iji  which  the  whole 
trouble  was  due  to  middle-ear  disease.  In  an  instance  which  I  saw 
recently  the  child  had  made  little  or  no  complaint  of  the  pain  in  the  ear, 
and  it  was  not  till  the  third  or  fourth  day,  after  presenting  symptoms 
of  great  severity,  that  a  discharge  took  place  from  the  right  ear,  with 
prompt  relief. 

Second,  the  cerebral  symptoms  which  are  associated  with  gastro- 
enteritis in  children.  There  may  be  convulsions,  coma,  squint,  and  con- 
tracted pu]iils,  with  irregularity  of  the  pulse  and  Cheyne-Stokes  respi- 
rations. The  condition  has  been  called  false  hydrocephalus,  or,  as 
Marshall  Hall  termed  it,  the  "  hydrencephaloid"  state.  The  child 
is  in  a  semicomatose  condition,  with  the  eyes  open  and  the  fontanelles 
depressed. 

A  third  important  condition  is  associated  wdth  pneumonia,  more  fre- 
quently in  children  than  in  adults.  The  cerebral  symptoms  maybe  the 
more  marked  from  the  onset,  and  not  a  single  feature  of  the  early 
stages  of  meningitis  may  be  lacking — the  vomiting,  constipation,  intense 
headache,  photophobia,  and  even  the  cry.  The  local  pulmonary  symp- 
toms may  be  completely  obscured  or  overlooked.  Very  often,  too,  in 
these  cases  the  pneumonia  is  of  the  apex,  and  there  may  be  little  or  no 
expectoration.  I  have  known  cases  in  which  there  w^as  not  a  suspicion 
entertained  of  the  existence  of  pneumonia ;  but  the  autopsy  showed  the 
meninges  to  be  perfectly  free  from  exudate  and  a  localized  consolidation 
of  the  apex  or  of  a  lower  lobe. 

In  a  few  instances,  too,  children  who  are  teething  or  who  have  a 
transient  dyspepsia  present  for  a  day  or  \\\o  cerebral  symptoms  which 
mav  sugg&st  meningitis. 

Typhoid  fever  may  simulate  closely  tuberculous  meningitis.  On 
several  occasions  I  have  performed  autopsies  on  supposed  meningitis 
and  found  the  meninges  free  from  all  inflammation,  while  the  intestines 
showed  the  lesions  of  typhoid  fever.  It  is  w'ell  to  remember  Stokes' 
dictum,  that  in  the  fevers  "  there  is  no  single  nervous  symptom  which 
may  not  and  does  not  occur  independently  of  any  appreciable  lesion  of 
the  brain,  nerves,  or  spinal  cord." 

The  differential  diagnosis  between  the  tuberculous  and  the  simple 
forms  of  meningitis  is  not  always  possible.  The  history  of  a  previous 
tuberculous  lesion  or  the  presence  of  some  focus  of  disease  or  caseous 
glands,  the  recent  recovery  from  one  of  the  fevers,  the  more  insid- 
ious onset,  the  protracted  course,  and  the  symptoms  pointing  specially 


760  TUBERCULOSIS. 

to  involvement  of  the  base  are  all  points  which  favor  the  diagnosis 
of  tuberculous  meningitis. 

Peog-nosis. — Tuberculous  meningitis  is  almost  invariably  fatal  In- 
stances of  recovery  are  on  record,  but  there  is  always  in  these  a  doubt 
as  to  the  diagnosis.  I  have  not  seen  an  instance  of  recovery  in  a  case 
which  I  regarded  as  tuberculous.  The  possibility,  however,  cannot  be 
denied.  Wallis  Ord  and  Waterhouse  have  reported  a  case  of  recovery 
in  a  child  of  five  years  after  trephining  and  drainage.  A  recovery  has 
followed  Quincke's  lumbar  puncture. 


III.  TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM. 

I.  Tuberculosis  op   the  Lymph   Glands   (Scrofula). 

The  very  word  scrofula  has  almost  disappeared  from  our  vocabularies. 
In  a  recently  issued  voluminous  work  on  Pediatrics  the  name  does  not 
occur  in  the  index.  This  remarkable  change  has  followed  the  demon- 
stration of  the  tuberculous  nature  of  scrofulous  lesions.  Formerly 
special  attention  was  given  to  different  types  of  scrofula,  of  which  two 
important  forms  were  recognized — the  sanguine,  in  which  the  child  was 
slightly  built,  tall,  with  small  limbs,  a  fine  clear  skin,  soft  silky  hair, 
and  was  mentally  very  bright  and  intelligent ;  and  the  phlegmatic  type, 
in  which  the  child  was  short  and  thick-set,  with  coarse  features,  muddy 
complexion,  and  a  dull,  heavy  aspect. 

Tuberculous  adenitis  occurs  at  all  ages,  and,  though  more  common 
in  children  than  in  adults,  it  is  not  at  all  infrequent  in  the  middle 
periods  of  life,  and  may  be  met  with  in  extreme  old  age.  So  far  as  I 
know,  there  is  no  instance  on  record  of  congenital  tuberculous  adenitis. 
Practically,  in  all  cases  the  disease  follows  infection  from  without,  and 
it  is  specially  prevalent  in  the  three  great  groups  of  glands  which  stand 
at  the  gateways  of  the  lymphatic  system — namely,  the  cervical,  the 
tracheo-bronchial,  and  the  mesenteric.  While  it  is  doubtless  possible 
for  tubercle  bacilli  to  pass  through  a  normal  mucous  membrane,  yet  re- 
curring catarrhal  inflammation,  by  rendering  the  passage  more  easy  and 
by  exciting  slight  adenitis  of  the  neighboring  glands,  is  probably  a 
special  predisposing  factor.  In  a  child  with  a  constantly  recurring  naso- 
pharyngeal catarrh  the  bacilli  find  the  gateways  less  strictly  guarded, 
and  are  taken  up  by  the  lymphatics  and  passed  to  the  nearest  glands. 
The  importance  of  the  tonsils  as  an  infection  atrium  will  be  referred  to 
later,  as  local  disease  of  these  glands  seems  not  uncommon.  In  condi- 
tions of  health  the  local  resistance — or,  as  some  would  put  it,  the 
phagocytes — would  be  active  enough  to  deal  with  the  invaders,  but  the 
irritation  of  a  chronic  catarrh  weakens  the  resistance,  and  the  bacilli  are 
enabled  to  develop  and  gradually  to  change  a  simple  into  a  tuberculous 
adenitis.  The  frequent  association  of  tuberculous  adenitis  of  the 
bronchial  glands  with  whooping  cough  and  with  measles,  and  the  de- 
velopment of  tubercle  in  the  mesenteric  glands  in  children  with  intesti- 
nal catarrh,  find  in  this  way  a  rational  explanation.  After  all,  as  Vir- 
chow  pointed  out,  an  increased  vulnerability  of  the  tissue,  however 
brought  about,  is  the  most  important  factor  of  the  disease. 


TUBERCULOSIS   OF   TlIK   LYMrHATK^  SYSTEM.  7(51 

Certiiin  ucncnil  icaturcs  ol"  (iibcrciiloiis  adenitis  iiia\'  Ix-  first  I'dciTcd 
to: 

The  local  cliaractci'  ol"  the  diseaso.  In  a  iii'cat  inajorily  ol"  all  cases 
tlic  cervical  iN'inph  j^lands  are  alone  involved,  [)crlia])s  on  only  one  side. 
The  bronchial  lymph  "lands  are  very  often  f'onnd  affected  withont  any 
evidence  of  other  tuhercnlous  lesions  in  the  hody,  and  one  oi-  two  of  tiie 
mesenteric  t>lands  may  he  fonnd  cheesy. 

Tuhercnlous  adenitis  tends  to  heal  spontaneously  in  a  very  consid- 
erable ])roportion  of  all  cases.  Nowhere  are  healed  tuben-ulous  lesions 
more  common  than  in  the  bronchial  and  mesenteric  lymph  glands. 

The  cheesy  masses  in  tuberculous  adenitis  frequently  break  down 
into  puslike  liquid,  which  is  nsnally  sterile.  This  softening; — or  su])- 
puration,  as  it  is  often  called  (though  true  pus  may  not  be  present) — is 
often  the  result  of  a  mixed  infe(;tion. 

The  existence  of  an  unhealed  focus  of  tuberculous  adenitis  is  a  con- 
stant menace.  One  can  safely  say  that  in  more  than  three  fourths  of 
all  cases  of  acute  tuberculosis  the  infection  has  been  derived  from  cheesy 
lymph  glands.  It  has  been  urged  by  Marfan  that  scrofula  in  childhood 
affords  a  sort  of  protection  against  tuberculosis  in  adult  life,  but  the 
evidence  of  this  is  by  no  means  satisfactory. 

Clinical  Forms. — (1)  Generalized  Tuberculous  Lymphadenitk. — 
There  are  cases  in  which  the  lymphatic  system  is  alone  affected,  and  the 
glands,  internal  and  external,  with  or  without  the  serous  surfaces,  pre- 
sent advanced  tuberculosis  without  much  involvement  of  the  viscera. 
This  is  a  more  common  type  of  the  disease  than  is  usually  supposed, 
and  occurs  both  in  children  and  in  adults.  In  the  former  there  are 
cases  in  which  the  lymph  glands  are  progressively  involved,  usually  be- 
ginning in  the  groin  and  then  attacking  those  of  the  axilla,  and  lastly 
the  cervical  and  internal  groups.  Lesage  and  Paschal,  who  have  de- 
scribed a  nu?nber  of  cases,  believe  that  the  affection  is  due  in  some  to 
cutaneous  tuberculosis,  but  in  others  they  think  it  may  be  congenital. 

The  symptoms  are  those  of  a  progressive  cachexia  without  much  fever 
and  without  signs  of  disease  of  the  lungs  or  of  the  abdominal  organs. 
In  children  such  cases  must  be  carefully  distinguished  from  the  general 
slight  enlargement  of  the  glands  in  syphilis,  and  from  the  moderate 
enlargement  of  the  superficial  lymph  glands  which  may  follow  the  infec- 
tious fevers.  In  adults  a  tuberculous  polyadenitis  is  not  so  common, 
but  there  are  cases  in  which  the  bronchial,  retroperitoneal,  and  mesen- 
teric glands  are  greatly  enlarged  and  caseous,  usually  with  involvement 
of  the  cervical  groups ;  there  may  be  high  and  irregular  fever,  and  the 
patient  may  die  without  involvement  of  any  of  the  viscera.  In  the 
acute  form  some  of  these  cases  resemble  very  closely  Hodgkin's  disease, 
as  in  a  patient  in  the  Montreal  General  Hospital  in  whom  this  disease 
was  diagnosed,  and  whose  enormously  enlarged  cervical  and  axillary 
glands  were  found  post-mortem  to  be  tuberculous, 

(2)  Loccd  Tuberculous  Adenitis. — («)  Cervical  Group. — The  drainage 
area  of  the  lymph  glands  of  the  neck  includes  the  superficial  and  deep 
structures  of  the  head  and  neck.  The  most  important  groups  are  the 
superficial  cervical  beneath  the  platysma,  which  drains  the  side  of  the 
head  and  neck  and  face  and  external  ear,  and  the  deep  cervical  group 
along  the  carotid  sheath,  which  drains  the  mouth,  the  tonsils,  the  palate, 


762  .  TUBERCULOSIS. 

pharynx^  and  larynx.  The  submaxillary  and  suprahyoid  groups  drain 
the  lower  gums,  the  front  of  the  mouth  and  tongue,  the  chin,  and  lower 
lip. 

Tuberculous  adenitis  of  the  glands  of  the  neck  is  by  far  the  most 
common  form.  Fortunately,  it  often  remains  local,  and  formerly  was 
regarded  as  the  most  typical  and  characteristic  manifestation  of  scrofula. 
It  is  very  prevalent  among  the  children  of  the  poor  and  in  those  who 
live  in  the  crowded,  unhealthy  dwellings  in  large  cities.  Children  in 
foundling  hospitals  and  asylums  are  also  specially  subject  to  it.  In 
this  country  it  is  very  prevalent  among  the  children  of  the  negro  race. 
In  the  widespread  prevalence  of  tubercle  bacilli  in  the  dust  of  cities 
and  in  institutions  any  of  us  may  inhale  or  swallow  the  germs.  The 
habits  of  children  render  them  very  much  more  liable  than  others  to 
become  infected.  As  already  mentioned,  the  bacilli  can  probably  pass 
through  healthy  mucosa.  The  slight  catarrhal  troubles  of  the  naso- 
pharynx which  are  so  common  in  children  probably  open  the  portals 
and  allow  the  bacilli  to  reach  the  lymph  glands.  Preliminary  irritation 
and  enlargement  of  the  glands  in  connection  with  eczema  of  the  scalp 
or  ear  or  with  conjunctivitis  or  keratitis  weaken,  no  doubt,  the 
powers  of  resistance.  The  glands  may  enlarge  rapidly  at  first,  and 
become  soft  and  painful.  The  swelling  may,  however,  be  gradual  and 
painless  from  the  outset.  The  enlarged  "  kernels,"  as  they  are  popu- 
larly called,  are  usually  more  prominent  on  one  side  than  on  the  other. 
As  they  increase  the  individual  tumors  can  be  felt,  separate,  smooth, 
and  firm.  Often  a  chain  of  glands  can  be  felt  from  the  angle  of  the 
jaw  to  the  clavicle.  As  they  enlarge  they  form  knotted  masses  in 
which  the  outlines  of  the  individual  tumors  can  be  just  felt.  The 
skin  is,  as  a  rule,  freely  movable,  but  as  areas  of  softening  occur  it 
becomes  adherent  and  reddened,  and  finally  ulcerates,  discharging  a 
cheesy  matter  and  a  thin,  watery  pus.  The  opening  thus  formed  has 
very  little  tendency  to  heal,  and  the  skin  about  it  is  livid  and  under- 
mined. Many  of  the  glands  may  suppurate  in  this  way,  and  when 
healing  ultimately  takes  place  the  sides  of  the  neck  are  disfigured  by 
irregular,  unsightly  scars.  When  the  glands  are  large  and  growing 
actively  there  is  fever,  and  the  patients  are  usually  anaemic.  Death 
rarely  follows,  and  a  considerable  proportion  of  all  cases  get  quite  well. 
In  other  instances  the  axillary  glands  are  involved,  and  there  is  a  con- 
tinuous chain  extending  beneath  the  clavicle  and  the  pectoral  muscles. 
In  many  of  these  cases  the  tracheal  and  bronchial  glands  are  also 
attacked,  and  there  is  a  special  liability  to  involvement  of  the  pleura ; 
and  in  young  adults  tuberculosis  of  the  cervical  lymph  glands  is  not 
infrequently  followed  by  involvement  of  the  apex  of  one  lung. 

(6)  Tracheo-hronchial  Group. — The  lymph  glands  within  the  thorax 
are  of  the  greatest  importance  in  connection  with  tuberculosis.  The 
sternal  are  placed  along  the  course  of  the  internal  mammary  vessels ; 
the  intercostal,  along  the  heads  of  the  ribs  and  sometimes  extending  out- 
ward ;  the  anterior  mediastinal  group,  between  the  lower  part  of  the 
sternum  and  the  pericardium ;  the  cardiac  group,  in  the  interpleural 
space  about  the  arch  of  the  aorta ;  and,  lastly,  the  tracheal  glands,  on 
either  side  of  the  windpipe,  and  the  bronchial  proper,  continuous  with 
them,  which  surround  the  main  bronchi  and  pass  deeply  in  the  roots  of 


TUBERCULOSIS   OF   T1U-:   LYMPHATIC  SYSTEM.  7(}3 

the  lungs.  Tlu'rc  arc  also  elands  in  the  |»(>stcrior  nicdiastiniini  aloiiu-  the 
thoracic  aorta  and  (os()j)hatins.  Tnl)crculosis  ot"  these  <i;rouj)s  is  extra- 
ordinarily common,  and  in  a  vi-rv  lar^e  proportion  of  all  cases  in  children 
tiie  first  infection  is  in  them.  Of  125  cases  of  tuberculosis  examined  by 
Xorthruj)  in  children,  the  bronchial  glands  were  involved  in  every  in- 
stance, and  in  1.")  of  these  cases  the  disease  was  limited  to  these  ulands 
alone.  The  observations  of  li.  P.  Loomis  show  that  even  in  a[)parently 
normal  glands  tubercle  bacilli  may  be  present  and  the  tissue  prove  infec- 
tive to  animals. 

The  anatomical  condition  of  the  glands  varies  greatly.  There  may 
be  gray  miliary  nodules  or  large  cheesy  areas  with  foci  of  softening,  or 
the  glands  may  be  hard,  deeply  pigmented,  and  calcified.  The  traciieal 
group  may  be  atiected  without  great  involvement  of  the  bronchial  glands. 
In  some  instances  the  substernal  glands  are  found  much  more  enlarged 
than  those  about  the  bronchi.  In  children  the  greatly  enlarged  caseous 
glands  often  pass  deeply  into  the  hilus  of  a  lung,  and  in  some  instances, 
destroying  the  capsule  of  the  gland,  merge  directly  with  areas  of  caseation 
in  the  lung  tissue  itself.  When  the  glands  suppurate  the  abscesses  may 
perforate  in  different  directions.  The  effects  of  these  enlarged  glands 
are  very  varied,  and  for  full  details  the  reader  is  referred  to  the  elaborate 
section  in  the  Traite  of  Barthez  and  Sannee  (tome  iii).  It  is  sutfieient 
here  to  say  that  there  are  instances  on  record  of  compression  of  the  supe- 
rior cava,  of  the  pulmonary  artery,  and  of  the  azygos  vein.  The  trachea 
and  bronchi,  though  often  flattened,  are  rarely  seriously  compressed. 
The  pneumogastric  nerve  may  be  involved,  particularly  the  recurrent 
laryngeal  branch.  More  important,  really,  are  the  perforations  of  the 
enlarged  and  softened  glands  into  the  bronchi  or  trachea,  or  a  sort  of 
secondary  cyst  may  be  formed  between  the  lung  and  the  trachea.  Per- 
forations of  the  vessels  are  much  less  common,  but  the  pulmonary  artery 
has  been  opened.  Perforation  of  the  cesophagus  has  been  described  in 
several  cases.  One  of  the  most  serious  effects  is  infection  of  the  lung  or 
pleura  by  the  caseous  glands  situated  deep  along  the  bronchi.  This  may, 
as  is  often  clearly  seen,  be  by  direct  contact,  and  it  may  be  difficult  to 
determine  in  some  sections  where  the  caseous  bronchial  gland  terminates 
and  the  pulmonary  tissue  begins.  In  other  instances  it  takes  place  along 
the  root  of  the  lung  and  is  subpleural.  Among  other  sequences  may  be 
mentioned  diverticula  of  the  oesophagus  following  adhesion  of  an 
enlarged  gland  and  its  subsequent  retraction,  and,  in  the  case  of  the 
anterior  mediastinal  and  aortic  groups,  the  frequent  production  of  peri- 
carditis, either  by  contact  or  by  rupture  of  a  softened  gland  into  the 
sac. 

Authors  differ  widely  in  their  views  as  to  the  symptoms  caused  by 
enlarged  glands  along  the  bronchi  and  trachea.  Certainly  in  a  great 
many  cases  the  manifestations  are  quite  trivial.  How  often  does  one 
find  enormous  enlargement  of  these  glands  in  a  child  who  has  presented 
no  symptom  whatever  pointing  to  disturbance  of  the  organs  within 
the  chest !  Among  the  symptoms  Barthez  and  Sannee  speak  of  com- 
pression of  the  veins,  leading  to  dropsy ;  of  dilatation  of  the  veins, 
causing  cyanosis  ;  of  alterations  in  the  character  of  the  heart  sounds  ;  and 
of  attacks  of  paroxysmal  dyspnoea,  crouplike  in  character,  watli  cyanosis. 
By  some  these  paroxysms  have  been  ascribed  to  compression  of  the  vagi, 


764  TUBERCULOSIS. 

and  not  to  direct  pressure  on  the  bifurcation  of  the  trachea.  A  bronchus 
may  be  compressed  by  the  enlarged  and  caseous  glands,  and  cause  feeble 
breathing  in  one  lung,  with  sibilant  rales. 

In  the  diagnosis  of  enlarged  mediastinal  glands  some  writers  have 
laid  great  stress  npon  the  information  obtained  by  percussion,  particu- 
larly the  dulness  on  the  npper  part  of  the  sternum  and  in  the  interscap- 
ular spaces. 

(c)  Mesenteric  and  Retroperitoneal  Groups. — Tuberculous  affection 
of  the  glands  of  the  mesentery,  of  the  retroperitoneum,  and  of  the 
gastro-hepatic  omentum  is  extremely  common,  particularly  in  children. 
Of  127  cases  of  fatal  tuberculosis  in  children  noted  by  Woodhead,  these 
structures  were  involved  in  100,  while  Ashby  states  that  of  103  consec- 
utive post-mortem  examinations  on  children  dying  of  tuberculosis,  in 
62  there  was  tuberculous  ulceration  of  the  intestines ;  in  71  there  were 
cheesy  mesenteric  glands ;  in  55,  both  ulcers  and  cheesy  glands ;  in  7, 
tuberculous  ulcers  without  involvement  of  the  glands  ;  and  in  16,  cheesy 
glands  without  ulcers.  Of  144  children  in  whom  the  mesenteric  glands 
were  tuberculous,  only  44  showed  neither  ulcerations  nor  tubercles  in 
the  intestines  (Barthez  and  Sannee).  In  a  large  number  of  the  cases 
the  infection  is  primary  in  these  glands ;  a  lesion  of  the  mucosa  of  the 
bowels  is  not  necessary.  In  children  it  is  highly  probable  that  many 
cases  are  due  directly  to  infection  with  tuberculous  milk. 

The  symptoms  of  "  abdominal  scrofula,"  as  it  was  called  by  the  older 
writers,  are  very  varied.  Slight  tuberculous  aifection  of  a  few  glands  is 
met  with  commonly  enough  in  children  who  have  died  of  various  disor- 
ders. These  groups  may  be  involved  in  tuberculous  polyadenitis,  particu- 
larly with  the  general  lymphatic  tuberculosis  already  referred  to.  The 
most  important  condition  is  that  to  which  the  term  tabes  mesenterica  is 
usually  applied.  The  cases  are  seen  chiefly  in  children  between  the  ages 
of  eighteen  months  and  five  years  who  have  had  chronic  intestinal 
catarrh.  The  diarrhoea  is  the  most  troublesome  symptom.  The  stools 
are  frequent,  yellow  brown  in  color,  and  contain  mucus,  but  not  often 
blood.  The  abdomen  is  distended,  a  little  painful  on  deep  pressure,  but 
no  nodules  are  felt.  There  is  usually  slight  fever,  but  the  general  wast- 
ing and  debility  are  the  most  characteristic  features.  The  disease  is 
chronic,  extends  over  a  year  or  two,  and  leads  to  the  most  extreme 
emaciation.  It  is  sometimes  not  at  all  easy  to  determine  w^hether  there 
is  actual  tuberculous  disease  of  the  bowel  or  not,  as  a  chronic  intestinal 
catarrh  may  be  associated  with  a  similar  condition  of  extreme  debility 
and  wasting. 

In  other  instances  of  tabes  mesenterica  the  peritoneum  is  involved 
and  nodular  masses  may  be  felt,  and  the  abdominal  distention  may  be 
still  greater. 

In  a  few  cases  the  tuberculous  mesenteric  glands  form  large  abdom- 
inal tumors. 

n.  Tuberculosis  of  the  Serous  Membranes. 

(1)  Tuberculosis  of  the  Pleura. — The  relationship  of  acute  pleurisy 
to  tuberculosis  has  been  the  subject  of  much  discussion.  While  the 
views  on  the  subject  are  varied,  the  general  trend  of  opinion  has  been 


TUBERCULOSIS  OF  '1111-:  SEROUS  MEMBRANES.  7(30 

strongly  in  favor  of  the  closcno.s.s  of  the  association.  Landouzy  and  his 
])iipils  believe  that  nearly  all  eases  of  pleurisy  are  tnhereidoiis  in  origin. 
Pleurisv  dfrir/orc  is  held  to  he  of  very  rare  oeeiirrenee,  and  the  great 
majority  are  held  to  he  an  expression  of  an  incipient  pulmonary  tnher- 
eulosis  which  may  appear  at  any  subsec^uent  time,  even  after  the  lapse 
of  years.  Fiedler  states  that  of  112  pleurisies  tliat  were  aspirated,  21 
recovered,  25  died  of  phthisis,  and  the  6()  which  recovered  from  the 
pleurisy  were  found  to  be  the  victims  of  other  tuberculous  diseases. 
Vincent  Y.  Bowditch  in  looking  uj)  the  subsc(pient  history  of  90  cases 
of  pleurisy  which  occurred  in  iiis  father's  practice  found  that  32  had 
either  died  of  tuberculosis  or  had  developed  some  definite  tuberculous 
disease.  Sears  collected  from  the  literature  records  of  451  cases  of 
pleurisy,  of  which  17G,  or  about  39  per  cent.,  had  either  died  of  pul- 
monary tuberculosis  or  had  become  the  subject  of  some  tuberculous 
affection.  There  are  others,  particularly  Blachez,  Vidal,  Dreyfus- 
Brisac,  who  think  that  the  tendency  to  regard  the  great  majority  of  cases 
of  pleurisy  as  tuberculous  in  origin  or  as  precursors  of  later  tuberculous 
disease  has  been  exaggerated.  Statistics  of  writers  who  hold  the  latter 
opinion  would  seem  to  show  that  persons  who  have  been  the  subject  of 
pleurisy  do  not  develop  tuberculosis  subsequently  any  oftener  than  those 
who  have  not  had  an  attack.  The  balance  of  opinion,  however,  favors 
a  more  or  less  intimate  relationship  between  the  two  diseases.  In  the 
study  of  the  cases  in  the  Johns  Hopkins  Hospital  which  I  made  for  the 
Shattuck  Lecture  (1893)  I  fonnd  that  the  incidence  of  tuberculous 
pleurisy  in  post-mortem  examinations  on  individuals  who  had  been  the 
subjects  of  pleuritic  effusion — either  fibrinous,  sero-fibrinous,  hemor- 
rhagic, or  purulent — was  a  trifie  less  than  32  per  cent.  The  pleurisy 
was  tuberculous  in  32  instances  out  of  101  successive  cases  in  which 
effusion  was  present. 

Although,  clinically,  there  is  nothing  positively  characteristic  of 
tuberculous  pleurisy,  there  are  features,  to  say  the  least,  suggestive.  A 
slow,  insidious  onset  is  common,  although  by  no  means  distinctive.  In- 
deed, the  disease  may  come  on  abruptly  with  a  stitch  in  the  side  or  even 
with  a  chill.  The  order  of  frequency  of  the  commonest  symptoms  of 
which  the  patients  complain,  and  for  which  they  seek  relief,  are  cough, 
dyspnoea,  pain  in  the  side,  and  lastly  chills  and  fever.  Cough  and  loss 
of  weight  for  several  months,  haemoptysis,  or  a  previous  attack  of 
pleurisy  are  significant  points  in  the  patient's  history.  There  may  be 
tuberculosis  in  the  fiimily,  although  in  many  cases  no  such  positive 
information  is  obtainable.  The  character  and  contents  of  the  exudate 
vary  greatly.  It  may  be  sero-fibrinous,  simply  serous,  hemorrhagic, 
sero-purulent,  or  purulent.  Of  these  the  hemorrhagic  and  sero-purulent 
are  the  most  frequent.  The  thin,  slightly  opalescent,  sero-purulent 
exudate,  often  with  a  greenish  tint,  and  which  microscopically  contains 
granular,  fatty  matter  and  only  a  few  leucocytes,  is  almost  characteristic 
of  a  tuberculous  lesion.  The  cover-slip  and  culture  tests  give  variable 
results.  It  is  generally  conceded  by  bacteriologists  that  the  great 
majority  of  tuberculous  effusions  are  sterile ;  organisms  are  neither 
found  on  the  cover-slip  preparations  nor  is  any  growth  obtained  on 
culture  media.  A  sterile  effusion  is  therefore  regarded  as  favoring  the 
tuberculous  character  of  a  pleurisy.     In  one  of  my  cases  with  sero- 


766  TUBERCULOSIS. 

fibrinous  exudate  tubercle  bacilli  were  definitely  determined  in  the  effu- 
sion after  the  patient  had  been  tapped  on  repeated  occasions.  The  bac- 
teriological examination  of  the  purulent  tuberculous  exudates  also  gives 
variable  results.  In  a  certain  percentage  of  acute  cases  tubercle  bacilli 
may  be  abundant.  They  may  occur  alone,  as  was  demonstrated  by 
Prudden  in  one  of  his  cases.  In  other  instances  only  pus  organisms  or 
diplococci  are  present,  or  the  exudate  may  be  entirely  negative.  Pansini 
has  emphasized  the  importance,  from  a  technical  standpoint,  of  examin- 
ing larger  quantities  of  exudate  than  can  be  obtained  by  the  usual  ex- 
ploratory puncture  with  the  hypodermic  syringe  and  the  use  of  animal 
iiioculations,  as  without  such  precautions  the  bacilli  may  readily  escape 
observation.  His  own  studies,  made  on  large  quantities  of  the  exudate, 
showed  tubercle  bacilli  present  in  6  instances  out  of  15  cases  of  sero- 
fibrinous effusion.  The  importance  of  the  injection  of  the  exudate  into 
the  peritoneal  cavity  of  guinea-pigs  has  been  demonstrated  by  French 
observers,  who  have  obtained  positive  results  in  the  sero-fibrinous  and 
purulent  pleurisies  of  individuals  apj)arently  not  tuberculous. 

The  nature  of  a  pleurisy  may  not  be  apparent  for  months  or  years, 
when  the  onset  of  tuberculosis  in  other  parts  may  indicate  the  true 
character  of  the  process.  From  year  to  year  I  am  more  and  more 
impressed  with  the  frequency  with  which  the  subjects  of  pleurisy  with 
effusion  subsequently  develop  tuberculosis. 

Tuberculous  pleurisy  may  be  a  part  of  a  general  miliary  infection, 
but  rarely  do  the  pleuritic  symptoms  dominate,  or  even  become  pro- 
nounced enough  to  attract  attention.  From  the  character  of  the  onset 
and  the  course  of  the  disease  one  recognizes  two  main  classes — acute, 
and  the  subacute  and  chronic  tuberculous  pleurisies,  to  which  may  be 
added  a  third,  the  pleurisy  which  forms  a  part  of  a  general  serous  mem- 
brane tuberculosis. 

1.  Acute  Tubeeculous  Pleurisy. — As  already  stated,  it  is  im- 
possible to  estimate  the  proportion  of  instances  of  acute  pleurisy  due 
to  tuberculosis,  which  has  been  variously  placed  at  from  40  to  80  per 
cent,  of  all  cases.  The  disease  is  rarely  fatal  during  the  acute  attack. 
Many  cases  entirely  recover,  a  few  become  chronic  in  their  course,  and 
a  variable  number  develop  tuberculosis  at  some  later  date.  AVe  are  able 
to  recognize  three  groups  of  cases  in  which  the  onset  is  acute : 

(a)  Acute  Tubercidous  Pleurisy  with  Subsequent  Chronic  Course. — 
Cases  of  tuberculous  pleurisy  occur  in  which  the  onset  is  abrupt,  with 
pain  in  the  side,  fever,  cough,  and  sometimes  with  a  chill.  The  possi- 
bility of  their  tuberculous  nature  may  not  be  considered,  as  the  patient 
may  be  in  excellent  physical  development  and  the  family  history  may 
be  good.  There  is  nothing  in  the  course  of  the  disease  to  at  first  excite 
suspicion.  Owing  to  the  accumulation  of  fluid,  repeated  aspirations  may 
be  necessary,  and  the  patient  finally  recovers  from  the  attack  with  or 
without  a  thickened  pleura.  The  pleurisy  may  recur,  and  the  case 
becomes  one  of  chronic  pleurisy  with  thickening  of  the  membranes, 
whilst  eventually  the  true  nature  of  the  disease  is  manifested  by  the  dis- 
covery of  definite  tuberculous  lesions  in  the  lungs  and  possibly  also  in 
other  parts  of  the  body. 

(6)  The  Secondary  and  Terminal  Acuie  Tubercidous  Pleurisy, — Cases 
of  general  miliary  tuberculosis  in  which  the  pleural  membranes    are 


TUBERCULOSIS  OF  TlIK  SEROUS  MEMBRANES.  767 

itivolvcd  with  otlici-  parts  do  not  conic  imdcr  lliis  lic:idin<i'.  A  miliary 
ei'uptioii  is  very  ofti'ii  secondary  to  a  local  tiil)crcnlosis  in  the  Ihiil'-,  and 
under  these  eireunistanees  tlie  exudate  is  usually  liWrinous.  It  must  bo 
riMnt'nilx'i'cd,  liowevcr,  that  a  pUnirisy  in  the  course  ol"  a  pulinonaiy 
tuberculosis  is  uot  always  due  to  the  presence  of  tubercles.  Post-mor- 
teni  we  certainly  sec  acute  miliary  tuberculosis  of  the  pleura  most  fre- 
quently in  the  subjects  of  some  chronic  malady — affections  of  the  heart 
and  arteries,  chronic  Briji:;ht's  disease,  and  scleroses  of  various  sorts, 
(rcucrally  there  are  found  old  foci  of  tuberculous  disease  somewhere  in 
tile  Ixtdy,  a  caseous  nodule  at  the  apex  of  one  of  the  lunj^s  or  in  the 
bronchial  or  mesenteric  g-hinds.  Attention  has,  in  recent  years,  been 
repeatedly  directed  to  the  association  of  tuberculosis  of  the  serous  mem- 
branes, most  commonly  of  the  peritoneum,  with  cirrhosis  of  the  liver, 
but  a  number  of  instances  of  terminal  tuberculosis  of  the  pleura  as  well 
have  come  under  my  care  in  this  disease,  and  it  may  exist  without  hav- 
ing causetl  sufficient  symptoms  to  arouse  attention. 

(c)  Acute  Tuberculous  ^Suppurative  Pleurisy. — It  has  been  recognized 
that  a  considerable  number  of  the  purulent  pleurisies  designated  as 
latent  and  chronic  depend  on  tuberculosis,  but  it  is  not  so  generally 
knowai  that  acute  ulcerative  and  suppurative  disease  of  a  most  severe 
type  may  occur  and  run  a  very  rapid  course.  Here,  also,  the  onset  of 
tlie  disease  is  often  abrupt,  with  pain  in  the  side,  cough,  fever,  and  not 
infrequently  a  chill,  and  no  suspicion  of  its  tuberculous  nature  is  at  first 
entertained.^ 

2.  Subacute  and  Cheonic  Tuberculous  Pleurisies. — The 
cases  under  this  heading  group  themselves  into  two  classes — those 
with  effusion,  and  the  chronic  adhesive  form,  the  former  being  the 
most  common. 

(a)  With  Sero-fibrinous  Ejfusion. — The  affection  may  be  primary,  or 
at  least  most  extensive  in  the  pleura,  or  secondary  to  manifest  tubercu- 
losis of  the  lungs.  This  forms  a  most  important  division  of  the  tuber- 
culous pleurisies,  and  comprises  a  considerable  proportion  of  all  the  cases 
with  insidious  onset  and  chronic  course.  The  true  character  of  the  dis- 
ease is  often  overlooked,  and,  although  it  is  spoken  of  as  primary  in  the 
pleura,  in  almost  every  instance  there  are  tuberculous  foci  in  the  lungs 
or  bronchial  glands  or  the  process  has  extended  from  the  peritoneum. 
There  are  cases  in  which  the  termination  is  in  pulmonary  tuberculosis 
or  general  miliary  tuberculosis.  In  these  cases  the  sero-fibrinous  effu- 
sion often  has  a  greenish  tint,  and  is  sometimes  a  little  turbid.  Bacterio- 
logically,  the  exudate  is  commonly  sterile,  though  occasionally  tubercle 
bacilli  are  found  in  considerable  numbers. 

(b)  With  Purulent  Exudate, — The  acute  form  already  spoken  of  is 
very  rare.  Much  more  frequently  it  is  subacute  in  onset,  chronic  and 
latent  in  its  course.  The  effusion  is  usually  sero-purulent,  thin,  and 
often  contains  a  large  amount  of  fatty  matter. 

(e)  Chronic  Adhesive  Tuberculous  Pleurisy. — This  form,  character- 
ized by  an  enormous  thickening  of  the  pleural  layers,  may  exist  as  a 
primary  proliferative  process,  in  which  the  tubercles,  developing  in  the 
pleural  membranes,  cause  an  early  adhesion  of  the  surfaces,  and  there 
is  at  no  time  much,  if  any,  serous  exudate.     With  the  gradual  develoj)- 

'  For  a  remarkable  illustrative  case  see  my  Shattuck  Lecture,  1893. 


768  TUBERCULOSIS. 

ment  of  the  tubercles  the  layers  become  greatly  thickened,  measuring 
from  1  to  2  cm.  or  more  in  diameter,  and  on  section  they  are  seen  to 
be  made  up  of  diffuse  tuberculous  tissue,  with  sometimes  caseous  layers 
and  great  development  of  fibrous  tissue.  With  the  exception  of  the 
involvement  of  the  bronchial  glands  this  may  be  the  only  tuberculous 
disease  in  the  body.  The  affection  may  be  limited  to  one  side  or  bilat- 
eral. Much  more  frequently,  with  very  great  thickening,  and  perhaps 
in  the  upper  zone  union  of  the  pleural  membranes,  there  is  separation 
of  the  layers  below  and  on  the  diaphragmatic  surface  by  an  exudate, 
usually  sero-fibrinous,  but  sometimes  containing  curdy  or  even  cheesy 
material.  It  may  be  extremely  difficult  to  recognize  on  first  examina- 
tion that  the  process  is  tuberculous.  A  chronic  tuberculous  pleurisy 
may  exist  for  a  long  time  and  lead  to  great  thickening,  without  any 
extension  of  the  fibroid  process  into  the  lung  :  only  in  very  rare  instances 
do  the  fibroid  processes  of  the  pleura  invade  the  lung  tissue  and 
lead   to   extensive   sclerosis. 

3.    As  A  PART  OF    A    GENERAL    SEROUS    MEMBRANE   TUBERCULOSIS, 

a  form  which  will  be  considered  later.  (See  p.  774.) 

Tuberculous  pleurisy  secondary  to  disease  in  the  lungs  is  of  very 
frequent  occurrence.  Adhesions  and  a  chronic  pleurisy  result,  which 
in  some  instances  may  be  simple,  but  usually  tubercles  are  scattered 
throughout  the  adhesions.  An  acute  pleurisy  with  effusion  may  result 
from  direct  extension  from  the  lungs.  The  pleural  exudate  may  be 
sero-fibrinous  or  hemorrhagic  or  may  become  purulent.  Finally,  a 
very  common  occurrence  in  pulmonary  tuberculosis  is  the  perforation 
of  a  superficial  spot  of  softening,  with  the  production  of  a  pyo-pneu- 
mothorax. 

In  a  majority  of  cases  the  pleura  is  directly  infected  from  the  lung, 
in  other  instances  from  tuberculous  glands  in  the  mediastinum  or  from 
cold  abscesses  in  the  thoracic  wall.  There  may  be  a  direct  infection 
of  the  lymphatic  system.  A  majority  of  us  inhale  tubercle  bacilli  from 
time  to  time.  Should  any  of  these  escape  the  phagocytes  of  the  bron- 
chial tree  or  of  the  alveoli,  they  pass  through  the  openings  in  the  latter 
and  reach  the  alveolar  stroma.  Those  which  reach  the  most  superficial 
air  cells  may  pass  into  the  wide  subpleural  lymph  spaces.  It  is  stated 
that  there  is  an  intimate  connection  between  these  lymph  spaces  and 
the  pleural  sac,  so  that  it  is  quite  possible  to  conceive  of  a  direct  en- 
trance of  the  bacilli  into  the  pleura.  More  commonly,  however,  the 
disease  spreads  from  a  subpleural  nodule  or  lymph  node  in  which  tubercle 
bacilli  have  overcome  the  tissue  resistance  and  have  set  up  a  local  tuber- 
culous focus.  Hernandez  has  studied  the  subject  of  pleural  infection 
from  tuberculous  foci  in  the  vertebral  or  cervical  lymph  glands.  Owing 
to  the  wide  communication  which  exists  between  the  lymphatics  of  the 
peritoneum  and  those  of  the  diaphragmatic  pleura  and  mediastinum,  it 
is  quite  apparent  that  infection  from  the  peritoneal  cavity  may  readily 
take  place.  In  rare  instances  the  tuberculous  process  may  result  from 
direct  extension  from  tuberculous  disease  of  neighboring  bones. 

Diagnosis. — The  diagnosis  of  tuberculous  pleurisy  often  presents 
great  difficulties.  Neither  the  appearance  of  the  individual,  the  family 
history,  the  mode  of  onset,  the  course,  nor  the  character  of  the  exudate 


TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES  769 

may  in  any  way  be  sutjtror^tivc.  The  groups  of  lymph  glands  conliguous 
to  the  pleura  should  be  thoroughly  examined.  Ke}K'ated  examinations 
of  the  sputum  should  be  made,  as  not  infrequently  doul)tful  eases  are 
eleared  uj)  l)y  the  tindiug  of  bacilli,  which  may  come  from  a  vcrv  small 
focus  of  softeninir  tul)erele  in  connection  with  a  ijronchus.  Althou<xh 
there  is  nothing  })athognomonic  in  the  macroscopical  ap[)carancc  of  the 
exudate,  yet,  as  already  stated,  it  may  present  suggestive  features.  The 
negative  result  on  bacteriological  examination  favors  the  tuberculous 
nature.  The  most  suspicious  instances  are  those  in  which  the  fluid 
constantly  recurs  in  spite  of  repeated  tappings,  and  in  which,  with  ap- 
parent diminution  in  the  amount  of  the  exudate,  the  flatness  persists, 
with  shrinkage  of  the  atfected  side. 

(2)  Tuberculosis  of  the  Pericardium. — On  both  the  epi-  and  peri- 
cardium miliary  tubercles  are  not  infrequently  found  in  cases  of  general 
infection.  Extensive  tuberculous  disease,  causing  great  thickening  of 
the  membranes  or  exudate,  is  much  more  common  than  is  supposed  and 
is  often  overlooked. 

(a)  Acute  Tuben-ulous  Pericarflitis. — This  is  caused  most  commonly 
by  direct  invasion  of  the  membrane  from  a  tuberculous  lymph  gland. 
Less  frequently  it  is  due  to  direct  extension  from  the  lung,  and  it  may 
develop  also  as  a  secondary  infection  from  caseous  masses  in  other  parts. 
While  usually  sero-fibrinous,  the  exudate  is  in  many  cases  hemorrhagic. 
The  tubercles  are  often  small,  and  unless  carefully  sought  for  readily 
overlooked.  The  exudate  may  become  purulent ;  the  membranes  thicken, 
and  the  nature  of  the  trouble  may  not  be  evident  without  microscopical 
examination.  The  purulent  tuberculous  effusion  in  these  cases  may  be 
enormous,  and  the  condition  has  frequently  been  mistaken  for  pleurisy. 
In  a  case  reported  by  Musser  the  pericardial  sac  contained  64  ounces 
of  pus. 

(6)  Chronic  Tuberculous  Pericarditis. — This  may  occur  in  association 
with  caseation  of  the  bronchial  glands  or  more  frequently  of  the  anterior 
mediastinal  lymph  glands.  Other  instances  are  associated  with  tuber- 
culosis of  the  pleura  or  of  the  lung.  Sometimes  the  jjericarditis  is  onlv 
a  part  of  a  general  infection  of  the  serous  membranes.  Occasionallv  it 
is  due  to  extension  of  tuberculous  disease  from  the  sternum  or  from  the 
spine. 

The  disease  is  met  with  at  all  periods  of  life,  and  among  my  cases 
there  was  a  child  of  five  years  and  a  man  of  seventy-two  years  of  age. 
The  layers  of  the  pericardium  are  thickened,  and  present  cheesy  masses 
or  diffuse  infiltrated  tubercle.  The  membranes  are  closely  adherent,  and 
in  the  fibrous  connective  tissue  between  the  thickened  layers  (wliich  has 
often  a  grayish  red  appearance)  there  may  be  miliary  tubercles. 

We  may  recognize  four  groups  of  cases  of  tuberculous  pericarditis : 

First,  those  in  which  the  condition  is  entirely  latent,  and  the  disease 
is  discovered  accidentally  in  individuals  who  have  died  of  other  affec- 
tions or  of  chronic  pulmonary  tuberculosis. 

A  second  group,  in  which  the  symptoms  are  those  of  cardiac  insuf- 
ficiency following  the  dilatation  and  hypertrophy  consequent  upon  a 
chronic  adhesive  pericarditis.  The  symptoms  are  those  of  cardiat; 
dropsy,  and  suggest  either  idiopathic  hypertrophy  and  dilatation,  or,  if 
there  is  a  loud  blowing  systolic  murnuu'  at  the  apex,  mitral  valve  dis- 

VoL.  I.— 49 


770  TUBERCULOSIS. 

ease,  either  insufficiency  or  stenosis.^    The  condition  of  adherent  peri- 
cardium is  usually  overlooked. 

In  a  third  group  the  clinical  picture  is  that  of  an  acute  tuberculosis, 
either  general  or  with  cerebro-spinal  manifestations,  which  has  had  its 
origin  from  the  tuberculous  pericardium  or  tuberculous  mediastinal 
lymph  glands. 

A  fourth  group,  with  symptoms  of  acute  pericarditis,  includes  cases 
in  which  the  aifection  is  acute  and  accompanied  with  more  or  less  exu- 
dation of  a  sero-fibrinous,  hemorrhagic,  or  purulent  character.^  There 
may  be  no  suspicion  whatever  of  the  tuberculous  nature  of  the  trouble. 

Diagnosis. — The  diagnosis  of  tuberculous  pericarditis  is  extremely 
uncertain.  In  the  large  group  of  cases  in  which  the  membranes  are 
thickened  and  united  the  difficulties  are  those  which  pertain  to  the 
recognition  of  adherent  pericardium — difficulties  which  are  enormously 
enhanced  by  the  state  of  cardiac  insufficiency  with  which  these  cases 
usually  come  under  observation  for  the  first  time.  In  children  with  a 
history  of  repeated  attacks  of  rheumatism  the  bulging  prsecordium,  sys- 
tolic retraction  of  the  apex  region,  the  fixation  of  the  upper  limit  of  car- 
diac dulness,  and  the  diastolic  rebound  speak  for  adherent  pericardium ; 
and  if  in  a  case  of  this  sort  there  has  been  no  history  of  rheumatism, 
and  if,  on  the  other  hand,  there  are  indications  elsewhere  of  tuberculosis, 
a  probable  diagnosis  may  be  made.  In  the  cases  which  set  in  as  acute 
pericarditis,  unless  there  are  evidences  of  tuberculosis  in  other  parts,  as, 
for  instance,  in  the  left  pleura  or  in  the  peritoneum,  or  there  are  signs 
of  local  disease  in  the  lung,  and  tubercle  bacilli  have  been  found  in  the 
expectoration,  the  diagnosis  cannot  be  made.  The  effusion  may  be 
equally  as  great  in  tuberculous  as  in  rheumatic  pericarditis.  If  para- 
centesis be  performed,  the  presence  of  a  bloody  exudate  is  decidedly  in 
favor  of  tuberculosis ;  once,  at  least,  tubercle  bacilli  have  been  found 
(Kast).  The  clinical  features  themselves  offer  no  criteria,  though  it 
would  seem  probable  that  in  the  acute  cases  with  sero-fibrinous  exuda- 
tion the  course  is  more  protracted  and  the  fever  more  irregular  than  in 
the  ordinarv  forms  of  pericarditis ;  and  in  such  a  case  the  development 
of  diffuse  signs  in  the  lungs  may  lead  to  a  strong  suspicion  that  the 
process  is  tuberculous. 

(3)  Tuberculosis  of  the  Peritoneum. — Our  knowledge  of  this  affec- 
tion has  been  much  extended  of  late  years,  partly  owing  to  the  care  and 
attention  with  which  the  cases  have  been  studied,  and,  owing  to  the 
facility  with  which  surgeons  and  gynecologists  now  explore  the  abdomi- 
nal cavity  for  obscure  conditions  of  all  sorts,  we  have  learned  a  great 
deal,  not  only  about  the  mode  of  origin  of  the  disease,  but  about  the 
various  phases  of  its  evolution. 

The  disease  occurs  at  all  ages.  It  is  very  common  in  children  in 
association  with  intestinal  and  mesenteric  tuberculosis.  It  may  occur 
in  advanced  life.  I  have  described  a  case  in  a  patient  eighty-two  years 
of  age.     Of  357  cases  which  I  have  collected  from  the  literature,^  there 

^  There  are  cases  of  adherent  pericardium  in  which  a  bruit  is  heard  which  resem- 
bles the  rumbling  presystolic  murmur  (Hale  White). 

^  For  illustrative  cases  of  the  different  clinical  forms  see  American  Journal  of  the 
Medical  Sciences,  January,  1893. 

^  Johns  Hopkins  Hospital  Reports,  vol.  ii. 


TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES  771 

were  under  ten  years,  27  ;  between  ten  and  twenty,  75 ;  from  twenty  to 
thirty,  87;  from  thirty  to  forty,  71  ;  from  forty  to  fifty,  61  ;  from  fifty 
to  sixty,  19  ;  from  sixty  to  seventy,  4;  above  seventy,  2. 

It  is  ocnorally  stated  that  males  arc  more  fr('(|ii('nt]y  attacked  than 
femah's.  In  tlie  recently  collected  statistics  females  predominate,  owing 
to  the  frequency  with  which  laparotomy  has  been  perfoi'med  for  this 
condition.  In  America  it  is  a  more  common  disease  in  the  negro  than 
in  the  Avhite  race. 

The  process  may  be  primary  in  the  peritoneum  and  confined  to  this 
membrane,  which  was  the  case  in  5  of  17  post-mortem  examinations. 
In  a  very  considerable  proportion  of  all  the  cases  the  disease  is  sec- 
ondary to  tuberculosis  of  the  Fallo})ian  tubes ;  in  a  smaller  number  of 
cases  to  affection  of  the  vesiculse  seminales  and  prostate.  Tuberculous 
salpingitis  is  an  extremely  common  disease.  In  ray  colleague  Kelly's 
department  there  were  examined  anatomically,  by  Dr.  Cullen,  12  speci- 
mens during  a  period  of  twenty-seven  months. 

J.  Whitridoe  AVilliams  has  also  shown  that  certain  forms  which  look 
like  ordinary  salpingitis  show  on  microscopical  examination  the  presence 
of  tubercles. 

Another  common  method  of  infection  is  through  the  intestines,  and 
some  of  the  most  severe  cases  are  those  in  which  the  disease  has  followed 
a  primary  tuberculosis  of  the  bowel.  Some  authors  have  insisted 
specially  upon  the  great  frequency  of  infection  from  the  bowel,  though 
it  is  probably  not  of  equal  importance,  in  women  at  least,  to  infection 
from  the  tubes. 

In  another  group  of  cases  the  infection  seems  to  be  through  the 
lymphatics,  and  the  peritoneum  is  involved,  with  the  pleural  and  peri- 
cardial surfaces,  in  a  general  serous  membrane  tuberculosis. 

It  is  interesting  to  note  that  certain  morbid  conditions  of  the  ab- 
dominal organs  predispose  to  the  development  of  the  disease ;  thus 
patients  with  cirrhosis  of  the  liver  very  often  die  of  an  acute  tuberculous 
peritonitis.  The  frequency  with  which  the  condition  is  met  with  in 
operations  upon  ovarian  tumors  has  been  commented  upon  by  gynecolo- 
gists. Many  cases  have  followed  trauma  of  the  abdomen.  A  very 
interesting  feature  is  the  development  of  tuberculosis  in  hernial  sacs. 
The  condition  is  not  very  uncommon.^  In  a  majority  of  the  instances 
the  condition  has  been  found  accidentally  during  the  operation  for  radi- 
cal cure  or  for  strangulation.     In  7  instances  the  sac  alone  was  involved. 

Three  forms  may  be  recognized  : 

(a)  Acute  MUiary  Tuberculosis. — This  form  may  be  latent  or  form 
part  of  a  general  tuberculosis,  and  the  abdominal  symptoms  may  not 
attract  attention,  but  in  other  cases  the  symptoms  from  the  outset  are 
those  of  an  acute  peritonitis.  On  opening  the  cavity  post-mortem  there 
is  usually  a  sero-fibrinous  or  sero-sanguineous  exudate,  rarely  purulent, 
which  may  be  in  large  amount.  The  entire  membrane  is  covered  with 
miliary  granulations  of  various  sorts,  which  are  fresh  and  usually  sur- 
rounded by  zones  of  hypersemia.  In  a  few  of  the  very  acute  cases  the 
process  is  really  ulcerative,  and  there  are,  without  much  exudate,  tuber- 
cles which  have  rapidly  undergone  softening — an  anatomical  condition 
the  counterpart  of  that  which  has  been  described  in  the  pleura  as  acute 

'  See  Brims'  Beiirdge,  Bd.  xi. 


772  TUBERCULOSIS. 

ulcerative  tuberculous  pleurisy.  In  a  few  of  these  cases  tuberculous 
lesions  have  not  been  found  elsewhere,  but  in  a  large  proportion  of  the 
subjects  the  disease  is  secondary.  The  symptoms  of  the  acute  form  are 
very  varied.  The  onset  may  be  so  sudden  that  the  diagnosis  of  enteritis 
or  of  hernia  is  made,  and  in  one  case  an  operation  for  strangulated  her- 
nia was  performed.  More  frequently  the  acute  symptoms  of  the  onset 
lead  to  the  diagnosis  of  a  simple  peritonitis.  The  patient  complains  of 
abdominal  pain ;  there  is  tenderness  on  pressure  and  the  symptoms  of 
ascites  gradually  develop.  In  a  large  group  of  cases  the  onset  is  more 
gradual,  and  the  general  symptoms  overshadow  entirely  the  local  condi- 
tion. The  fever,  slight  abdominal  tenderness,  the  tympanites,  and  the 
chronic  course  and  low  typhoid  state  lead  very  frequently  to  the  diag- 
nosis of  enteric  fever.  In  other  acute  cases  the  disease  sets  in  with  the 
most  persistent  vomiting.  Acute  pleurisy  sometimes  develops.  The 
fever  is  variable.  It  is  usually  a  marked  symptom  in  the  acute  cases, 
in  which  the  temperature  may  reach  103°  or  104°  F.  In  this  form  of  the 
disease  recovery  may  occur,  either  spontaneously  or  after  laparotomy. 

(6)  Chronic  ulcerative  tuberculosis,  perhaps  the  most  common  form 
of  the  disease,  is  characterized  by  the  presence  of  larger  growths,  which 
tend  to  caseate  and  ulcerate  and  which  may  lead  to  jjerforation  of  the 
intestinal  coils.  The  exudate  is  sero-purulent  or  purulent ;  in  other 
instances  it  has  a  slightly  chocolate  color  or  may  have  a  fatty  appear- 
ance. It  is  often  sacculated.  The  abdomen  is  usually  prominent  and 
tender,  and  nodular  masses  can  be  felt.  Adhesions  sometimes  take  place 
about  the  navel,  and  there  is  a  redness  or  a  region  of  infiltration ;  some- 
times there  is  periumbilical  suppuration,  and  a  discharge  of  pus  takes 
place.  The  fever  is  usually  irregular,  and,  when  there  is  much  suppu- 
ration or  encapsulated  pockets  of  pus,  may  have  a  hectic  character. 
Low  temperatures  are  not  so  common  in  this  type  as  in  the  chronic 
fibrous  form.  AValter  Channing  made  a  veiy  interesting  study  of  the 
temperature  in  a  case  of  tuberculosis  of  the  tubes,  with  tuberculous 
pelvic  abscess  and  perforation  into  the  rectum  and  chronic  tuberculosis 
of  the  peritoneum  and  mesenteric  glands.  The  temperature  was 
recorded  for  a  period  of  two  years  and  three  months.  The  total  num- 
ber of  observations  amounted  to  1582  :  409  times  there  was  a  rise 
between  100°  and  102°  ;  87  times  there  was  a  rise  between  102°  and 
105°  ;  twice  105°  and  several  times  104.4°  was  reached.  Ascites  may 
occur  in  this  variety,  but  the  exudate  is  rarely  in  large  amount  and  is 
usually  sero-purulent. 

(c)  Chronic  Fibroid  Tuberculosis. — In  this  variety  the  tubercles  are 
hard  and  sclerotic,  often  surrounded  by  areas  of  pigmentation ;  the 
membranes  are  usually  agglutinated  and  the  omentum  is  puckered  and 
rolled  into  a  firm,  hard  mass.  The  form  is  not  infrequently  found  as  an 
accidental  condition  in  persons  who  have  died  of  other  diseases.  It  is 
in  this  chronic  fibroid  type  that  we  most  frequently  see  deep  pigmenta- 
tion of  the  skin,  which  may  be  so  pronounced  as  to  lead  to  the  diagnosis 
of  Addison's  disease.  The  temperature  may  be  subnormal,  and  for 
weeks  at  a  time  the  morning  temperature  may  not  be  above  96°  or  97°. 
This  form  is  very  frequently  associated  Avith  chronic  fibroid  tuberculosis 
of  one  apex. 

There  are  several  points  about  tuberculous  peritonitis  which  require 


TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES.  773 

special  (•(iiisitlci-atidii.  ( )!'  these  the  most  iiii|>{ii-taiit  is  the  loriiiatioii  (tf 
tunun'-like  bodies.     These  iiuiy  he — 

{(t)  Oiiu'ittd/,  duv  to  })iiekeriii^'  and  i-<)iliiin  ,,|'  thj.,  incmhraiie  until 
it  forms  an  elonuated  linn  mass  attached  to  the  ti'ans\'erse  colon  and 
lyinj;-  athwart  the  ii])j)i'r  ])art  of  tiu;  abdomen.  Tliis  cordlikc  .structure 
is  tbuntl  also  with  cancerous  peritonitis,  but  is  much  more  common  in 
tuberculosis.  (Jairdner  has  called  .s])eeial  attention  to  this  form  of 
tumor,  and  in  children  has  seen  it  undergo  (gradual  resolution.  A  reso- 
nant |)ercussion  note  may  sometimes  be  elicited  above  the  mass.  Thou<^h 
usually  situated  in  the  umbilical  region,  the  omental  mass  may  form  a 
})roniiiient  tumor  in  the  right  iliac  region. 

(6)  S((ccu/((ted  exudation,  in  which  the  effusion  is  limited  and  con- 
fined by  adhesions  between  the  coils,  the  parietal  ])eritoncum,  the  mesen- 
tery, and  the  abdominal  or  pelvic  organs.  This  encysted  exudate  is 
mo.st  connnon  in  the  middle  zone,  and  has  frequently  been  mistaken  for 
ovarian  tumor.  It  may  occupy  the  entire  anterior  portion  of  the  peri- 
toneum, or  there  may  be  a  more  limited  saccular  exudate  on  one  side  or 
the  other.  It  may  lie  completely  within  the  pelvis  proper,  a.ssociated 
with  tuberculous  disease  of  the  Fallopian  tubes. 

(c)  lit  rare  cases  the  tumor  formation  may  be  due  to  great  retraction 
or  thickening  of  the  intestinal  coils.  The  small  intestine  is  found  .short- 
ened, the  walls  enormously  thickened,  and  the  entire  coil  may  form  a 
firm  knot  close  against  the  spine,  giving  on  examination  the  idea  of  a 
solid  mass.  Not  the  small  intestine  only,  but  the  entire  bowel  from 
the  duodenum  to  the  rectum,  has  been  found  forming  such  a  hard  nod- 
idar  tumor. 

(d)  Mesenteric  glands,  which  occasionally  form  very  large,  tumor-like 
masses,  more  commonly  found  in  children  than  in  adults.  This  condi- 
tion may  be  confined  to  the  abdominal  glands.  Ascites  mav  coexist. 
The  condition  must  be  distinguished  from  that  in  children,  in  which, 
with  ascites  or  tympanites — sometimes  both — there  can  be  felt  irregular 
nodular  masses,  due  to  large  caseous  formations  between  the  intestinal 
coils.  Xo  doubt  in  a  considerable  number  of  cases  of  the  so-called  tabes 
mesenterica,  particularly  in  those  with  enlargement  and  hardness  of  the 
abdomen — the  condition  which  the  French  call  carreau — there  is  involve- 
ment also  of  the  peritoneum. 

Another  important  event  in  tuberculous  peritonitis  is  the  occurrence 
of  occlusion  of  the  bowel,  which  may  be  due  either  to  contraction  of 
fibroid  bands  or  to  a  kink  in  the  bowel  caused  by  adhesions.  In  other 
cases  there  has  been  chronic  ulcerative  disease  of  the  mucous  membrane, 
with  secondary  involvement  of  the  peritoneum  and  cicatricial  contrac- 
tion of  some  of  the  ulcers.  It  is  possible,  too,  that  the  great  retraction 
and  thickening  of  the  intestinal  coils  may  lead  to  symptoms  of  obstruc- 
tion, while  in  other  instances  the  acute  tuberculous  peritonitis  mav  cause 
such  infiltration  of  the  muscular  coats  as  to  induce  a  paralytic  distention. 

The  diagnosis  of  tuberculous  peritonitis  is  often  very  easy.  In  other 
cases  it  is  extremely  complicated.  The  only  general  disease  with  which 
it  is  apt  to  be  confounded  is  tyjjhoid  fever.  The  slow  onset,  the  slight 
abdominal  .symptoms,  the  local  tenderness,  and  the  gastric  features 
often  suggest  enteric  fever.  The  gradual  development  of  the  ascites  or 
the  presence  of  nodular  masses  may  be  the  first  .symptom  to  suggest  a 


774  TUBERCULOSIS. 

local  peritonitis.  In  the  ascitic  form  the  diagnosis  may  rest  between  an 
acute  miliary  cancer,  cirrhosis  of  the  liver,  and  a  chronic  simple  peri- 
tonitis— conditions  which  usually  offer  no  special  difficulties  in  difFer- 
entiation.  A  most  important  point  is  the  simultaneous  presence  of  a 
pleurisy.  The  diagnosis  of  the  peritoneal  tumors  in  this  affection  is 
sometimes  very  difficult.  The  omental  tumor  is  a  less  frequent 
source  of  error  than  any  other,  but  a  similar  condition  may  occur 
in  cancer.  The  diagnosis  of  the  saccular  exudate  from  ovarian 
tumor  is  now  made  much  more  frequently  than  a  few  years  ago.  The 
most  suggestive  j)oints  for  consideration  are  the  history  of  the  patient 
and  the  evidence  of  old  tuberculous  lesions.  The  physical  condition  is 
not  of  much  moment,  as  in  many  instances  the  patients  have  been  robust 
and  well  nourished.  Irregular  febrile  attacks,  gastro-intestinal  disturb- 
ance, and  pains  are  more  common  in  tuberculous  disease.  Unless  in- 
flamed, there  is  usually  not  much  fever  with  ovarian  cysts.  The  local 
signs  are  very  deceptive,  and  in  certain  cases  have  conformed  in  every 
particular  to  those  of  cystic  disease.  The  outlines  in  saccular  exudation 
are  rarely  so  well  defined.  The  position  and  form  may  be  variable^ 
owing  to  alterations  in  the  size  of  the  coils  of  which  in  parts  the  walls 
are  composed.  Nodular  cheesy  masses  may  sometimes  be  felt  at  the 
periphery.  Depression  of  the  vaginal  wall  is  mentioned  as  occurring 
in  encysted  peritonitis,  but  it  is  also  found  in  ovarian  tumor.  Lastly, 
the  condition  of  the  Fallopian  tubes,  of  the  lungs,  and  of  the  pleurae 
should  be  thoroughly  examined.  The  association  of  salpingitis  or  epi- 
didymitis with  an  ill  defined  anomalous  mass  in  the  abdomen  should 
arouse  suspicion,  as  should  also  involvement  of  the  pleura  or  the  apex 
of  one  lung. 

(4)  General  Serous  Membrane  Tuberculosis. — There  is  a  group  of 
cases  of  tuberculosis  in  which  the  serous  membranes  are  chiefly  involved, 
either  simultaneously  or  more  commonly  one  after  another,  forming  a 
clinical  type  fairly  distinctive  and  readily  recognized.  There  have  been 
several  interesting  studies  of  this  condition,  notably  the  Paris  Theses 
of  Moran  and  Boulland  in  1884  and  1885  and  the  careful  study  of 
Vierordt.^  The  pleuro-peritoneal  membranes  may  be  alone  involved 
or  the  pleuro-peritoneal  and  pericardial  surfaces.  There  are,  as  noted 
by  Boulland,  three  groups  of  cases  :  First,  an  acute  tuberculosis,  with 
rapid  evolution  of  the  disease  in  pleurae  and  peritoneum,  generally  con- 
secutive to  local  disease  of  the  tubes  in  women,  or  of  the  mediastinal 
or  bronchial  lymph  glands. 

Second,  cases  in  which  the  disease  is  more  chronic  in  its  nature,  with 
exudation  in  both  peritoneum  and  pleurae,  the  formation  of  cheesy 
masses,  and  the  occurrence  of  ulcerative  and  suppurative  processes.  In 
this  group  the  pleural  involvement  is  much  more  commonly  secondary 
to  the  peritoneal,  or  both  may  be  a  sequence  of  pulmonary  tuberculosis. 

And,  third,  there  are  instances  in  which  the  pleuro-peritoneal  affec- 
tion is  still  more  chronic,  the  tubercles  hard  and  fibroid,  both  the  mem- 
branes showing  much  thickening,  often  with  very  little  exudation. 

A  knowledge  of  the  existence  of  this  combined  infection  is  some- 
what important,  as  the  cases  are  often  of  great  obscurity.  More  com- 
monly the  affection  begins  in  the  peritoneum  and  may  be   extremely 

'^  Zeitschrift  fur  kliniiiche  Medicin,  Bd.  xi. 


ACUTE  PNEUMONIC  I'lITHLSIS.  775 

chronic,  ami  tlicn  <;r;uliially  invades  tlic  |)lcnra.  In  other  instances 
there  is  a  snbaeute  plenrisy  and  snl)se((nent  invasion  of  tlie  peritonenni. 
The  eases  often  liave  a  very  protraeti'd  course;  there  are  periods  of 
great   iin[)rovenient  and   there  may  he  little  or  no  fever. 


IV.  TUBERCULOSIS  OF  THE  LUNGS  (PHTHISIS ;  CONSUMPTION). 

I.  Acute  Pneumonic  Phthisis. 

Synonyms. — Tuberculous  infiltration  (Laennec);  Caseous  pneumonia  ; 
Scrofulous  pneumonia  (Virchow). 

Two  main  types  are  recognized — the  pneumonic  and  the  broncho- 
pneumonic.  The  former  is  more  common  in  adults,  the  latter  in  chil- 
dren. The  disease  is  apt  to  attack  persons  who  have  been  debilitated 
by  previous  illness  or  weakened  by  exposure  and  dissipation.  Either 
form  may,  however,  occur  in  persons  in  apparently  good  health. 

Pathology  and  Morbid  Anatomy. — This  acute  form  of  pul- 
monary disease,  also  known  as  pAf/ws?*.?  florida  and  galloping  con- 
sumption, is  essentially  an  aspiration  tuberculosis. 

In  nearly  all  instances  the  disease  is  secondary  to  a  pre-existing 
tuberculous  focus,  most  frequently  in  the  lung  itself,  either  an  apical 
cavity,  often  of  very  small  size  and  usually  communicating  freely  with 
a  bronchus,  or  a  softened  gland  has  ruptured  into  a  neighboring 
bronchus. 

In  the  pneumonic  type  a  whole  lobe,  or  even  a  whole  lung,  is  in- 
volved, while  in  the  broncho-pneumonic  only  lobules  or  collections  of 
lobules  are  affected.  According  to  the  observations  of  Prudden,  this 
varying  distribution  of  the  lesions  would  seem  to  depend  partly  upon 
mechanical  causes  and  partly  upon  the  number  of  tubercle  bacilli  dis- 
tributed from  the  infecting  area,  as  he  was  able  bv  resulatino-  the  dosap-e 
and  the  method  of  distribution  to  produce  experimentally  either  the 
lobar  or  lobular  form.  When  in  his  experiments  relatively  small 
quantities  of  the  bacilli  were  introduced  into  the  lung,  and  care  was 
taken  to  distribute  them  equally  throughout  the  organ,  small  discrete 
areas  of  consolidation  resulted.  When  larger  quantities  of  bacilli,  in 
larger  amounts  of  fluid,  were  introduced,  and  no  great  effort  was  made 
to  bring  about  an  equal  distribution  of  the  suspension,  large  areas  of 
consolidation,  resembling  the  areas  of  pneumonic  tuberculosis  in  man, 
resulted.  According  to  Frankel  and  Troje,  the  morphological  differ- 
ences between  the  so-called  cheesy  pneumonia,  which  is  a  tubercu- 
lous broncho-pneumonia,  and  the  organized  tissue  structures  known  as 
tubercles  is  primarily  due  to  the  fact  that  while  the  tubercles  are  devel- 
oped in  the  interalveolar  structures  of  the  lungs,  to  which  the  bacilli  are 
brought  by  the  blood  or  lymph  vessels,  largely  free  from  intermingled 
poisonous  substances,  the  infection  by  aspiration  is  intra-alveolar,  and 
the  bacilli  are  accompanied  by  greater  or  less  quantities  of  diffusible 
poisonous  material  developed  at  their  original  seat.  Thus,  while  in  the 
vicinity  of  metastatic  tubercles,  miliary  or  otherwise,  the  metabolic  prod- 
ucts of  the  growth  of  the  tubercle  bacillus  gradually  produced  may 
incite  exudation  and  cell  proliferation  beyond  the  limits  of  the  focus  of 


776  TUBERCULOSIS. 

productive  inflammation,  this  is  not,  and  cannot  be,  so  extensive  and 
quickly  developed  as  under  conditions  which  involve  the  sudden  acces- 
sion to  the  air  spaces  of  the  lungs  not  only  of  tubercle  bacilli,  but  of 
greater  or  less  quantities  of  already  elaborated  poison,  as  is  the  case 
in  the  tuberculous  broncho-pneumonia  of  acute  phthisis  incited  by 
aspiration. 

Notwithstanding  this  community  of  causation,  the  types  of  the  dis- 
ease present  certain  differences,  both  clinically  and  pathologically,  that 
deserve  separate  description. 

(o)  The  Pneumonic  Form. — On  removal  of  the  lung  the  portion 
affected  does  not  collapse,  but  is  solid  and  airless.  The  overlying 
pleura  is  usually  covered  by  a  layer  of  exudate,  either  fibrinous  or  case- 
ous, of  varying  thickness.  The  appearances  on  section  vary  consider- 
ably according  as  the  exudative  or  the  tubercle  element  predominates. 
AVhen  the  former  only  is  present,  with  but  slight  formation  of  actual 
tubercle  nodules,  the  gross  appearances  can,  in  the  earlier  stages,  almost 
exactly  resemble  those  seen  in  croupous  pneumonia,  though  a  close 
search  will  almost  invariably  reveal  the  presence  of  miliary  tubercles  in 
the  consolidated  area.  In  other  cases,  when  the  formation  of  actual 
tubercles  is  on  a  par  with  or  exceeds  the  exudative  process,  the  appear- 
ance on  section  is  somewhat  different.  The  cut  surface  does  in  a  man- 
ner resemble  that  seen  in  lobar  pneumonia  in  that  it  is  studded  with 
granulations,  which,  however,  are  larger  and  smoother  than  those  seen 
in  the  disease  mentioned.  On  close  inspection  these  granules  are  seen 
to  be  miliary  tubercles,  and  the  surrounding  lung  may  present  the  ap- 
pearances of  an  ordinary  pneumonia,  or,  more  commonly,  those  associ- 
ated with  desquamative  pneumonia — viz.  a  reddish  gray,  very  translucent 
appearance.  These  appearances  of  desquamative  pneumonia  or  of  ordi- 
nary croupous  pneumonia  may  often  be  combined  in  the  same  lung,  cer- 
tain areas  showing  one  variety,  whilst  the  other  variety  is  seen  in  ad- 
jacent or  distant  areas.  In  the  later  stages  of  the  disease  the  picture 
is  much  more  characteristic  ;  but  the  origin  of  the  process  in  the  nodular 
or  exudative  form  cannot  be  made  out  with  the  naked  eye,  the  subse- 
quent caseation  having  masked  the  original  lesion.  The  appearance  of 
the  cut  surface  at  this  time  has  been  described  as  resembling  Rochfort 
cheese — a  whitish  yellow  background  streaked  with  blackish  lines,  the 
background  representing  the  caseous  material,  the  streakings  the  pig- 
mented bands  of  connective  tissue.  Occasionally  cavities  are  seen  with 
ragged,  necrotic  walls.  These  are  probably,  for  the  most  part,  due  to 
secondary  infection  of  the  tuberculous  tissue  with  pus-producers. 

Various  intermediate  steps  can  be  seen  between  the  early  and  caseous 
stages  as  above  described ;  the  process  is  not,  as  a  rule,  uniform,  so  that 
the  lungs  are  frequently  seen  presenting  a  mixture  of  the  above  appear- 
ances, in  parts  caseous,  in  parts  gelatinous,  and  in  parts  showing  tuber- 
cle  nodules. 

The  bronchi  in  all  these  cases,  particularly  the  smaller  ones,  usually 
show  evidences  of  active  inflammation  in  a  congested  and  thickened 
mucous  membrane  and  purulent  or  muco-purulent  contents. 

The  tubercle  nodules  as  seen  in  these  lungs  differ  in  no  respect  from 
those  seen  elsewdiere  and  previously  described.  The  exudative  phenom- 
ena vary  within  very  wide  limits,  but  the  essential  elements  of  the 


ACUTK  I'SEUMONIC  rimifsis.  717 

exiuhitt'  arc  in  all  casrs  the  saiiu — red  and  white  (polyniiclear  aM<l 
luoiKtniU'lcar)  cdrpiisclcs  ot"  tlic  Moctd,  tlic  hloud  srniiii,  Hhriii,  and  the 
cnitlu'lial  rrW:^  linin«i-  tiic  alveoli.  The  exndate  may  roseinhle  that  seen 
in  er()U])()Us  j)neiiin()nia,  eontaininii'  lar*ri'  nunil)ers  of  red  c()rj)usele.s  or 
hir<:>e  ijiiantities  of  tibrin,  and  in  fact  any  of  the  various  combinations 
of  the  above  described  essential  elements  may  occur.  The  most  typical 
form  of  j)neinnonia,  however,  is  that  first  accnrately  described  by  Laen- 
iiec  as  ii'elatinons  pneumonia — a  form  in  which  the  exndate  consists  of 
an  albuminous  fluid  deri\'ed  from  the  blood  and  i^reater  or  smaller  lunn- 
bers  of  cells  of  an  e})itlielioid  ty])e  originatin*^  from  the  descpiamation 
and  proliferation  of  the  epithelial  lining  of  the  alveoli.  The  appear- 
ances under  the  microscope  in  the  last  stage  are  those  of  large  areas  of 
caseation  surrounded  by  larger  or  smaller  areas,  either  of  one  of  the 
tvpes  of  pneumonia  above  mentioned  or  of  tubercle  formation. 

(b)  The  Broiic/to-pncionoiilr  Tiqh'. — Little  need  be  said  of  this  type, 
which  occurs  more  freipiently  in  children  than  in  adults.  As  has  been 
stated  above,  the  difference  between  this  and  the  preceding  form  is 
merelv  one  of  degree.  Here,  as  in  the  pneumonic,  we  have  the  differ- 
ences in  appearance  according  to  the  stage  of  the  disease  and  according 
as  the  exudative  or  nodular  elements  predominate.  The  sole  difference 
lies  in  the  distribution  of  the  lesions,  which  in  this  class  of  cases  are 
confined  to  limited  areas  of  lung  substance,  generally  in  the  neighbor- 
hood of  small  bronchi. 

In  connection  with  both  these  forms  of  tuberculosis  it  is  necessary  to 
discuss  the  question  of  associated  or  secondary  infections  in  acute  lung 
tuberculosis.  Can  all  the  above  described  changes  be  due  to  the  action 
of  the  tubercle  bacillus  itself  or  are  they  due  to  mixed  infections  ?  The 
careful  observations  of  Frankel  and  Troje  would  seem  to  support  the 
view  of  the  specificity  of  the  tubercle  bacillus,  whilst  the  equally  care- 
ful studies  of  Ortner  appear  to  negative  these  results.  The  recent  re- 
searches of  Prudden  would  seem  to  put  the  matter  beyond  all  ques- 
tion of  doubt.  This  observer  was  able  to  show  in  the  clearest  manner 
that  the  tubercle  bacillus  could  produce  not  only  distinct  tubercle 
nodules,  but  also  the  various  kinds  of  exudative  phenomena,  the  exu- 
dates varying  in  appearance  in  different  cases,  which  phenomena  occurred 
absolutely  without  association  with  other  organisms.  The  fact  that 
these  latter  had  not  subsequently  crept  in  was  shown  by  cultures  at 
the  autopsy  on  the  affected  animal. 

Symptoms. — (a)  Pneumonic  Form. — In  many  cases  the  disease 
sets  in  abruptly  wdth  a  chill,  which  may  follow  an  exposure  to  cold 
or  come  on  in  the  course  of  a  drinking  bout  (Frankel  and  Troje)  ;  in 
others  the  disease  sets  in  more  insidiously.  The  temperature  rises 
quickly,  and  there  are  all  the  initial  sym])toms  of  ordinary  pneumonia — 
pain  in  the  side,  cough,  and  shortness  of  breath.  Usually  by  the  time 
a  physician  sees  the  case  hepatization  is  well  marked,  and  he  discovers 
an  area  of  consolidation  in  a  low^er  lobe  or  in  an  upper  lobe,  with  pos- 
sibly a  friction  murmur  and  loud  tubular  breathing.  The  expectoration 
is  usually  blood-tinged  and  typically  pneumonic.  The  local  disease 
progresses,  and  an  entire  lobe  may  be  involved  or  the  upper  and  middle 
lobe  on  the  right  side.  Occasionally  an  entire  lung  is  invaded  with  greqt 
rapidity.     Xo  doubt  at  this  time  may  be  in  the  mind  of  the  physician 


778  T  UBER  C  UL  OSIS. 

as  to  the  nature  of  the  case,  which  is  regarded  as  one  of  simple  hjbar 
pneumonia.  In  some  instances  the  previous  history  of  the  patient 
affords  warrant  for  a  suspicion  which  is  unheeded  in  the  presence  of 
such  a  characteristic  onset.  The  fever  is  at  first  high  and  persistent^ 
with  but  slight  daily  variations,  but  it  becomes  more  irregular  as  the 
disease  progresses.  The  pulse  is  rapid,  from  120  to  140  beats  per 
minute.  The  respirations  are  much  accelerated  at  first,  but  with  exten- 
sive consolidation  and  high  fever  there  may  be  neither  urgent  dyspnoea 
nor  cyanosis.  Instead  of  the  expected  crisis  on  the  ninth  or  tenth  day, 
the  fever  persists  and  becomes  more  irregular.  The  expectoration 
changes,  is  less  rusty,  and  becomes  muco-purulent  or  purulent  and  of  a 
greenish  color.  There  may  be  no  expectoration  throughout.  In  a  case 
under  my  care  a  few  years  ago,  in  which  the  consolidation  was  uniform 
from  apex  to  base,  there  was  no  expectoration  and  very  little  coughs 
Even  in  the  second  or  third  week  the  physician  comforts  himself  with 
the  thought  that  perhaps  it  is  a  case  of  unresolved  pneumonia,  and  it  is 
not  until  signs  of  cavity-formation  develop  or  until  tubercle  bacilli  or 
elastic  tissue  is  detected  in  the  sputa  that  he  becomes  convinced  of  the 
existence  of  an  acute  pneumonic  phthisis.  A  diagnosis  may  never  be 
reached  intra  vitam,  and  the  case  may  be  sent  to  the  post-mortem  room 
without  the  slightest  suspicion  that  it  is  anything  but  an  instance  of 
protracted  pneumonia.  A  violent  haemoptysis  may  occur  at  any  time 
in  the  course  of  the  disease.  Among  other  points  which  may  be  men- 
tioned are — enlargement  of  the  spleen,  a  diazo  reaction  in  the  urine,  and 
occasional  oedema  of  the  lower  extremities.  There  may  be  active  de- 
lirium or  only  an  apathy  and  dulness  proportional  to  the  extent  of  the  fever. 

The  diagnosis  of  acute  pneumonic  phthisis  offers  many  difficulties. 
The  mode  of  onset  may  be  in  every  respect  identical  with  that  of 
croupous  pneumonia.  A  healthy,  robust-looking  young  Irishman,  a 
cab-driver,  who  had  been  kept  waiting  for  hours  on  a  cold,  blustering 
night,  was  seized  the  next  afternoon  with  a  violent  chill,  and  the  fol- 
lowing day  was  admitted  to  my  wards  at  the  University  Hospital, 
Philadelphia.  He  was  made  the  subject  of  a  clinical  lecture  on  the 
fifth  day,  when  there  was  absent  no  single  feature  in  history,  symptoms, 
or  physical  signs  of  acute  lobar  pneumonia  of  the  right  upper  lobe.  It 
was  not  until  ten  days  later,  when  bacilli  were  found  in  his  expectora- 
tion, that  we  were  made  aware  of  the  true  nature  of  the  case.  I  know 
of  no  criterion  by  which  cases  of  this  kind  can  be  distinguished  in  the 
early  stage. 

The  presence  of  the  greenish,  often  grass-green  sputa,  upon  which 
Traube  laid  much  stress,  is  a  point  of  a  good  deal  of  importance.  By 
far  the  most  valuable  information  is  obtained  by  a  systematic  study  of 
the  expectoration.  The  tubercle  bacilli,  as  a  rule,  are  not  present  at 
first,  and  may  not  be  found  for  a  week  or  ten  days  or  even  later.  They 
may  be  present  early,  and  Friinkel  and  Troje  found  them  in  one  case  in 
which  the  sputa  were  still  pneumonic.  The  examination  for  elastic 
tissue  is  very  important,  as  in  a  majority  of  the  cases  the  caseous  areas 
begin  to  break  early.  Traube  called  attention  to  the  absence  of  breath 
sounds  in  the  consolidated  region,  a  point  which  Herard  and  Cornil  also 
speak  of  as  important,  but  suppression  or  enfeeblement  of  the  breath 
sounds  is  by  no  means  uncommon  in  other  types  of  pneumonia. 


ACUTE  PNEUMONIC  PHTHISIS.  779 

The  course  of  flic  (liscosc  is  very  varial)lc.  In  :i  majority  of  the 
cases  death  occurs  within  six  weeks.  Death  may  l)e  caused  as  early  as 
the  eighth  or  tenth  (l:iy.  Tiiere  are  cases  in  wliich  with  very  severe 
onset  and  rapid  consolidation  of  a  lobe  the  symptoms  subside  within 
three  or  four  weeks,  and  the  condition  passes  into  one  of  chronic 
phthisis,  which  does  not  prove  fatal  for  hve  or  six  months  or  even 
longer. 

(/>)  P>ronc}io-pneuiiionk-  Fonn. — In  adults  the  picture  is  that  of  a 
rapidlv  progressing  y>//^A/.s/N  /for/r/o.  Persons  in  good  health  are  rarely 
attacked,  but  most  frequently  those  who  are  debilitated  from  any  cause 
or  convalescent  from  the  acute  diseases.  Some  of  the  most  rapid  cases 
follow  luemoptysis.  There  may  be  at  the  outset  repeated  chills,  with 
sweats  and  intermittent  pyrexia,  which  may  lead  to  the  diagnosis  of 
malarial  intermittent  fever.  The  temperature  is  high,  the  pulse  rapid, 
and  the  cough  distressing.  The  general  symptoms  may  be  out  of  pro- 
portion to  the  amount  of  local  disease.  The  apices  are  most  commonly 
involved,  and  there  is  at  first  only  slightly  impaired  resonance,  with 
harsh  breathing  and  numerous  fine  rales.  Subsequently,  as  the  areas 
coalesce,  the  resonance  becomes  still  more  defective  and  the  breathing 
may  be  tubular.  In  very  acute  cases  the  fever  may  be  high.  There  is 
early  delirium  and  the  patient  sinks  into  the  so-called  typhoid  state. 
With  the  progress  of  the  local  disease  there  is  rapid  loss  in  weight  and 
strength,  irregular  fever,  sweating,  and  the  sputa  show  numerous  tu- 
bercle bacilli  and  much  elastic  tissue.  The  disease  may  prove  fatal 
within  from  six  to  ten  or  twelve  weeks,  and  a  majority  of  the  cases  of 
galloping  consumption  belong  to  this  type.  There  are  cases  in  which 
for  five  or  six  weeks  the  symptoms  are  of  the  greatest  severity,  and  the 
immediate  prognosis  looks  hopeless,  but  the  fever  subsides,  the  consti- 
tutional symptoms  mitigate,  and  a  case  which  may  have  looked  des- 
perate drags  on  and  eventually  becomes  chronic. 

The  acute  tuberculous  broncho-pneumonia  is  a  very  common  form 
in  children,  and  may  come  ou  spontaneously  or  follow  one  of  the  in- 
fectious diseases.  Clinically,  it  is  very  difficult  to  distinguish  from  the 
simple  form.  The  onset  may  be  acute  in  a  previously  healthy  child  or 
the  disease  follows  measles,  diphtheria,  or  whooping  cough.  The  tem- 
perature rises  rapidly,  the  cough  is  severe,  and  there  may  be  signs  of 
consolidation  with  fine  crepitant  and  subcrepitant  rales  at  one  or  both 
apices.  There  are  no  physical  signs  which  enable  us  to  differentiate  a 
simple  form  of  tuberculous  broncho-pneumonia.  The  localization  is  not 
of  much  value,  since  we  find,  commonly  enough,  in  children  the  tuber- 
culous process  beginning  at  the  base  or  in  the  central  portions  of  the 
lung.  In  the  course  of  the  disease  indications  of  value  develop.  The 
oscillations  in  temperature  are  greater  in  the  tuberculous  cases  ;  sweats 
are  more  common.  The  child  emaciates  rapidly,  and  there  may  be 
local  features  indicating  breaking  down  of  the  lung  tissue.  As  young 
children  rarely  expectorate,  there  is  great  difficulty  in  getting  the  sputa 
for  examination.  Occasionally  they  can  be  obtained  in  the  vomitus, 
and  as  the  sputum  is  swallowed  the  tubercle  bacilli  can  occasionally  be 
determined  in  the  stools.  The  duration  of  the  very  acute  cases  is  from 
three  to  five  weeks.  In  other  instances  the  severity  of  the  symptoms 
mitigates  within  two  or  three  weeks,  but  the  irregular  fever  persists ; 


780  TUBERCULOSIS. 

there  is  loss  of  flesh,  cough,  hectic  fever,  and  sweats.  The  physical 
signs  indicate  softening,  and  there  is  gradually  developed  a  clinical 
picture  of  chronic  pulmonary  tuberculosis. 

n.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs. 

Synonyms. — Phthisis  pulmonum  ;  Consumption  ;  Chronic  phthisis ; 
Chronic  ulcerative  phthisis. 

In  this  form,  which  embraces  by  far  the  largest  number  of  cases  of 
pulmonary  tuberculosis,  the  lesions  proceed  to  caseation  and  ulceration, 
and  there  is  produced  at  last  the  only  too  common  picture  of  pulmonary 
consmnption,  characterized  by  cough,  irregular  fever,  emaciation,  night- 
sweats,  etc.  Though  at  first  a  tuberculous  process,  in  a  majority  of 
cases  the  lungs  become  the  seat  of  mixed  infection,  and  many  of  the 
prominent  symptoms  are  due  to  the  absorption  of  the  toxins  of  various 
organisms  in  purulent  foci  and  cavities. 

Pathological  Anatomy. — (1)  The  Distribution  of  the  Lesions. — 
The  primary  lesion  is,  as  a  rule,  in  one  of  the  upper  lobes,  usually  at  a 
point  a  short  distance  below  the  apices.  The  question  as  to  which 
apex  is  involved  the  most  frequently  has  been  studied  by  various 
authors.  The  statistics  on  the  subject  vary,  some  claiming  that  the 
right,  others  that  the  left,  side  is  most  often  aifected,  while  in  other 
cases  the  two  sides  have  been  equally  involved.  Of  427  successive 
cases  at  the  Johns  Hopkins  Hospital,  the  right  apex  was  involved  in 
172,  the  left  in  130,  and  both  in  111. 

Various  hypotheses  have  been  advanced  to  explain  the  cause  of  this 
peculiarity  of  distribution  of  the  lesions,  but  none  are  entirely  satis- 
factory. The  distribution  cannot  be  explained  on  mechanical  grounds 
alone,  and  in  our  present  knowdedge  of  the  subject  we  feel  obliged  to 
call  in  a  local  weakness  of  the  part  or  a  predisposition,  a  weakness  con- 
sisting perhaps  in  some  preceding  catarrhal  condition.  From  its  original 
seat  near  the  apex  the  tuberculous  process  travels  downward  with  greater 
or  less  rapidity  toward  the  base.  This  process  of  spreading  is  in  the 
great  majority  of  cases  the  result  of  the  aspiration  of  infected  material 
from  already  affected  regions  in  the  upper  part  of  the  lung  into  the 
lower  bronchi.  Associated  with  this  process  there  is  also  a  gradual 
dissemination  of  new  tubercles  from  the  old  centres.  The  colonization, 
radial  in  character,  is  due  to  the  carriage  of  tubercle  by  the  lymph 
streams.  Much  more  rarely  local  extension  may  occur  through  the 
blood  current. 

The  tubercles  of  aspiration  origin  have  their  most  frequent  seat  at 
the  point  where  the  bronchioles  narrow  down  just  at  the  entrance  to  the. 
vestibule  of  the  air  sac ;  they  are  also  found  in  the  walls  of  the  smaller 
and  larger  bronchi.  Tubercles  of  blood  origin  are  generally  evenly 
scattered  throughout  the  lung,  those  of  lymph  origin  occurring  near 
old  foci. 

The  mode  of  extension  has  been  carefully  described  by  Kingston 
Fowler,  who  finds  that  in  its  onward  progress  through  the  lungs  the 
disease  follows,  in  a  majority  of  the  cases,  distinct  routes.  In  the  upper 
lobe  the  primary  lesion  is  not,  as  a  rule,  at  the  extreme  apex,  but  from 
an  inch  to  an  inch  and  a  half  below  the  summit  of  the  lung;  and  nearer 


ClinOXIC   ULCERATIVE  TUBERCULOSIS  OF  THE  LUNGS.       781 

to  the  })()sl('ri()r  and  cxtciiial  borders.  'I'lic  lesion  here  tends  to  spread 
downward,  i)rol)al)lv  iVoni  inhalation  of  the;  virus,  and  this  accounts  for 
the  frequent  circumstance  that  examination  behind,  in  the  supraspinous 
fossa,  will  give  indications  of  disease  before  any  evidences  exist  at  the 
apex  in  front.  Anteriorly,  this  initial  focus  corresponds  to  a  spot  just 
below  the  centre  of  the  clavicle,  and  the  direction  of  extension  in  front 
is  along  the  anterior  aspect  of  the  upper  lobe,  along  a  line  running 
about  an  inch  and  a  half  from  the  inner  ends  of  the  iirst,  second,  and 
third  interspaces.  A  second  less  common  site  of  the  primary  lesion  in 
the  apex  "  corresponds  on  the  chest  wall  with  the  tirst  and  second  inter- 
spaces below  the  outer  third  of  the  clavicle."  The  extension  is  down- 
ward, so  that  the  outer  part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  the 
upper  lobe  on  the  same  side.  In  the  involvement  of  the  lower  lobe  the 
first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall 
to  a  spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the 
greatest  importance  clinically,  as  "in  the  great  majority  of  cases,  when 
the  physical  signs  of  the  disease  at  the  apex  are  sufficiently  definite  to 
allow  of  the  diagnosis  of  phthisis  being  made,  the  lower  lobe  is  already 
affected."  Examination,  therefore,  should  be  made  carefully  of  this 
posterior  apex  in  all  suspicious  cases.  In  this  situation  the  lesion 
spreads  downward  and  laterally  along  the  line  of  the  interlobular  septa 
— a  line  which  is  marked  by  the  vertebral  border  of  the  scapula  when 
the  hand  is  placed  on  the  opposite  scapula  and  the  elbow  raised  above 
the  level  of  the  shoulder.  Once  present  in  an  apex,  the  disease  usually 
extends  in  time  to  the  opposite  upper  lobe,  but  not,  as  a  rule,  until  the 
apex  of  the  lower  lobe  of  the  lung  first  affected  has  been  attacked. 

Lesions  of  the  base  may  be  primary,  though  this  is  rare.  Percy 
Kidd  makes  the  proportion  of  basic  to  apical  phthisis  one  to  five  hun- 
dred, a  smaller  number  than  existed  in  my  series.  In  very  chronic 
cases  there  may  be  arrested  lesions  at  the  apex  and  more  recent  lesions 
at  the  base. 

(2)  The  Lesions  in  Chronic  Ulcerative  Phthisis. — («)  Tubercles. — The 
miliary  tubercle  is  the  essential  element  in  the  early  stages  of  chronic 
ulcerative  phthisis,  the  nodules  at  this  time  being  usually  situated  at  the 
apex  in  connection  with  the  air  cells  and  smaller  bronchi.  As  the  pro- 
cess proceeds  the  nodules  coalesce  and  form  conglomerate  tubercles,  the 
breaking  down  of  which,  with  the  subsequent  further  destruction  of 
tissue,  leads  to  cavity  formation. 

When  the  disease  has  reached  its  chronic  form  the  miliary  tubercles 
present  in  the  lung  are  found,  in  the  great  majority  of  instances,  to  have 
one  of  two  distributions  :  (1)  A  dissemination  due  to  aspiration  of 
tuberculous  material,  the  tubercles  being  situated  in  the  air  cells  or  the 
walls  of  the  smaller  bronchi ;  (2)  the  distribution  due  to  dissemination 
of  tubercle  bacilli  by  the  lymph  current,  the  tubercles  being  scattered 
about  the  old  foci  in  a  radial  manner.  ]Much  more  rarely  there  is  a 
scattered  dissemination  from  infection  here  and  there  of  the  smaller 
vessels,  the  tubercles  then  being  situated  in  the  vessel  walls. 

(6)  Pneumonia. — In  all  cases  of  chronic  phthisis  patches  of  pneu- 
monia are  found  distributed  throuo;h  the  lung.     One  form  is  a   true 


782  TUBERCULOSIS. 

broncho-pneumonia,  having  its  origin  in  the  smaller  bronchi.  The 
exudate  in  these  cases  fills  up  the  bronchus  and  the  surrounding 
air  cells,  and  may  present  varying  appearances.  In  the  beginning 
it  is  in  some  cases  the  ordinary  muco-purulent  exudate,  in  some 
fibrinous  or  fibrino-purulent,  in  others  gelatinous.  Subsequently,  when 
the  exudate  undergoes  (;aseation,  a  cross  section  of  the  aiFected  area 
then  gives  the  typical  appearance  of  caseous  broncho-pneumonia — viz. 
the  bronchus  in  the  centre  of  the  cheesy  material,  surrounded  by  an 
area  of  lung  consolidation,  also  caseous.  The  longitudinal  section  has 
a  somewhat  dendritic  or  foliaceous  appearance.  As  these  areas  soften 
cavities  are  formed  ;  the  breaking  down  is  due  in  most  instances  to  a 
secondary  infection  with  pus  organisms,  though  the  tubercle  bacillus 
itself  is  capable  of  causing  it.  In  other  instances,  particularly  in  very 
chronic  cases,  a  chronic  interstitial  pneumonia  is  set  up  in  the  region 
surrounding  the  caseous  mass,  with  the  result  that  it  may  be  completely 
surrounded  by  a  dense  fibrous  capsule.  Under  these  circumstances  the 
fluid  elements  of  the  cheesy  mass  may  be  absorbed,  and  it  remains  as  a 
firm,  dry,  friable  nodule,  or  it  becomes  the  seat  of  a  deposition  of  lime 
salts,  and  a  hard,  calcareous  mass  results. 

The  second  type  of  pneumonia  is  not  connected  with  the  bronchi, 
but  with  the  tubercle  nodules.  This  pneumonia  may  occur  at  any  stage 
of  the  tuberculous  process,  and  is  often  seen  surrounding  the  very 
youngest  tubercles.  The  exudate  is  sharply  confined  to  the  alveoli  in 
the  immediate  neighborhood  of  the  tubercles,  and  where  these  are 
closely  packed  almost  the  v/hole  of  the  lung  substance  between  them 
may  be  consolidated.  Here,  as  in  the  acute  pneumonic  tuberculosis,  the 
exudate  may  be  of  varying  types,  the  essential  elements  being  the  serum, 
leucocytes,  and  red  corpuscles  of  the  blood,  together  with  fibrin  and  the 
desquamated  and  proliferated  alveolar  epithelium.  The  proportion  of 
these  elements  varies  greatly,  but,  though  the  type  of  exudate  may 
simulate  any  form  of  pneumonic  exudate,  by  far  the  most  common 
variety  in  these  cases  is  the  gelatinous  (described  by  Laennec),  an  exu- 
date containing  often  but  few  cellular  elements,  and  these  mostly  epi- 
thelial in  character.  The  number  of  tubercle  bacilli  found  in  such  an 
exudate  is  very  small  indeed,  and  from  the  arrangement  of  the  pneu- 
monic patches  about  tubercles  and  their  sharp  localization  it  seems 
probable  that  the  exudate  is  due  to  the  products  of  the  tubercle  bacillus, 
and  not  to  the  organism  itself. 

The  exudate  in  this  form  of  pneumonia  may  undergo  caseation  or 
fatty  degeneration,  the  former  much  more  frequently.  The  caseous 
material  presents  the  same  appearance  here  as  elsewhere ;  the  fatty 
degenerated  alveolar  contents  have  a  whitish  or  yellowish  white  opaque 
appearance. 

(c)  Cavities. — Two  kinds  of  cavities  are  found  in  the  lung  in  chronic 
phthisis — the  bronchiectatic  and  the  ulcerative. 

Though  not  necessarily  of  tuberculous  origin,  bronchiectatic  cavities 
are  frequently  met  with,  most  commonly  at  the  apices  of  the  lungs,  for 
the  reason  that  the  tuberculous  process  is  most  common  there.  The 
cavities  are  found  particularly  in  connection  with  the  medium  sized  and 
small  bronchi,  and  vary  in  size  from  a  pea  to  a  hen's  egg ;  pure  bron- 
ochiectatic   cavities,  however,  rarely  reach  the  latter  size.     The  shape 


CHRONIC  ULCERATIVK  TUBERCULOSIS  OF  Till:  LUNGS      783 

varies  eonsideraWly  :  in  soiiu'  iiistaiiccs  a  loiiji;  stretch  of  hi'oiiclms  is 
ditl'usolv  dilated,  eaiisinti"  a  I'lisiibriii  ea\ity  ;  in  other  instances  only  u 
part  ot"  the  bronchial  wall  tiives  way,  eausinti'  a  saceidated  cavity.  In 
another  elass  ot" cases  shar|)ly  delined  dilatations  occur,  takinji'  in  the  whole 
bronchial  circumference  and  causing  a  localized  globular  cavity.  In  all 
the  wall  of  the  cavity  is,  as  the  name  implies,  of  bronchial  origin, 
usuallv  sharply  defined  and  smooth  on  its  inner  surface,  though  the 
granulation  tissue  which  lines  it  may  be  the  seat  of  more  or  less  exten- 
sive ulceration.  In  the  larger  cavities  the  ulcerative  process  genendly 
extends  bevond  the  bronchial  wall  and  involves  the  lung  substance,  and 
we  have  a  combination  of  the  bronchietatic  and  ulcerative  forms  of 
cavities. 

The  ulcerative  cavity  may  occur  in  one  of  two  ways — either  as  the 
result  of  an  extension  of  the  ulcerative  process  from  a  bronchiectatic 
cavitv  into  the  lung,  or  from  the  breaking  down  of  tuberculous  masses 
in  the  lung  irrespective  of  connection  with  bronchi.  In  both  of  these 
cases  it  is  probable  that  the  destructive  process  results  in  most  instances 
from  an  invasion  of  a  tuberculous  lung  by  the  pus  organisms,  particu- 
larly the  streptococcus,  though,  as  the  work  of  Prudden  has  shown,  the 
bacillus  of  tuberculosis  is  capable  itself  of  causing  ulcerative  processes 
of  limited  extent.  The  ulcerative  cavities,  like  the  bronchiectatic,  are 
most  frequently  found  at  the  apices,  though  in  late  stages  of  the  disease 
they  may  be  scattered  through  the  lungs.  They  vary  in  size  from  cav- 
ities the  size  of  a  marble  to  those  involving  a  whole  lobe  or  even  a  whole 
lung,  in  some  instances  only  a  thin  shell  of  a  lung  remaining  outside  of 
the  cavitv.  A  majority  of  these  cavities  communicate  with  bronchi  by 
openings  of  various  sizes  and  having  varying  positions. 

The  appearance  of  the  ulcerative  cavity  differs  in  the  acute  and 
chronic  stages.  The  acute  form,  which  is  seen  in  acute  phthisis,  and  in 
chronic  phthisis  in  those  parts  of  the  lung  in  which  the  disease  is  pro- 
gressing, is  distinguished  from  the  chronic  by  its  lack  of  a  definite  wall, 
and  is  Ijounded  only  by  broken-down  caseous  material  and  necrotic  lung 
tissue.  In  the  caseous  tissue  of  the  fresh  lung  cavity  tubercle  bacilli 
are  often  present  in  enormous  numbers.  As  the  process  of  formation 
of  these  cavities  is  acute,  they  are  the  form  especially  liable  to  rupture 
into  the  pleura  and  cause  pneumothorax. 

The  chronic  form  differs  from  the  acute  in  having  a  definite  wall, 
composed  in  the  main  part  of  dense  fibrous  tissue,  the  result  of  a  chronic 
interstitial  pneumonia  in  the  surrounding  lung.  Inside  this  framework 
is  a  layer  of  granulation  tissue,  which  shades  gradually  into  the  fibrous 
layer,  and  may  contain  tubercles  or  show  caseation  of  its  most  internal 
portion.  At  times  no  definite  tubercles  can  be  made  out,  but  the  tissue 
may  present  the  microscopical  appearances  spoken  of  as  tuberculous 
granulation  tissue,  the  process  consisting  in  a  diffuse  infiltration  with 
epithelioid  cells  and  occasionally  giant  cells.  The  walls  of  such  cavities 
are  generally  extremely  irregular,  being  crossed  by  bands  representing 
resistant  areas  of  dense  fibrous  tissue  or  the  remains  of  bronchi  or 
bloodvessels.  The  cavities  are  often  crossed  from  side  to  side  by  tra- 
beculae  in  which,  as  in  those  of  the  walls,  are  bloodvessels,  many  of 
which  are  obliterated,  either  as  a  result  of  an  endarteritis  or  by  an  atro- 
phy, following  the  destruction  of  the  tissues   which  they  supply.     In 


784  TUBERCULOSIS. 

many  instances,  however,  obliterative  process  does  not  take  place,  and 
the  bloodvessels,  being  more  resistant  to  the  ulcerative  process  than  the 
surrounding  tissue,  remain  exposed,  either  in  the  wall  of  the  cavity  or 
in  one  of  the  bands  crossing  it.  In  these  exposed  vessels,  devoid  of 
their  normal  support,  aneurysms  are  particularly  liable  to  form,  varying 
in  size  from  a  pea  to  a  walnut,  and  their  rupture  in  the  later  stages  of 
the  disease  is  the  most  common  cause  of  profuse  haemoptysis. 

The  extension  of  the  cavities  takes  place  by  the  gradual  ulceration 
of  their  inner  walls,  which  occurs  in  a  patchy  manner,  some  portions  of 
the  wall  being  resistant,  whilst  others,  especially  those  containing  caseous 
tubercles,  are  easily  broken  down. 

The  contents  of  the  cavities  consist  of  broken-down  tissue  (caseous 
material  or  destroyed  lung  tissue)  and  pus  secreted  from  the  lining  wall ; 
more  or  less  blood  may  be  present  from  the  rupture  of  small  vessels. 

In  the  most  chronic  forms  of  tuberculosis,  where  the  reparative  tends 
to  exceed  the  destructive  processes,  cavities  become  surrounded  by  an 
exceedingly  dense  fibrous  Avail  and  a  cessation  of  the  ulcerative  process 
may  occur.  Such  cavities,  termed  quiescent,  have  smooth,  almost  fibrous 
walls,  which  secrete  practically  nothing.  They  may  undergo  contrac- 
tion by  the  shrinking  of  the  outlying  fibi'ous  tissue,  but,  except  in  very 
small  ones,  complete  obliteration  does  not  occur. 

(c?)  Involvement  of  the  Pleura. — The  pleura  is  involved  to  a  greater  or 
less  extent  in  all  cases  of  tuberculosis,  either  in  an  acute  or  chronic 
process.  In  the  acute  form  the  various  types  of  exudate  may  occur, 
the  sero-fibrinous  being  the  most  common.  A  large  number  of  the 
pleural  exudates,  which  are  bacteriologically  sterile,  are  of  a  tuber- 
culous origin.  Purulent  and  hemorrhagic  exudates  are  less  often 
found  ;  in  the  case  of  the  former  the  polynuclear  leucocytes  may  con- 
tain large  numbers  of  tubercle  bacilli.  Definite  tubercles  are  not  neces- 
sarily associated  with  any  of  these  processes,  though  in  the  great  major- 
ity of  instances  they  will  be  found  if  carefully  looked  for.  Here,  as  in 
other  forms  of  pleurisy,  complete  return  of  the  pleura  to  normal  does 
not  take  place.  In  many  instances  partial  or  entire  obliteration  of  the 
pleural  sac  occurs  from  the  adhesions  and  subsequent  organization  of  the 
exudate  :  in  other  cases,  particularly  in  connection  with  the  more  acute 
forms  of  phthisis,  the  exudate  undergoes  extensive  caseous  changes.  The 
pleurisy  is  quite  commonly  secondary  to  a  pneumothorax. 

The  chronic  forms  of  pleurisy  are,  as  a  rule,  more  sharply  localized 
than  the  acute,  though  they  often  spread,  coincident  Avith  the  spread  of 
lung  involvement.  They  almost  invariably  result  in  adhesions  between 
the  tAvo  layers  of  exudate,  which  subsequently  undergo  organization  and 
may  become  extremely  dense  and  firm. 

(e)  Changes  in  the  Bronchi. — The  larger  bronchi  are  generally  the 
seat  of  inflammation,  acute  or  chronic  in  character  and  due  to  organisms 
other  than  the  tubercle  bacillus.  Besides  these  non-specific  lesions, 
tuberculous  lesions  occur,  either  in  the  form  of  tubercles  in  the  mucous 
membrane  or  of  ulcerations  varying  from  small  superficial  losses  of 
substance  to  large  serpiginous  ulcerations,  invohnng  at  times  all  the 
coats  and  leading  to  dilatation  of  the  bronchus.  The  medium-sized 
bronchi  are  also  subject  to  both  nodular  and  ulceratiA'c  processes.  As 
has  been  previously  mentioned,  the  smaller  bronchi  are  the  starting  point 


CHROyiC  VLCERATIVK  rrilERCULOSIS  OF  THE  Luxas.      7<So 

in  most  cases  of  lung  tuberculosis,  and  show  various  lesions  due  to  the 
action  ol'  the  tubercle  bacillus,  most  of  which  have  been  already  de- 
scril)ed.  Besides  these  specific  lesions,  they  may  be  the  seat,  especially 
in  children,  of  iuHanimation  due  to  secondary  invasion,  most  frcciueiitly 
bv  the  uiicrococcus  lanceolatus,  with  the  [)r<)duction  of  a  broncho- 
pneuuionia. 

( /')  Lcxlons  iit  the  Bronchia/  Ulniiilf<. — The  lyni})!!  glands  are  involved 
in  almost  all  cases  of  pulmonary  tuberculosis.  In  some  instances  only 
one  or  two  glands  show  signs  of  the  disease,  and  in  others,  particularly 
in  children,  the  whole  of  the  bronchial  grouj)  may  be  converted  into  a 
dense  caseous  mass  which  extends  deep  into  the  roots  of  the  lungs.  In 
the  adult  the  process  is  usually  less  extensive,  beginning  with  a  few 
tubercles  in  the  gland  :  caseation  follows,  and  in  a  large  number  (jf 
instances  calcification  subsequently  occurs.  Secondary  changes  are  not 
very  common,  but  infection  with  the  pus  organisms  may  be  followed  by 
abscess,  which  may  Ijreak  into  a  bronchus,  the  })leura,  the  trachea,  the 
oesophagus,  or  even  into  the  blood  current. 

((/)  Changes  in  Other  Orrjanx. — The  changes  occurring  in  other  organs 
secondary  to  pulmonary  tuberculosis  may  be  due  to — {«)  direct  exten- 
sion of  the  disease  process;  (6)  dissemination  by  the  blood  or  lymph 
currents  of  the  tubercle  bacillus  or  secondary  invading  organisms ;  (c) 
dissemination  of  tuberculous  products  by  the  alimentary  canal ;  (d)  dis- 
semination of  toxins. 

The  changes  due  to  the  direct  extension  of  the  disease  are  seen  par- 
ticularly in  the  respiratory  tract,  in  the  bronchi,  as  mentioned  above, 
and  in  the  trachea  and  larynx,  all  of  which  may  show  tuberculous 
lesions,  either  in  the  form  of  tubercles  or  of  ulcerative  processes.  Under 
this  head  would  come  also  certain  cases  of  tuberculous  pericarditis,  the 
extension  taking  place  by  way  of  the  pleura.  A  certain  number  of 
tubercle  bacilli  no  doubt  reach  the  circulation  in  every  case  of  lung 
tuberculosis :  they  originate  in  the  various  organs  the  scattered  tuber- 
culous foci  w^hich  are  seen  at  every  autopsy  on  cases  of  lung  tuberculo- 
sis. The  endocarditis  associated  with  lung  tuberculosis  is  also  due  to 
blood  infection,  and  may  be  caused  l)y  the  tubercle  bacillus  alone  or  the 
secondary  invaders,  or  mav  be  a  mixed  infection. 

The  sputa  are  responsible  for  the  lesions  of  the  Ijuccal  tract,  and 
when  swallowed  may  cause  lesions  in  the  oesophagus,  stomach,  and 
intestine. 

The  amyloid  degeneration  of  certain  organs,  and  perhaps  also  the 
peculiar  bone  changes  occasionally  seen,  are  probably  due  to  the  absorp- 
tion of  toxins,  but  whether  derived  from  the  tubercle  bacilli  themselves 
or  from  secondary  invaders  must  remain  a  matter  of  conjecture. 

The  importance  of  secondary  infections  in  tuberculosis  is  apparent 
when  we  consider  what  a  large  percentage  of  patients  show  at  autopsy 
general  infection  with  the  pus  organisms. 

Symptoms. — Modes  of  Onset. — Xo  one  of  the  protean  features  r)f 
pulmonary  tuberculosis  is  more  striking  than  the  diverse  Avays  in  which 
the  disease  may  begin.  Among  the  more  important  of  these  are  the 
following : 

{a)  There  is  a  small  but  important  group  of  cases  in  which  the  dis- 
ease makes  considerable  progress  before  there  are  serious  symptoms  to 

A'oL.  I.— 50 


786  TUBERCULOSIS. 

arouse  the  attention  of  the  patient.  This  latent  form  of  the  disease  is 
seen  most  frequently  in  workingmen,  and  the  disease  may  even  advance 
to  excavation  of  an  apex  before  they  seek  advice.  In  some  of  these 
cases  it  is  not  a  little  remarkable  how  slight  the  lung  symptoms  have 
been. 

A  different  type  of  latent  pulmonary  tuberculosis  is  the  form  in 
which  the  symptoms  are  masked  by  the  existence  of  serious  disease  in 
other  organs,  as  in  the  peritoneum,  intestines,  or  bones. 

(6)  With  Symptonis  of  Dyspepsia  and  Ancemia. — The  gastric  mode 
of  onset  is  very  common,  and  the  early  manifestations  may  be  great 
irrital)ility  of  the  stomach  with  vomiting  or  a  type  of  acid  dyspepsia 
with  eructations.  In  young  girls  (and  in  children)  ^^dth  this  dyspepsia 
there  is  very  frequently  a  pronounced  chloro-ansemia,  and  the  patient 
complains  of  palpitation  of  the  heart,  increasing  weakness,  slight  after- 
noon fever,  and  amenorrhoea. 

(c)  In  a  considerable  number  of  cases  the  onset  of  pulmonary'  tuber- 
culosis i's  with  symptoms  which  suggest  malarial  fever.  The  patient 
has  repeated  paroxysms  of  chills,  fevers,  and  sweats,  which  may  recur 
with  great  regularity.  In  districts  in  which  intermittents  prevail  there 
is  no  more  common  mistake  than  to  confound  the  initial  rigors  of  pul- 
monary tuberculosis  with  malaria. 

(d)  Onset  with  Pleurisy. — The  first  symptoms  may  be  a  dry  pleurisy 
over  an  apex,  with  persistent  friction  murmur.  In  other  instances  the 
pulmonary  symptoms  have  followed  an  attack  of  pleurisy  with  effusion. 
The  exudate  gradually  disappears,  but  the  cough  persists  and  the  patient 
becomes  feverish,  and  gradually  signs  of  disease  at  one  apex  become 
manifest.  Of  90  cases  of  pleurisy  with  effusion,  the  history  of  which 
was  followed  by  H.  I.  Bowditch,  one-third  developed  jDulmonary  tuber- 
culosis. 

(e)  With  Laryngeal  Sympjtoms. — The  primary  localization  may  be  in 
the  larynx,  though  in  a  majority  of  the  instances  in  which  huskiness 
and  laryngeal  symptoms  are  the  first  noticeable  features  of  the  disease 
there  are  doubtless  foci  already  existing  in  the  lung.  The  group  of 
cases  in  which  for  many  months  throat  and  larynx  symptoms  precede 
the  graver  manifestations  of  pulmonary  phthisis  is  a  very  important  one. 

(/)  Onset  with  Hcemoptysis. — Frequently  the  very  first  symptom  of 
the  disease  is  a  brisk  hemorrhage  from  the  lungs,  following  which  the 
pulmonary  symptoms  may  develop  with  great  rapidity.  In  other  cases 
the  hsemoptysis  recurs,  and  it  may  be  months  before  the  symptoms 
become  well  established.  In  a  raajority  of  these  cases  the  local  tuber- 
culous lesion  exists  at  the  date  of  the  haemoptysis. 

(g)  With  Tuberculosis  of  the  Cervico-axillary  Glands. — Preceding  the 
onset  of  pulmonary  phthisis  for  months,  or  even  for  years,  the  lymph 
glands  of  the  neck  or  of  the  neck  and  axilla  of  one  side  may  be  enlarged. 
These  cases  are  by  no  means  infrequent,  and  they  are  of  importance 
because  of  the  latency  of  the  pulmonary  lesions.  Nowadays,  when 
operative  interference  is  so  common,  it  is  well  to  bear  in  mind  that  in 
such  patients  the  corresponding  apex  of  the  lung  may  be  extensively 
involved. 

(h)  And,  lastly,  in  by  far  the  largest  number  of  all  cases  the  onset 
is  with  a  bronchitis  or,  as  the  patient  expresses  it,  a  neglected  cold. 


CHRONIC  ULCERATIVE  TUBERCULOSIS  OF  THE  LUNGS.       787 

There  has  l)eeii,  perhaps,  a  Hahility  to  eatch  cdM  easily  oi'  tlie  jtalient 
has  been  suhjeet  to  iiaso-pharvii^'eal  catarrh  ;  then,  lolh)win<;'  some 
nnusnal  exposure,  a  bronchial  couiih  (h'\'eht|)s,  which  may  be  f'recpient 
and  very  irritating-.  Tlie  examination  of"  tlie  bMit;s  may  reveal  localized 
moist  sounds  at  one  apex  and  perhaps  wheezing  bronchitic  nlles  in  other 
parts.  In  a  few  cases  the  early  synij)tonis  are  often  suggestive  of  asthma 
with  marked  wheezing  and  diffuse  pi])ing  nllcs. 

The  older  writers  divided  the  stages  of  pulmonary  tuberculosis  into 
plithisiK  iiicij)ic)is,  plifhisis  conjiniiata,  and  j)}if/iisl.s  dcspcrafn,  corre- 
sponding to  the  stages  (of  modern  authors)  of  the  growth  and  develoj)- 
ment  of  the  tubercles,  their  softening,  and  finally  the  formation  of  cav- 
ities. While  in  a  way  useful  in  discussing  the  symptomatology  of  the 
disease,  it  is  perhaps  better  to  discard  these  stages,  which  arc,  after  all, 
more  or  less  arbitrary,  and  speak  of  the  symptoms  in  detail. 

Local  Si/inptoii)x. — Of  these  cough,  shortness  of  breath,  expectora- 
tion, haemoptysis,  and  pain  in  the  side  are  the  most  prominent. 

Cough. — In  a  few  instances  this  important  symptom  may  scarcely 
attract  the  attention  of  the  patient  or  of  the  friends.  In  a  majority  of 
all  cases  it  is  present  from  the  onset  to  the  close.  In  the  early  stages  it 
is  short,  dry,  and  hacking,  without  any  paroxysmal  quality.  It  may  be 
verv  worrving  shortly  after  the  patient  goes  to  bed  and  in  the  early 
hours  of  the  morning.  It  is  a  cough  of  irritation,  accompanied  Avith 
only  a  small  amount  of  expectoration.  A  very  distressing  form  of  the 
cough  in  the  early  stages  is  that  wdiich  is  aggravated  or  brought  on  by 
eating,  and  which  is  apt  to  be  followed  by  vomiting.  This  is  sometimes 
called  Morton's  cough.'  It  is  occasionally  a  very  distressing  feature, 
and  the  patient  may  become  emaciated  in  consequence  of  failure  to 
retain  sufficient  nourishment.  In  children  the  cough  may  be  paroxys- 
mal, particularly  w'hen  the  tracheal  and  bronchial  glands  are  greatly 
enlarged. 

As  the  disease  progresses  to  the  stage  of  softening  the  cough  is  less 
irritating  and  is  easier,  being  accompanied  with  more  expectoration. 
While  it  occurs  throughout  the  day,  the  early  morning  is  still  the  time 
at  wdiich  it  is  most  marked.  Sometimes  with  the  rise  of  fever  toward 
evening  it  becomes  aggravated.  In  the  later  stages,  when  cavities 
have  formed,  the  cough  is  more  paroxysmal,  violent,  and  painful. 
This  is  not,  how-ever,  always  the  case,  and  in  very  many  patients  with 
large  excavations  the  cough  is  easy  and  the  expectoration  brought  up 
without  much  difficulty.  At  this  stage  position  frequently  has  a  very 
great  influence  on  the  cough,  which  may  be  aggravated  when  the 
patient  lies  on  the  affected  side. 

Cough  is  a  feature  of  pulmonary  tuberculosis  singularly  variable  in 
its  intensity.  Highstrung  nervous  subjects  are  apt  to  be  greatly 
troubled  in  all  stages.  The  nervous  element  must  always  be  taken  into 
account,  and,  making  use  of  this,  Brehmer  urges  upon  his  patients  most 
insistently  the  importance  of  not  coughing.^ 

^  "  Tussi  phtliisicae  sicuti  fere  semper  inappentia,  et  sitis  accedunt,  ita  etiiim  post 
cibum  vomitio  fere  supervenire  solet ;  aden  uti  aeger  a  pasta  oontiniio  fere  tussire  soleat, 
donee  cibus  tandem  vomitione  fuerit  rejectus"  ( Phthisinlof/ia,  London,  1689,  p.  101). 

-  In  one  of  the  most  celebrated  of  the  Bejceted  Addresses  occurs  the  line,  '"And 
awed  consumption  checks  his  chided  couali,"  which  would  appear  to  indicate  that  the 
practice  of  Brehmer  had  some  warrant  in  popular  opinion. 


788  TUBERCULOSIS. 

The  laryngeal  complications  give  a  peculiarly  husky  quality  to  the 
cough,  and  when  erosion  and  ulceration  have  proceeded  far  in  the  vocal 
cords  the  eiForts  of  coughing  are  much  less  effective. 

Expectoration. — In  the  early  stages,  when  the  cough  is  dry,  there 
may  be  no  sputum,  and  not  infrequently  in  a  suspected  case  it  is  dif- 
ficult to  get  sufficient  for  examination.  Often,  however,  with  a  morning 
cough  a  little  mucoid  or  muco-purulent  matter  is  brought  up.  It  may 
be  more  distinctly  catarrhal,  and  consist  of  a  thin,  sometimes  watery 
mucus,  frothy  and  streaked  in  places  with  yellowish,  opaque  fragments. 
A  not  uncommon  form  in  the  early  stage  is  the  tenacious,  gelatinous- 
looking  sputum  resembling  boiled  sago,  and  which  on  microscopical 
examination  is  found  to  be  made  up  largely  of  desquamated  cells  of  the 
alveolar  epithelium  containing  myelin  droplets  and  carbon  grains. 
There  is  no  distinctive  character  in  this  variety,  which  is  met  with  in 
perfectly  healthy  individuals  with  slight  bronchitic  cough.  In  examin- 
ing the  sputum  it  should  be  spread  on  glass  and  the  opaque  yellow  and 
greenish  yellow,  sharply  defined  streaks  should  be  picked  out  to  stain 
for  bacilli  and  to  examine  for  elastic  tissue.  As  softening  proceeds  the 
sputa  become  more  uniformly  purulent,  less  mucoid,  and  frothy.  The 
mucoid  and  puriform  and  glairy  viscid  varieties  may  occur  together, 
though  more  commonly  as  the  disease  progresses  the  sputa  become 
more  and  more  purulent.  Finally,  in  the  stage  of  cavity  formation 
there  are  expectorated  rounded,  flattened,  greenish  gray  masses,  which 
lie  separated  from  each  other  in  the  spit-cup  or  at  the  bottom  of  the 
vessel,  and  which  from  their  flattened,  rounded  form  have  been  termed 
nummular  sputa.  When  the  expectoration  is  collected  in  a  deep  vessel 
these  rounded  masses  tend  to  sink  to  the  bottom.  The  older  writers 
believed  these  sputa  glohosa  fundum  petentia  to  be  a  sure  sign  of  the 
existence  of  cavities.  In  a  typical  form  they  certainly  are  most  sug- 
gestive, and  are  rarely  seen  except  when  vomicae  are  present.  The 
color  may  be  either  of  a  greenish  gray  or  of  an  ashy  gray ;  the  odor  is 
often  heavy  and  stale,  rarely  sweetish  or  fetid,  except  when  the  bronchi 
are  dilated.  In  some  instances,  when  the  lung  is  rapidly  breaking 
down,  the  sputa  may  be  very  copious  and  contain  fragments  of  cheesy 
matter.  What  is  called  the  sputum  of  Bayle  is,  I  should  think  from 
his  description,  the  form  I  have  spoken  of  as  resembling  boiled  sago  or 
boiled  rice.  His  original  description  is  as  follows  :  "  Lors  meme  que  la 
phthisic  a  debute  par  une  toux  seche,  au  bout  d'un  certain  temps  il 
survient  une  expectoration  muqueuse,  dans  laquelle  on  voit  tantot  des 
filets  blancs  opaques,  tantot  de  petitis  grumeaux  semblables  a  du  riz 
bien  cuit,  et  quelquefois  des  filets  de  sang."  ^  He  is  speaking  of  the 
early  stages  of  phthisis,  in  which  this  variety  is  most  common.  I 
quote  here  Wilson  Fox's  remarks  on  this  subject,  as  there  has  been 
some  confusion  about  the  precise  character  of  Bayle's  sputa :  "  Under 
this  name  are,  however,  included  elements  of  the  sputa  having  differ- 
ent origins.  One,  which  is  more  common  in  the  mucoid  forms  of  ex- 
pectoration, consists  merely  of  small  tenacious  masses  of  secretion  pro- 
ceeding from  the  follicles  of  the  throat,  trachea,  and  bronchi,  and  also, 
I  believe,  in  some  instances  from  the  ultimate  air  vesicles.  They  are 
composed  of  mucous  and  pyoid  cells  imbedded  in  a  dense  material  of 

^  BecJierches  sur  la  Phthisie  pulmonaire,  G.  L.  Bayle,  1810,  pp.  24  and  25. 


CHRONIC   ULCI'.ltA'riVK    IT llEl'jriJtSIS   OF   THE  LUXCS.       7S0 

secretion.  Uiulcr  tlic  same  ii.iiuc  :ii-c  iiicliidcd  siiiall  l)ut  mure  opacjuc 
bodies,  seldom  ex(!eediiio;  a  ]>o|)|»y  or  millet  seed  in  size,  but  with  ra«i<;-ed 
edges  and  angular  shapi',  wliirli  are  necrotizing  fragments  of  pulmonary 
tissue  sej)arated  during  the  process  of  excavation.  I  have  found  these 
identical  in  structure  in  one  case  with  the  small  masses  often  loosely 
attached  to  the  interior  of  cavities,  consisting  of  i-apidiv  degenerating  cells 
and  nuclei,  and  having  precisely  the  same  apj)earances  as  are  found  in 
caseous  tubercle."  Andral  states  that  this  form  of  sputa  was  noted  by 
Hippocrates,  who  compared  them  with  grains  of  hail.  Occasionally  in 
cases  of  very  rapidly  softening  tuberculosis  quite  coarse  fragments  of 
the  necrotic  lung  tissue  may  be  expectorated.  Fil)riuous  casts  of  the 
bronchial  tubes  are  occasionally  expectorated  in  pulmonary  tuberculosis. 

Jficroscopieal  Examination. — The  chief  jwrtion  of  the  muco-puru- 
lent  sputum  of  pubnonary  tuberculosis  is  made  up  of  pus  cells.  E})ithe- 
lial  cells  from  the  mouth  and  pharynx  and  trachea  and  bronchi  are  also 
present  in  vai'ying  numbers. 

Alveolar  epithelial  cells  are  present  in  numbers  in  the  early  stages  of 
the  disease,  and  their  siguiiicance  has  been  much  discussed.  The  lumps 
of  gelatinous-looking  sputa  which  Bayle  compared  to  boiled  rice  are 
composed  almost  entirely  of  these  swollen,  rounded  cells,  containing 
myelin,  often  carbon  grains  and  fragments  of  dust.  They  were  thought 
by  Buhl  to  be  distinctive  of  desquamative  pneumonia,  but  they  may 
occur  in  large  numbers  in  simple  bronchitis,  and  are  quite  common  even 
in  the  morning  expectoration  of  perfectly  healthy  individuals.  I  do  not 
think  their  presence  is  of  any  significance  whatever  in  tuberculosis. 

E/axfic  Tissue. — The  presence  of  elastic  fibres  in  the  sputum  is  an 
indication  of  destruction  of  tissue  in  the  air  passages  or  lungs.  It  is 
found  in  gangrene,  abscess,  and  in  all  cases  of  tuberculosis  with  soften- 
ing. For  the  purpose  of  examination  it  is  unnecessary  to  resort  to  the 
tedious  method  of  boiling  the  sputum  with  caustic  potash.  I  have  used 
for  many  years  the  following  plan,  which  was  shown  to  me  at  the  Lon- 
don Hospital  by  Sir  Andrew  Clark.  The  method  depends  upon  the  fact 
that  if  the  sputum  be  spread  in  a  sufficiently  thin  layer  fragments  of  the 
elastic  tissue  can  be  readily  seen  with  the  naked  eye.  The  thicker,  puru- 
lent portions  are  placed  upon  a  glass  plate  15  by  15  cm.,  and  flattened 
by  a  second  glass  plate  10  by  10  cm.  In  this  compressed  grayish  layer 
of  sputum  any  fragment  of  elastic  tissue  shows  at  once  as  a  grayish  yel- 
low spot,  and  can  be  examined  at  once  under  a  low  power,  or  the  upper- 
most glass  is  slid  along  until  the  fragment  is  exposed,  when  it  is  picked 
out  and  placed  upon  the  ordinary  microscopic  slide.  Fragments  of 
bread,  collections  of  milk  globules,  portions  of  epithelium  of  the  tongue 
infiltrated  Avith  micrococci,  also  show  opaquely  against  a  black  back- 
ground, but  with  a  little  practice  they  can  readily  be  distinguished. 
Every  portion  of  elastic  tissue  in  the  sputum,  even  \vhen  quite  small, 
can  be  readily  picked  out  in  this  Avay.  The  elastic  tissue  from  the  lungs 
is  very  characteristic.  The  arrangement  of  the  fibres  is  such  that  they 
show  the  outlines  of  the  air  cells.  Elastic  tissue  from  the  bronchial 
wall  forms  an  elongated  network  or  two  or  three  long  narrow  fibres  may 
be  seen  close  together.  From  the  bloodvessels  a  somewhat  similar 
arrangement  of  elastic  tissue  may  be  seen,  or  occasionally  a  fenestrated 
membrane  which  looks  as  if  it  had  come  from  the  intima  of  a  o^ood-sized 


790  TUBERCULOSIS. 

artery.  Elastic  tissue  is  present  in  every  instance  of  pulmonary  tuber- 
culosis with  destruction.  It  may  be  found,  too,  very  early  in  the  disease, 
before  the  local  signs  of  softening  are  at  all  marked. 

Tubercle  Bacilli. — The  presence  of  the  bacillus  tuberculosis  in  the 
sputum  has  enabled  us  to  make  the  diagnosis  of  the  disease  at  a  much 
earlier  period  than  formerly,  and  with  an  absolute  certainty,  even  before 
the  physical  signs  are  in  any  way  distinctive.  While  the  bacilli  may  be 
present  in  sputum  which  looks  entirely  glairy  and  mucoid,  they  are  more 
likely  to  be  found  in  the  grayish  yellow  streaks  of  purulent  sputum, 
which  should  be  picked  out  for  the  purpose  of  examination.  They  may 
be  found  sometimes  in  the  expectoration  in  a  case  of  fresh  haemoptysis 
in  a  person  who  has  had  no  suspicion  whatever  of  tuberculous  disease. 
The  method  has  already  been  given  for  demonstrating  the  bacilli  in 
sputa  (p.  734). 

The  number  of  bacilli  varies  in  different  cases.  Usually  when  soft- 
ening is  progressing  rapidly  they  are  very  abundant,  and  they  occur  in 
large  numbers  also  in  the  nummular  sputa  of  old  cavities. 

On  the  other  hand,  there  are  patients  who  present  all  the  local  and 
general  features  of  pulmonary  tuberculosis,  yet  in  whose  sputa  bacilli 
cannot  be  demonstrated  for  weeks  or  even  for  months.  In  other  cases, 
again,  with  quite  pronounced  lesions  for  long  periods,  the  bacilli  in 
the  sputa  are  very  scanty.  Indeed,  there  are  cases  on  record  in  which 
the  bacillary  nature  of  the  lung  lesion  has  only  been  determined  post- 
mortem. 

Other  forms  of  micro-organisms  are  frequently  present  in  the  sputum 
in  pulmonary  tuberculosis — the  staphylococci,  streptococci,  the  pneumo- 
coccus,  the  bacillus  pyocyaneus,  and  the  proteus.  In  long  standing  cases 
with  cavity  there  may  be  aspergilli,  sarcinse,  the  leptothrix,  and  the 
oidium  albicans. 

Calcareous  fragments  may  be  coughed  up  in  chronic  pulmonary  tuber- 
culosis. Formerly  a  good  deal  of  stress  was  laid  upon  their  presence, 
and  Morton  described  a  phthisis,  a  calcidis  in  pulmonibus  generatis. 
Bayle  also  described  a  separate  form  of  j^hthisie  calculeuse.  The  size  of 
the  fragments  varies  from  a  small  pea  to  a  large  cherry.  As  a  rule,  a 
single  one  is  coughed  up ;  sometimes  large  numbers  are  coughed  up  in 
the  course  of  the  disease.  Usually  they  are  not  associated  with  any 
special  symptoms,  though  there  are  cases  in  w^hich  hsemoptysis  has 
occurred.  They  are  formed  in  the  lung  by  the  calcification  of  caseous 
masses,  and  it  is  said  also  occasionally  in  obstructed  bronchi.  They 
may  come  from  the  bronchial  glands  by  ulceration  into  the  bronchi, 
and  there  is  a  case  on  record  of  suifocation  in  a  child  from  this  cause. 

Hcemoptysis. — One  of  the  most  famous  of  the  Hippocratic  axioms 
says,  "  From  a  spitting  of  blood  there  is  a  spitting  of  pus."  A  large 
majority  of  the  older  writers  on  the  subject  thought  that  the  phthisis 
was  directly  due  to  the  inflammatory  or  putrefactive  changes  caused 
by  the  hemorrhage  into  the  lung.  Morton  in  his  interesting  section, 
Phthisis  ah  Hcmnoptoe,  rather  doubted  this  sequence.  Laennec  and 
Louis,  and  later  in  the  century  Traube,  regarded  the  haemoptysis  as  an 
evidence  of  existing  disease  of  the  lung.  Desault,  indeed,  as  far  back 
as  1783  had  said  that  instead  of  the  term. phthisis  ab  hcemoptoe  the  state- 
ment should  be  haemoptysis  from  phthisis  (Wilson  Fox).     From  the 


CHRONIC   UlJ'F.nATIVE   TrilElU'ULOSIS  OF  THE  LUXOS.       791 

:U'('iii-;itr  xicws  of"  Laciiiicc  niid  Louis  the  |)ro(rssioii  wms  led  ;i\\;iv  Wv 
Graves,  and  partii'ularly  Wy  Xicincyer,  wiio  held  tliat  tlio  Ijlood  in  tlie 
air  tvlls  set  up  an  iullaininatory  process,  a  eoinnion  termination  of  wliich 
was  easeation.  Since  Koeh's  discovery  "vve  liave  learned  that  many  eases 
in  which  tlie  ])hysieal  examination  is  negative  show,  either  during  the 
period  of  hemorrhage  or  immediately  after  it,  tubercle  bacilli  in  the 
sputa,  so  that  o])inion  has  veered  to  the  older  view,  and  we  now  regard 
the  appearance  of  luemoj)tysis  as  an  indication  of  existing  disease.  In 
young,  apparently  healthy  persons  cases  of  haemoptysis  may  be  di- 
vided into  three  groups.  In  the  first  the  bleeding  has  come  on  with- 
out premonition,  without  overexertion  or  injury,  and  there  is  no  familv 
history  of  tuberculosis.  The  physical  examination  is  negative,  and  the 
examination  of  the  expectoration  at  the  time  of  the  hemorrhage  and 
subsequently  shows  no  tubercle  bacilli.  Such  instances  are  not  uncom- 
mon, and,  though  one  may  suspect  strongly  the  presence  of  some  focus 
of  tuberculosis,  yet  the  individuals  may  retain  good  health  for  many 
years  and  have  no  further  trouble.  Of  the  386  cases  of  haemoptysis 
noted  by  Ware  iu  private  practice,  62  recovered  and  pulmonary  disease 
did  not  subsequently  develop. 

In  a  second  group  individuals  in  apparently  perfect  health  are 
suddenly  attacked,  perhaps  after  a  slight  exertion  or  during  some  ath- 
letic exercises.  The  physical  examination  is  also  negative,  but  tubercle 
bacilli  are  found  sometimes  in  the  bloody  sputa,  more  frequently  a  few 
days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health 
for  a  month  or  two,  but  the  symptoms  have  not  been  urgent  and  perhaps 
not  noticed  by  the  patients.  The  physical  examination  shows  the  pres- 
ence of  well  marked  tuberculous  disease,  and  there  are  both  tubercle 
bacilli  and  elastic  tissue  in  the  sputa. 

A  very  interesting  systematic  study  of  the  subject  of  haemoptysis, 
particularly  in  its  relation  to  the  question  of  tuberculosis,  has  just  been 
completed  in  the  Prussian  army,  and  has  been  issued  by  Franz  Strieker.^ 
During  the  five  years  1890-95  there  were  900  cases  admitted  to  the 
hospitals,  which  is  a  percentage  of  0.045  of  the  strength  (1,728,505). 
These,  of  course,  were  selected  men  at  the  healthiest  periods  of  life. 
Of  the  cases,  in  480  the  hemorrhage  came  on  without  recognizable 
cause.  Of  these  417  cases,  86  per  cent,  were  certainly  or  probably 
tuberculous.     In  only  221,  however,  was  the  evidence  conclusive. 

In  a  second  group  of  213  cases  the  hemorrhage  came  on  during  the 
military  exercise,  and  of  these  75  patients  were  shown  to  be  tuberculous. 

In  118  cases  the  hemorrhage  followed  certain  special  exercises,  as  in 
the  gymnasium  or  in  riding  or  in  consecjuence  of  swimming.  In  24 
cases  it  developed  during  the  exercise  of  the  voice  in  singing  or  in  giv- 
ino;  command  or  in  the  use  of  wind  instruments.  A  verv  interesting- 
group  is  reported  of  24  cases  in  wliich  the  hemorrhage  followed  trauma, 
either  a  fall  or  a  blow  upon  the  thorax.  In  7  of  these  tuberculosis  was 
positively  present,  and  in  6  other  cases  there  was  a  strong  probability 
of  its  existence. 

Among  the  conclusions  which  Strieker  draws  the  folhjwing  are  the 

^  Festschrift  zur  100  jdhrixjen  Stiftungsjeier  des  medizinisch-chirurgischen  Fried  rich- Wil- 
hdms-Jnstiiuts,  Berlin,  1895. 


792  TUBERCULOSIS. 

most  important :  namely,  that  soldiers  attacked  with  haemoptysis  with- 
out special  cause  are  in  at  least  86.8  per  cent,  tuberculous.  In  the  cases 
in  which  the  hseraoptysis  follows  the  special  exercises,  etc.  of  military 
service,  at  least  74.4  per  cent,  are  tuberculous.  In  the  cases  which  come 
on  during  swimming  or  as  a  consequence  of  direct  injury  to  the  thorax 
about  one  half  are  not  associated  with  tuberculosis. 

Haemoptysis  occurs  in  from  60  to  80  per  cent,  of  all  cases  of  pul- 
monary tuberculosis.  It  is  more  frequent  in  males  than  in  females. 
While  it  may  occur  at  all  ages,  and  even  in  quite  young  children,  yet 
it  is  most  common  in  young  adults. 

In  a  majority  of  all  cases  the  bleeding  recurs.  There  are  cases  in 
which  it  is  a  special  feature  throughout  the  disease,  so  that  a  hemorrhagic 
or  hgemoptysical  form  has  been  recognized.  The  amount  of  blood 
brought  up  varies  from  a  couple  of  drachms  to  a  pint  or  more.  In  69 
per  cent,  of  4125  cases  of  haemoptysis  at  the  Brompton  Hospital  the 
amount  brought  up  was  under  half  an  ounce. 

A  distinction  may  be  drawn  between  the  haemoptysis  early  in  the 
disease  and  that  wdiich  occurs  in  the  later  periods.  In  the  former  the 
bleeding  is  usually  slight,  is  apt  to  recur,  and  fotal  hemorrhage  is  very 
rare.  In  these  instances  the  bleeding  is  usually  from  small  areas  of 
softening  or  from  early  erosions  in  the  bronchial  mucosa.  In  the  later 
periods,  after  cavities  have  formed,  the  bleeding  is,  as  a  rule,  more  pro- 
fuse and  is  more  apt  to  be  fatal.  Single  large  hemorrhages,  proving 
quickly  fatal,  are  very  rare,  except  in  the  advanced  stages  of  the 
disease.  In  these  cases  the  bleeding  comes  either  from  an  erosion  of  a 
good-sized  vessel  in  the  wall  of  a  cavity  or  from  the  rupture  of  an 
aneurysm  of  the  pulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Without  any  warning  the 
patient  may  notice  a  warm  salt  taste  and  the  mouth  fills  with  blood. 
It  may  come  up  with  a  slight  cough.  The  total  amount  may  not  be 
more  than  a  few  drachms,  and  for  a  day  or  two  the  patient  may  spit  up 
small  quantities.  When  a  large  vessel  is  eroded  or  an  aneurysm  bursts, 
the  amount  of  blood  brought  up  is  large,  and  in  the  course  of  a  short 
time  a  pint  or  two  may  be  expectorated.  Fatal  hemorrhage  may  occur 
into  a  very  large  cavity  without  any  blood  being  coughed  up.  The 
character  of  the  blood  is,  as  a  rule,  distinctive.  It  is  frothy,  mixed 
with  mucus,  generally  bright  red  in  color,  except  when  large  amounts 
are  expectorated,  and  then  it  may  be  dark.  The  sputa  may  remain 
blood-tinged  for  some  days  or  there  are  brownish  black  streaks  in  the 
sputa,  or  "  friable  nodules  consisting  entirely  of  blood  corpuscles  "  may 
be  coughed  up.  Blood  moulds  of  the  smaller  bronchi  are  sometimes 
expectorated. 

The  microscopical  examination  of  the  sputum  in  tuberculous  cases 
is  most  important.  If  carefully  spread  out,  there  may  be  noted,  even 
in  an  apparently  pure  hemorrhagic  mass,  little  portions  of  mucus  from 
which  bacilli  or  elastic  tissue  may  be  obtained. 

Dyspnoea. — In  the  early  stages  the  respirations  may  be  a  little  hur- 
ried, and  in  a  few  instances  the  dyspnoea  is  quite  marked.  When  the 
disease  is  advanced,  so  long  as  the  patient  remains  at  rest  there  is  no 
shortness  of  breath,  but  on  attempting  exercise  or  making  any  special 
effort  the  respirations  are  much  hurried.     It  is  remarkable  how  much 


CHROXrC  ULCERATIVE   TUBERCULOSIS  OE  THE  LUNGS.       793 

Iiinii"  tissue  nuiy  \)v  (lestn>yt'(l  without  any  sense  of  resjiiratorv  distress 
so  long  as  the  patient  remains  (juiet.  Occasionally,  even  early  in  the 
disease,  there  are  attacks  of  dyspntea  at  nitrht  almost  asthmatic  in  cha- 
racter. Emotion  or  sudden  exertion  may  at  any  time  cause  hurried 
hreathinii-.  Marked  dyspntea  is  usually  due  to  some  intercurrent  trouble, 
the  development  of  a  lobar  pneumonia  or  of  miliary  tuberculosis,  a 
rapidly  advancino*  broncho-])neum()nia  or  the  development  of  pneu- 
mothorax. 

Cifatiosis  is  also  not  a  common  sym])tom  in  chronic  pulmonary  tuber- 
culosis. It  is  seen  most  commonly  under  conditions  whicli  cause 
dyspncea.  In  advanced  cases  with  much  fibroid  change  the  dyspnoea 
may  be  cardiac,  and  the  advancing  cyanosis  may  also  residt  from  tlie 
gradual  dilatation  of  the  right  chamber  of  the  heart. 

P((ii)  in  the  chest  is  a  very  variable  symptom.  In  some  eases  it  is 
present  from  the  outset,  and  the  patient  at  the  examination  will  place 
his  hand  accurately  over  the  portion  of  the  lung  affected.  In  other 
instances  it  is  absent  throughout.  When  present  it  is  most  comraonlv 
due  to  pleurisy,  and  is  situated  below  the  clavicle,  along  the  sternal 
margin,  or  in  the  scapular  regions.  In  cases  of  apical  tuberculosis  with 
early  involvement  of  the  pleura  the  pain  may  be  a  very  distressing 
feature.  In  other  cases  the  lower  thoracic  zone  is  the  seat  of  the  chief 
pain,  particularly  on  drawing  a  deep  lireath.  In  many  instances  it  is 
only  a  dull,  aching  sensation.  When  such  shrinkage  and  contraction 
occur,  Avith  great  thickening  of  the  pleura,  the  intercostal  nerves  may 
be  involved,  and  the  pains  persist  long  after  the  active  symptoms  of  the 
disease  have  disappeared.  The  sensitiveness  to  percussion  may  be  very 
much  increased,  and  the  patient  may  wince  even  on  light  percussion 
over  the  affected  area. 

General  Symptoms. — Fever. — Aretaeus  seems  to  have  been  the 
first  to  recognize  phthisis  as  a  febrile  disease.  His  description  is  most 
characteristic  :  "  It  is  accompanied  by  febrile  heat  of  a  continued  cha- 
racter, but  latent,  ceasing  indeed  at  no  time,  but  concealed  during  the 
day  by  the  sweating  and  coldness  of  the  body  ;  for  the  characteristics  of 
phthisis  are  that  a  febrile  heat  is  lighted  up  which  breaks  out  at  night, 
but  during  the  day  lies  concealed  in  the  viscera,  as  is  manifested  by  the 
uneasiness,  loss  of  strength,  and  colliquative  wasting.  For  had  the 
febrile  heat  left  the  body  during  the  day,  how  should  not  the  patient 
have  acquired  flesh,  strength,  and  comfortable  feeling  ?  "  ^ 

Morton,  so  far  as  I  know,  was  the  first  to  recognize  two  types  of 
fever  in  pulmonary  tuberculosis — the  inflammatory  and  the  putrid  inter- 
mittent or  hectic.^ 

To  get  a  proper  idea  of  the  daily  range  of  fever  in  any  case  it  is 
necessary  to  take  the  temperature  every  two  or  three  hours.  The  usual 
8  A.  M.  and  8  p.  m.  record  may  be  very  deceptive,  giving  neither  the 
maximum  nor  the  minimum  temperature  of  the  day.  It  may  be  said 
at  the  outset  that  a  continuous  type  of  fever  is  not  often  seen  in  pul- 
monary tuberculosis.  Except  in  certain  instances  of  acute  pneumonic 
phthisis,  a  twenty-four  hour  record,  with  a  variation  of  only  a  degree, 
such  as  is  seen  not  infrequently  in  the  early  stage  of  lobar  pneumonia  or 
of  typhoid  fever,  is  most  exceptional.     Much  more  commonly  the  fever 

'Sydenham  Society's  ed.,  p.  310.  -  Phthisiolorfia,  p.  lUci. 


794  TUBERCULOSIS. 

is  remittent  in  character,  with  an  afternoon  exacerbation.  An  inter- 
mittent type  of  pyrexia,  also  quite  common,  is  met  with  sometimes  in 
the  very  early  stages  of  the  disease,  but  is  most  frequent  in  the  stage 
of  cavity.  In  the  initial  period  of  pulmonary  tuberculosis  fever  is  one 
of  the  most  important  sym})toms.  Usually  toward  the  afternoon  the 
patient  feels  a  little  flushed,  and  the  thermometer  records  a  temperature 
of  two  or  two  and  a  half  degrees  above  the  normal.  The  morning 
temperature  at  this  time  may  be  subnormal.  In  other  instances,  par- 
ticularly when  there  is  rapid  invasion  and  consolidation  of  the  lung 
tissue,  there  is  pyrexia  throughout  the  tweuty-four  hours  wdth  a  marked 
afternoon  exacerbation.  The  fever  of  onset  in  pulmonary  tuberculosis 
may  be  accompanied  with  chills  and  sweats,  simulating  very  closely  a 
malarial  intermittent  fever.  In  this  latitude  to  confound  early  tuber- 
culosis with  malarial  fever  is  an  extremely  common  error.  The  sweat- 
ing which  sometimes  accompanies  the  fever  of  the  early  stages,  and 
which  may  come  on  in  the  early  hours  of  the  night,  rarely  has  the  pro- 
fuse and  soaking  character  of  the  sweats  of  the  later  stages.  This  fever 
of  onset  is  often  associated  with  two  other  important  symptoms — a 
chloro-anseraia  and  dyspepsia.  Both  of  these  are  very  variable.  The 
aneemia  may  be  most  marked.  Generally  speaking,  the  presence  of 
fever  is  a  good  differential  criterion  between  early  tuberculosis  and 
chlorosis,  but  the  instances  of  the  latter  disease  in  which  fever  is  a 
marked  feature  may  for  a  time  be  quite  j)uzzling. 

The  dyspeptic  symptoms  are  common  accompaniments  of  the  fever, 
but  in  some  instances  with  a  daily  afternoon  pyrexia  the  tongue  may  be 
clean  and  the  appetite  and  digestion  good. 

In  the  period  of  softening — the  second  stage,  as  it  is  sometimes 
called — the  fever  is  more  pronounced,  and,  when  the  disease  is  progress- 
ing, remittent  in  character,  not  reaching  the  normal,  but  with  a  daily 
exacerbation  in  the  late  afternoon  or  evening.  At  this  period  a  temper- 
ature of  103°  or  103.5°  F.  is  common.  Temperatures  above  104°  are 
rare.  The  daily  remissions  are  from  two  to  three  degrees.  Often  in 
this  stage  the  remissions  may  be  more  marked,  and  the  temperature 
may  fall  through  the  morning  hours  to  normal,  or  even  below  this  point. 
In  a  few  instances  one  sees  the  so-called  inverse  type,  in  Avhich  the  tem- 
perature is  higher  in  the  morning  hours  than  in  the  evening.  In  the 
stage  of  cavity  the  hectic  tyjDC  of  temperature  may  be  strongly  pro- 
nounced. To  get  a  proper  idea  of  the  diurnal  range  a  two-hourly  record 
is  necessary,  A  morning  and  evening  observation  may  give  an  entirely 
incorrect  idea  of  the  range.  When  the  hectic  is  fully  established, 
during  a  very  considerable  part  of  the  twenty-four  hours  the  patient  is 
not  only  afebrile,  but  has  a  subnormal  temperature.  The  afternoon  ex- 
acerbation may  reach  from  103°  to  105°  F.,  and  the  maximum  is  usually 
reached  some  time  between  six  and  ten  in  the  evening.  After  midnight 
the  temperature  begins  to  fall,  and  by  eight  o'clock  is  usually  nor- 
mal, reaching  from  96.5°  to  97.5°  F.  The  fall  in  the  morning  is  usually 
accompanied  by  a  profuse  sweat.  A  slow  rise  then  takes  place  through 
the  late  morning  and  early  afternoon  hours.  The  extreme  daily  range 
may  be  remarkable,  from  eight  to  ten  degrees  being  not  uncommon,  and 
there  are  instances  on  record  of  a  diurnal  range  of  12  and  14.5°  F.  This 
wide  variation  is  most  commonly  seen  in  the  very  late  stages  of  the  disease. 


CHRONIC  ULCERATIVE  TUBERCULOSIS  OF  THE  LUNGS.       7J)o 

Fever  is  ilic  most  important  j)r()ti;n()sti(' syiiiptoiii  in  imlmoiiarv  tiihci- 
t'nK)sis.  With  a  tciniR-ratiirc  ranjiv  from  101'^  to  lO.'}"^  or  104°  F.  tlie 
disease  is  surely  progressing-.  It  is  most  exceptional  to  find  a[)yrexia 
associated  either  with  the  active  development  of  tnborclcs  (n*  of  caseation 
or  with  rapid  softening-.  There  are  rare  instances  on  record  in  which 
with  a  temperature  at  or  below  99°  the  local  signs  and  general  symp- 
toms indicate  a   i)r()gressive  lesion. 

TIk'  PiiJ.sc. — The  heart's  action  is  quickened  in  early  stages  in  [)ro- 
portion  to  the  height  of  the  fever,  in  later  stages  Ijcaring  a  closer  rela- 
tion to  the  degree  of  weakness.  In  young,  excitable  persons  the  pulse 
in  the  early  stages  may  be  very  ra])id,  from  112  to  120,  and  there  is 
great  irritability  of  the  heart,  palpitation  on  slight  exertion,  and  short- 
ness of  breath.  There  are  instances  in  which  pal])itation  and  cardiac 
irritability  are  the  most  distressing  symptoms  of  the  early  stage.  In 
the  high  fever  of  rapid  extension  the  pulse  may  be  dicrotic.  As 
the  emaciation  proceeds  the  superficial  veins,  particularly  of  the  arms 
and  hands,  may  be  very  prominent.  In  many  cases  of  chronic  phthisis 
the  pulse  is  soft  and  full  and  the  veins  of  the  hands  prominent.  It  is 
by  no  means  infrequent  to  see  pulsation  in  the  peripheral  veins,  particu- 
larly those  of  the  hands,  and  the  capillary  pulse  in  the  nails  may  at 
times  be  readily  seen. 

Sweats. — At  any  stage  of  the  disease  profuse  sweating  may  occur.  In 
the  fever  of  onset  this  may  be  associated  with  the  chills,  and  the  group- 
ing of  the  rigor,  fever,  and  perspiration  may  lead  to  the  diagnosis  of 
malarial  fever.  The  sweats  occur  more  frequently  in  the  stages  of  soft- 
ening and  cavity  formation.  The  most  characteristic  are  the  sweats 
Avhicli  occur  with  the  falling  temperature  of  the  early  morning  hours, 
and  which  may  be  of  a  drenching  character  and  very  exhausting  to  the 
patient.  They  may  occur  with  great  persistency  and  resist  all  treat- 
ment. As  a  rule,  they  are  general  over  the  surface,  but  in  some  in- 
stances they  may  be  localized  to  the  trunk.  While  the  most  profuse 
and  distressing  sweats  are  nocturnal,  in  many  cases  they  occur  at  any 
time  during  the  day  if  the  patient  happens  to  fall  asleep,  or  they  may 
follow  the  taking  of  food  or  any  sudden  emotional  disturbance.  In  con- 
sequence of  the  profuse  sweating  the  skin  of  the  trunk  is  often  covered 
with  sudaniina  or  a  red  miliary  eruption.  Sweats  in  the  early  stages 
are  sometimes  followed  by  a  sense  of  comfort,  and  the  patient  congratu- 
lates himself  that  the  fever  is  "  breaking."  Morton  speaks  of  this  as  a 
fraudidenta  pax.  In  a  much  larger  proportion  of  cases  the  sweats  are 
exhausting  and  excessively  disagreeable. 

Emaciation. — Loss  of  weight,  one  of  the  most  obvious  of  the  general 
symptoms  of  tuberculosis,  and  one  from  Avhich  the  two  most  common 
names,  phthisis  and  consumption,  have  been  derived,  is  an  early  and 
constant  feature  of  the  disease.  Next  to  the  thermometer,  the  scales 
give  us  the  best  index  to  the  progress  of  the  disease.^     In  a  few  rare 

'  The  wasting  of  a  consumptive  has  never  been  described  more  graphically  than  by 
Sir  Thomas  Browne  in  his  well  known  Letter  to  a  Friend:  "  In  this  consumptive  condi- 
tion and  remarkable  extenuation  he  came  to  be  almost  half  himself,  and  left  a  great  part 
behind  him  which  he  carried  not  to  the  grave.  And  though  that  story  of  Duke  .John 
Ernestus  Mansfield  be  not  so  easily  swallowed  that  at  his  death  his  heart  was  not  found  to 
be  so  big  as  a  nut,  yet  if  the  bones  of  a  good  skeleton  weigh  little  more  than  twenty 
pounds,  his  inwards  and  flesh  remaining  could  make  no  bouffage,  but  a  light  bit  for  the 


796  TUBERCULOSIS. 

instances  the  disease  may  make  rapid  progress  without  causing  great  loss 
of  weight,  but,  as  a  rule,  the  emaciation  is  in  a  measure  proportional  to 
the  extent  of  the  local  disease  and  its  progress.  It  bears  an  important 
relation  also  to  the  fever,  and  the  higher  and  the  more  persistent  this  is 
the  greater  is  the  loss  in  weight.  AVith  moderate  temperature  one  may 
see  occasionally  a  gain  in  weight,  but  rarely  with  a  pyrexia  reaching 
above  101°  F.  Other  agencies  besides  the  fever  may  influence  the  loss 
in  weight,  more  particularly  the  dyspepsia  which  is  so  common,  and  the 
diarrhoea. 

Physical  Signs. — («)  Inspection. — The  patient  should  be  in  the 
sittiug  posture,  before  a  good  light,  and  in  the  case  of  a  male  stripped,  in 
a  female  at  least  the  upper  portions  of  the  chest  exposed.  Attention 
should  be  first  given  to  the  shape  of  the  chest,  which  is  often  in  tuber- 
culous subjects  long  and  narrow.  Both  Hippocrates  and  Galen  laid 
great  stress  upon  defective  conformation  of  the  chest  in  phthisis,  the 
former  describing  particularly  the  so-called  winged  scapulae.  In  a  large 
proportion  of  cases  the  thorax  is  long  and  narrow,  with  wide  intercostal 
spaces,  the  ribs  more  vertical  in  direction  than  normal,  and  the  costal 
angle  very  narrow.  Frequently  the  chest  is  flattened  in  an  antero-pos- 
terior  direction,,  or  the  costal  cartilages  of  one  or  both  sides  may  be 
prominent,  while  the  sternum  is  depressed.  Occasionally  the  lower 
sternum  presents  a  deep  cavity,  the  so-called  funnel  breast  (Trichter- 
brust).  The  two  sides  of  the  chest  may  be  un symmetrical.  In  the 
earlv  stages  no  difference  may  be  noticed  in  the  clavicular  regions,  but 
in  apical  disease  w^hich  has  lasted  for  any  time  there  are  changes  which 
at  once  attract  attention  :  the  clavicle  on  the  affected  side  is  more 
prominent  ;  the  supra-  and  infraclavicular  spaces  are  more  distinct ; 
and  there  may  be  well  marked  flattening  corresponding  to  the  first, 
second,  and  third  ribs  of  this  side.  In  very  long  standing  cases  the 
intercostal  spaces  may  be  much  narrower  and  the  affected  side  con- 
siderably shrunken.  The  condition  of  the  prsecordia  should  be  carefully 
noted,  as  a  wide  area  of  impulse,  particularly  in  the  second,  third,  and 
fourth  interspaces,  is  often  associated  with  chronic  tuberculosis  of  the 
left  apex.  SjDCcial  attention  should  then  be  given  to  estimating  the 
mobility  of  the  two  sides,  noting  particularly  whether  the  apices 
expand  equally  or  whether  the  movement  on  one  side  is  retarded. 
Defective  expansion  of  one  apex  is  an  early  and  valuable  sign,  particu- 
larly in  women. 

While  marked  deviations  from  the  normal  are  common  enough  in 
the  thoraces  of  persons  affected  with  pulmonary  tuberculosis,  it  is  well 
to  bear  in  mind  that  there  are  many  cases  in  which  the  patients  show 
perfectly  well  formed  chests. 

(6)  Palpation. — With  the  hands  placed  beneath  the  clavicles  one  can 
estimate  well  the  degree  of  expansion  or  any  deficiency  on  either  side. 
Standing  behind  the  patient  with  the  thumbs  in  the  suprascapular 
and  the  fingers  in  the  infraclavicular  spaces,  one  can  often  judge  very 

grave.  I  never  more  lively  beheld  the  starved  characters  of  Dante  in  any  living  face ; 
an  aruspex  might  have  read  a  lecture  upon  him  without  exenteration,  his  flesh  being  so 
consumed  that  he  might  in  a  manner  have  discerned  his  bowels  without  opening  of  him  : 
so  that  to  be  carried,  sextd  cervice,  to  the  grave,  was  but  a  civil  unnecessity  ;  and  the  com- 
plements of  the  cofRn  might  outweigh  the  subject  of  it." 


CHRONIC   ULCERATIVE   TUIiEUCVLOSIS   OF   THE  LUNGS.       797 

accuratoly  the  relative  iii()l)ility  oi'  ilic  two  sides.  The  condition  of"  ilie 
intercostal  spaces,  the  exact  jiosition  of  the  aj)ex  heat,  the  j)resence  or 
absence  of"  })aiM  in  any  region,  are  als<»  pt)ints  to  he  estimated  by  paljtation. 
On  asking  the  patient  to  count  while  palpation  is  made  at  the  different 
parts,  one  estimates  the  vocal  vibrations,  which  are  normally  more 
forcible  at  the  right  than  at  the  left  apex,  and  which  are  much  increased 
in  all  stages  of  tuberculous  disease  at  the  apices  and  over  any  part  of 
the  lung  where  consolidation  has  taken  place.  On  the  other  hand,  if  a 
pleural  exudate  complicates  the  disease,  the  fremitus  is  greatly  diinin- 
ished  or  absent. 

(c)  Pereussio)!. — In  the  early  stages  of  pulmonary  tuberculosis  this 
method  of  examination  gives  us  less  valuable  information  than  inspec- 
tion or  auscultation.  With  well  marked  deficient  expansion  at  an  apex 
there  may  be  scarcely  any  change  in  the  percussion  note  Ijeneath  the 
clavicle.  In  other  instances  the  resonance  is  only  slightly  defective. 
In  a  few  cases  one  meets  with  a  hyperresonant  note  or  a  distinct  Skodaic 
resonance.  One  of  the  earliest  and  most  valuable  signs  is  defective 
resonance  above,  upon,  or  below  one  clavicle.  In  a  considerable  jjro- 
portion  of  all  cases  of  phthisis  the  change  in  the  note  is  first  found  in 
these  regions.  A  comparison  between  the  two  sides  should  be  made 
also  when  the  breath  is  held  after  a  full  inspiration,  as  the  defective 
resonance  may  then  be  more  clearly  marked.  In  the  early  stages  the 
percussion  note  is  usually  higher  in  pitch,  and  may  require  an  experi- 
enced ear  to  detect  the  difference.  In  recent  consolidation  from  caser»us 
pneumonia  the  percussion  note  often  has  a  tubular  or  tympanitic  quality. 
A  wooden  dulness  is  rarely  heard  except  in  old  cases  with  extensive 
fibroid  change  at  the  apex  or  base.  Over  large  thin-walled  cavities  at 
the  apex  the  so-called  cracked-pot  sound  may  be  obtained.  In  thin 
subjects  the  percussion  should  be  carefully  practised  in  the  supraspinous 
fossae  and  the  interscapular  spaces,  as  they  correspond  to  very  important 
areas  early  involved  in  the  disease.  In  cases  with  numerous  separated 
cavities  at  the  apex,  without  much  fibroid  tissue  or  thickening  of  the 
pleura,  the  percussion  note  may  show  little  change,  and  the  contrast 
between  the  signs  obtained  on  auscultation  and  percussion  is  most 
marked. 

In  the  direct  percussion  of  the  chest,  particularly  in  thin  patients 
over  the  pectorals,  one  frequently  sees  the  phenomenon  known  as 
myoidemrt,  a  local  contraction  of  the  muscle  causing  bulging,  which 
persists  for  a  variable  period  and  gradually  subsides.  It  has  been 
thought  by  some  to  be  more  frequently  met  with  in  pulmonary*  tuber- 
culosis than  in  other  diseases.     It  has,  I  think,  no  special  significance. 

(d)  Auscultation. — Corresponding  areas  on  the  two  sides  should  be 
examined,  at  first  during  quiet  respiration,  then  during  deep  breathing, 
and  finallv  durino-  the  act  of  couofhins;.  In  verv  earlv  disease  of  one 
apex  the  inspiration  on  quiet  breathing  may  be  scarcely  audible  ;  expira- 
tion is,  as  a  rule,  prolonged.  On  the  other  hand,  the  earliest  noticeable 
change  may  be  a  harsh,  rude  inspiratory  murmur.  On  deep  breathing 
it  is  well  to  remember  that  the  normal  pitch  is  somewhat  higher  and  the 
expiration  somewhat  more  prolonged  at  the  right  than  at  the  left  side, 
particularly  at  the  apex.  The  inspiration  may  be  jerking  or  wavy,  the 
so  called  cog-wheel  rhythm,  which  is  best  heard  when  the  patient  draws 


798  TUBERCULOSIS. 

a  deep  breath  slowly.  It  is  by  no  means  limited  to  or  characteristic  of 
tuberculosis.  With  pneumonic  consolidation  and  caseation  there  may 
be  during  both  inspiration  and  expiration  the  most  typical  tubular 
breath  sounds. 

Rales  early  accompany  these  changes  in  the  respiratory  murmur. 
They  are  due  to  the  associated  bronchitis.  They  may  be  only  heard  on 
deep  inspiration  or  on  coughing,  and  very  early  in  the  disease  are  crack- 
ling in  character — the  so-called  dry  crackling  or  subcrepitant  rales.  Ou 
coughing  they  may  disappear,  or  they  may  become  louder  and  moister 
in  quality.  With  this  there  may  be  sometimes  at  the  end  of  inspiration 
a  piping  bronchial  rale.  As  the  disease  progresses  the  adventitious 
sounds  become  louder,  and  what  is  known  as  the  mucous  or  moist  rale 
is  heard,  which  is  louder,  moister,  and  more  bubbling  in  character. 
Sometimes  at  the  very  end  of  inspiration  these  moist  rales  have  a  very 
clicking  quality.  In  each  instance  it  is  important  to  note  the  quality 
of  the  rales  on  quiet  and  deep  breathing  and  on  coughing,  and  to 
observe  whether  they  occur  with  both  inspiration  and  expiration,  and 
whether  the  character  of  the  respiratory  murmur  is  obscured  or  not. 

When  cavities  form  the  rales  are  louder,  more  gurgling,  and  resonant 
in  quality.  Over  an  area  of  consolidation  the  breath  sounds  are  tubu- 
lar, and  in  the  large  excavations  loud  and  cavernous  or  have  an  amphoric 
quality.  In  the  unaffected  portions  of  the  lobe  and  in  the  opposite  lung 
the  breath  sounds  may  be  harsh  and  even  puerile.  The  vocal  resonance 
is  usually  increased  in  all  stages  of  the  process,  and  bronchophony  and 
pectoriloquy  are  met  with  in  the  regions  of  consolidation  and  over  cav- 
ities. Pleuritic  friction  may  be  present  at  any  stage,  and,  as  mentioned 
before,  occurs  very  early.  There  are  cases  in  which  it  is  a  marked  fea- 
ture throughout.  When  the  lappet  of  lung  over  the  heart  is  involved 
there  may  be  a  pleuro-pericardial  friction,  and  when  this  area  is  consol- 
idated there  may  be  curious  clicking  rales  synchronous  with  the  heart 
beat,  due  to  the  compression  by  the  heart  of,  and  the  expulsion  of  air 
from,  this  portion.  An  interesting  auscultatory  sign,  met  most  commonly 
in  phthisis,  is  the  so-called  cardio-respiratory  murmur,  a  whiflBng  sys- 
tolic bruit  due  to  the  propulsion  of  air  out  of  the  tubes  by  the  impulse 
of  the  heart.  It  is  best  heard  during  inspiration  and  in  the  antero-lateral 
regions  of  the  chest. 

A  systolic  murmur  is  very  often  heard  in  the  subclavian  artery  of 
one  or  other  side.  It  has  been  thought  to  be  due  to  compression  of  the 
artery  by  the  apex  of  the  lung  or  to  pressure  by  a  thickened  pleura. 
It  is  heard  best,  as  a  rule,  during  expiration.  It  is  of  no  moment,  and 
occurs  in  thin-chested  persons  apart  altogether  from  any  disease  of  the 
apices. 

Sig'i'is  of  Cavity. — In  long  standing  cases,  if  the  cavity  is  at  the  apex, 
signs  of  retraction  in  the  infraclavicular  region  become  intensified. 
Very  pronounced  unilateral  retraction  in  this  region  with  immobility  is 
a  sign  of  great  value.  Usually  the  muscles  have  undergone  atrophy 
and  the  chest  walls  are  thin.  In  very  rare  instances  in  a  thin-walled 
cavity  there  is  slight  bulging  in  the  first  and  second  interspaces. 

The  vocal  fremitus  is  much  increased,  a  point  of  great  moment  in 
the  diiferentiation  of  very  large  cavities  from  pneumothorax.  The  per- 
cussion sound  over  a  cavity  may  be  very  variable.     In  a  few  instances, 


CHRONIC  ULCERATIVE   TUBERCULOSIS  OF  THE  LUNGS.      799 

wlu'ii  there  is  not  niiicli  thickeiiiiii;'  oi"  the  pleura  oi'  iii(hirati(»ii  oi"  the 
surromnliiiu'  hiiiii'  tissue,  the  note  nuiy  bo  lull  and  clear.  Mure  coni- 
nionlv  theii'  is  a  hiii'h-pitehed  wooden  note,  whieh  may  luivc  a  tympa- 
nitic or  even  an  amphoric  (|uality,  and  which  may  undcru-o  many  altera- 
tions. The  tympanitic  quality  may  disappear  when  the  cavity  is  lull 
of  liquid.  The  note  may  change  distinctly  in  pitch  when  the  mouth  is 
opened  or  closctl  (W'intrich's  sign),  or  alters  during  deej)  inspiration  or 
deep  e.\j)iration  or  with  the  change  in  the  position  of  the  patient.  The 
cracked-pot  sound — bruit  dc  pot  file — is  lieai'd  over  large  cavities  with 
thin  walls.  To  elicit  it  the  patient  should  draw  at  first  two  or  three 
deep  breaths,  and  then  breathe  quietly  with  the  open  mouth.  The  per- 
cussion stroke  shoidd  be  quick  and  forcible.  The  cracked-pot  sound 
is  not  distinctive  of  cavity.  It  is  heard  sometimes  over  the  normal  chest 
in  childhood,  over  the  upper  portion  of  a  lung  compressed  by  fluid,  in 
the  earlv  stages  of  pneumonia,  and  over  the  apices  in  some  instances  of 
acute  tuberculosis,  and  in  pneumothorax. 

On  auscultation  over  a  cavity  the  breath  sounds  are  heard  very  much 
altered  in  various  grades — tubular,  cavernous,  or  amphoric.  It  is  im- 
portant to  bear  in  mind  that  the  inspiratory  murmur  heard  over  cavities 
of  medium  size  may  be  typically  tubular  or  blowing.  In  larger  excava- 
tions the  quality  of  botli  inspiration  and  expiration  may  be  what  is 
termed  cavernous,  a  variety  of  the  bronchial  breathing  which  possesses 
in  a  high  degree  a  hollow  quality  very  difficult  to  define,  but  readily 
appreciated  by  the  ear.  In  very  large  cav'ities  both  inspiration  and 
expiration  may  be  typically  amphoric.  There  may  be  a  sharjj,  hissing 
sound,  as  if  the  air  was  passing  from  a  narrow  opening  into  a  wide  space. 
Over  the  entire  area  of  a  large  cavity  there  may  be  dead  silence  (Walshe), 
which  may  be  due  either  to  complete  filling  with  secretion  or  to  tempo- 
rary blocking  of  the  tubes.  Cavernous  rales  are  coarse,  bubbling  in 
quality,  resonant,  and  on  coughing  they  may  be  very  loud  and  gurgling. 
They  are  usually  increased  by  deep  inspiration  or  by  coughing  ;  they  are 
not  always  present,  and  in  some  large  cavities  the  breath  sounds  may  be 
perfectly  dry.  In  very  large,  thin-walled  cavities  the  rales  may  have 
an  amphoric  echo,  almost  resembling  that  of  pneumothorax.  Metallic 
tinkling  is  rarely  heard.  In  large  excavations  of  the  left  apex  the  heart 
impulse  may  cause  gurgling  sounds  or  clicks  synchronous  with  the  sys- 
tole. They  may  even  be  loud  enough  to  be  heard  at  a  little  distance 
from  the  chest  wall.  A  large  cavity  with  smooth  walls  and  thin  fluid 
contents  may  give  the  succussion  sound  when  the  trunk  is  abruptly 
shaken  (Walshe),  and  even  the  coin  sound  may  be  obtained. 

The  vocal  fremitus  is  greatly  increased  over  a  cavity.  The  whisper- 
ing pectoriloquy  is  heard  better  than  under  any  other  circumstances, 
though  it  is  not,  as  was  supposed,  pathognomonic  of  a  cavity.  In  large 
apical  cavities  the  heart  sounds  may  be  heard  with  great  intensity,  and 
there  may  be  a  loud  systolic  murmur,  which  is  probably  always  trans- 
mitted to,  and  not  produced  in,  the  cavity. 

Complications  of  Pulmoxary  Tuberculosis. — 1.  IntheBespi- 
ratory  System. — The  larynx  is  rarely  spared  in  chronic  pulmonary  tuber- 
culosis. As  already  stated,  the  first  symptom  may  be  huskiness  of  the 
voice.  Involvement  of  these  parts  is  indicated  by  alterations  in  the 
character  of  the  voice,  pain,  particularly  in  swallowing,  and  a  cough 


800  TUBERCULOSIS. 

which  is  often  wheezing,  and  in  the  hitter  stages  very  ineffectual. 
Aphonia  and  dysphagia  are  the  two  most  distressing  symptoms  of  the 
laryngeal  involvement.  When  the  epiglottis  is  seriously  diseased  and 
the  ulceration  extends  to  the  lateral  Avail  of  the  pharynx,  the  pain  in 
swallowing  may  be  very  intense,  or,  owing  to  the  imperfect  closure  of 
the  glottis,  there  may  be  coughing  spells  and  regurgitation  of  food 
through  the  nostrils.  Bronchitis  and  tracheitis  are  almost  invariable 
accompaniments  of  chronic  pulmonary  tuberculosis.  When  the  former 
extends  beyond  the  area  involved  in  the  local  disease  it  may  increase 
the  dyspncea,  and  in  the  smaller  tubes  may  lead  to  patchy  areas  of 
broncho-pneumonia.  Extensive  ulcerative  tracheitis  may  exist  with- 
out any  symptoms. 

Pneumonia  is  a  not  infrequent  terminal  complication  of  chronic 
phthisis.  It  may  run  a  perfectly  normal  course,  while  in  other  in- 
stances resolution  may  be  delayed,  and  one  is  in  doubt,  in  spite  of  the 
abruptness  of  the  onset,  as  to  the  presence  of  a  simple  or  a  tuber- 
culous pneumonia. 

Emphysema  of  the  uninvolved  portions  of  the  lung  is  a  common  fea- 
ture, rarely  producing  any  special  symptoms.  There  are,  however, 
cases  of  chronic  tuberculosis  in  which  emphysema  dominates  the  pic- 
ture, and  in  which  the  condition  develops  slowly  during  a  period  of 
many  years.  (General  subcutaneous  emphysema,  which  has  been  met 
with  in  a  few  rare  cases,  is  due  either  to  perforation  of  the  trachea  or 
to  the  rupture  of  a  cavity  closely  adherent  to  the  chest  wall.) 

Gangrene  of  the  lung  is  an  occasional  event  in  chronic  pulmonary 
tuberculosis,  due  in  almost  all  instances  to  sphacelus  in  the  walls  of  the 
cavity,  rarely  in  the  lung  tissue  itself. 

Complications  in  the  Pleura. — As  already  mentioned,  a  dry  pleurisy 
is  a  very  common  accompaniment  of  the  early  stages  of  tuberculosis. 
It  is  most  frequently  met  with  at  the  apices,  and  results  from  the  direct 
involvement  of  the  pleura  over  the  affected  portions  of  the  lung.  It  is 
always  a  conservative,  useful  process.  In  some  cases  it  is  very  exten- 
sive, and  friction  murmurs  may  be  heard  over  the  sides  and  back. 
The  cases  with  dry  pleurisy  and  adhesions  are  of  course  much  less 
liable  to  the  dangers  of  pneumothorax.  Pleurisy  with  effusion  more 
commonly  precedes  than  develops  in  the  course  of  pulmonary  tubercu- 
losis. Still,  it  is  common  enough  to  meet  with  cases  in  which  a  sero- 
fibrinous effusion  develops  in  the  course  of  the  chronic  disease.  There 
are  cases  in  Avhich  it  is  a  special  feature,  and  it  often,  I  think,  favors 
chronicity.  A  patient  may  during  a  period  of  four  or  five  years  have 
signs  of  local  disease  at  one  apex  with  recurring  effusion  in  the  same 
side.  Owing  to  adhesions  in  different  parts  of  the  pleura  the  effusion 
may  be  encapsulated.  Hemorrhagic  effusions,  which  are  not  uncommon 
in  connection  with  tuberculous  pleurisy,  are  comparatively  rare  in 
chronic  phthisis.  Chyliform  or  milky  exudates  are  sometimes  found. 
Purulent  effusions  are  not  frequent  apart  from  pneumothorax.  An 
empyema,  however,  may  develop  in  the  course  of  the  disease  or  as  a 
sequence  of  a  sero-fibrinous  exudate.  Pneumothorax  is  an  extremely 
common  complication  of  chronic  pulmonary  tuberculosis.  It  may  oc- 
cur early  in  the  disease,  but  more  frequently  is  late.  It  may  prove  fatal 
in  twenty-four  hours.     In  other  instances  a  pyo-pneumothorax  develops 


CHROMC  ULCERATIVE  Tl'liERCULOSIS  OF   TllE  IJ'SHS.      801 

and  till'  |t;ui('nt  liiiircrs  for  weeks  or  months.  In  a  third  ltoiij)  of  eases 
it  seems  to  have  a  beneheial  etfl'ct  on  the  (-(Xirse  of  the  (hsease.  Dahmd 
reported  a  etise  from  my  wards  in  Piiihidelj)hia  in  whicii  a  patient  with 
ehronie  |)hthisis  and  pneumothorax  was  luxlcr  observation  for  nearly 
four  years. 

2.  Symptoms  referable  to  Other  Organs. — («)  Cardio-vascular  System. 
— The  retraetion  of  the  left  upper  lobe  exposes  a  larfje  area  of  the  heart. 
In  thin-ehested  subjects  there  may  be  pulsation  in  the  second,  tiiird,  and 
fourth  interspaces  close  to  the  sternum.  Sometimes  with  much  retrac- 
tion of  tiie  left  upper  lobe  the  heart  is  drawn  up.  A  systolic  murmur 
in  the  second  left  intercostal  space,  near  the  sternimi,  is  common  in  all 
stages  of  phthisis.  Apical  murmurs  are  also  not  infrequent,  and  may 
be  extremely  rough  and  harsh  without  necessarily  indicating  that  endo- 
carditis is  present.  The  association  of  heart  disease  with  ])hthisis  is 
not,  however,  very  uncommon.  I  met  with  12  instances  of  endocar- 
ditis in  216  autopsies.  The  symptoms  are  indefinite,  and  a  diagnosis 
could  rarely  be  made  unless  embolic  features  were  present.  The 
arterial  tension  is  usually  low  in  phthisis,  and  the  capillary  resistance 
lessened,  so  that  the  pidse  is  often  full  and  soft  even  in  the  later  stages 
of  the  disease.  The  capillary  pulse  is  not  infrequently  met  with,  and 
pulsation  of  the  veins  in  the  back  of  the  hand  is  occasionally  to  be 
seen. 

(6)  Blood  Glandular  System. — An  early  chloro-ansemia  is  a  striking 
symptom  in  many  cases.  In  the  later  stages  the  blood  count  rarely 
sinks  below  2,000,000  per  c.mm.  The  blood  plates  are,  as  a  rule, 
enormously  increased,  and  are  seen  in  the  withdrawn  blood  as  the  so- 
called  Schultze's  granule  masses.  Thev  are  of  interest  chieflv  from  the 
fact  that  every  year  or  two  some  one  announces  their  discovery  as  a 
new  diagnostic  sign  in  phthisis.  The  leucocytes  are  greatly  increased, 
particularly  in  the  later  stages. 

(c)  Gastro-intestinal  System. — The  tongue  is  usually  furred,  but  may 
be  clean  and  red.  Small  aphthous  ulcers  are  sometimes  distressing.  A 
red  line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention 
was  paid  as  a  special  feature  of  phthisis,  occurs  in  other  cachectic 
states.  Extensive  tuberculous  disease  of  the  pharynx,  associated  with 
similar  affection  of  the  larynx,  may  interfere  seriously  with  deglutition 
and  prove  a  very  distressing  and  intractable  symptom. 

Of  late  special  attention  has  been  paid  to  the  gastric  symptoms  of 
this  affection.  Tuberculous  disease  of  the  stomach  is  rare.  Ulceration 
mav  occur  as  an  accidental  complication,  and  multiple  catarrhal  ulcers 
are  not  uncommon.  Interstitial  and  parenchymatous  changes  in  the 
mucosa  are  common  (possibly  associated  with  the  venous  stasis)  and 
lead  to  atrophy,  but  these  cannot  always  be  connoted  with  the  symp- 
toms, and  they  may  be  found  when  not  expected.  On  the  other  hand, 
when  the  gastric  symptoms  have  been  most  persistent  the  luucosa  may 
show  very  little  change.  It  is  impossible  always  to  refer  the  anorexia, 
nausea,  and  vomiting  of  consumption  to  local  conditions.  The  hectic 
fever  and  the  neurotic  influences,  upon  which  Iramermann  lays  much 
stress,  must  be  taken  into  account,  as  they  play  an  important  role. 
The  stomach  is  often  dilated,  and  to  muscular  insufficiency  alone  may  be 
due  some  of  the  cases  of  dyspepsia.     The  condition  of  gastric  secretion 

Vol..  T.— 51 


802  TUBERCULOSIS. 

is  not  constant  and  the  reports  are  discordant.  In  the  early  stages 
there  may  be  hyperacidity ;   later,  a  deficiency  of  acid. 

Anoi-exia  is  often  a  marked  sympton  at  the  onset ;  there  may  be 
positive  loathing  of  food,  and  even  small  quantities  cause  nausea. 
Sometimes  without  any  nausea  or  distress  after  eating  the  feeding  of 
the  patient  is  a  daily  battle.  Nausea  and  vomiting,  though  occasionallv 
troublesome  at  an  early  period,  are  more  marked  in  the  later  stages. 
The  latter  may  be  caused  by  the  severe  attacks  of  coughing.  S.  H. 
Habershon  refers  to  four  different  causes  of  the  vomiting  in  phthisis  : 
(1)  central,  as  from  tuberculous  meningitis ;  (2)  pressvire  on  the  vagi  by 
caseous  glands ;  (3)  stimulation  from  the  peripheral  branches  of  the  vagus, 
either  pulmonary,  pharyngeal,  or  gastric ;  and  (4)  mechanical  causes. 

Of  the  intestinal  symptoms  diarrhoea  is  the  most  serious.  It  may 
come  on  early,  but  is  usually  a  symptom  of  the  later  stages,  and  is 
associated  with  ulceration,  particularly  of  the  large  bowel.  Extensive 
ulceration  of  the  ileum  may  exist  without  any  diarrhoea.  The  associated 
catarrhal  condition  may  account  in  part  for  it ;  in  some  instances  it  is 
due  to  amyloid  degeneration  of  the  mucous  membrane. 

{d)  Nervou)i  System. — (1)  Focal  symptoms  may  be  due  to  the  devel- 
opment of  coarse  tubercles  and  areas  of  tuberculous  meningo-encepha- 
litis.  Aphasia,  for  instance,  may  result  from  the  growth  of  meningeal 
tubercles  in  the  fissure  of  Sylvius,  or  even  hemiplegia  may  develop. 
The  solitary  tubercles  are  more  common  in  the  chronic  phthisis  of  chil- 
dren. (2)  Basilar  meningitis  is  an  occasional  complication.  It  may  be 
confined  to  the  brain,  though  more  commonly  it  is  a  (3)  cerebrospinal 
meningitis,  which  may  come  on  in  persons  without  well  developed  local 
signs  in  the  chest.  Twice  have  I  known  strong,  robust  men  brought 
into  hospital  with  signs  of  cerebro-spinal  meningitis  in  whom  the  exist- 
ence of  pulmonary  disease  was  not  discovered  until  the  post-mortem. 
(4)  Peripheral  neuritis,  which  is  not  common,  may  cause  an  extensor 
paralysis  of  the  arm  or  leg,  more  commonly  the  latter,  causing  foot- 
drop.  It  is  usually  a  late  manifestation.  (5)  Mental  Symptoms.  It  was 
noted,  even  by  the  older  writers,  that  consumptives  had  a  peculiarly 
hopeful  temperament,  and  the  spes  phthisica  forms  a  curious  charac- 
teristic of  the  disease.  Patients  with  extensive  cavities,  high  fever, 
and  too  weak  to  move  will  often  make  plans  for  the  future  and  con- 
fidently expect  to  recover. 

Apart  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic 
phthisis  a  form  of  insanity  not  imlike  that  which  develops  in  the  con- 
valescence from  acute  affections.  The  question  of  the  mutual  relations 
of  insanity  and  phthisis  is  dwelt  upon  at  length  in  Mickle's  Goulstonian 
Lectures.^ 

(e)  A  remarkable  hypertrophy  of  the  mammary  gland  may  occur  in 
pulmonary  tuberculosis,  commonly  in  males.  It  may  only  be  on  the 
affected  side.     It  is  referred  to  in  another  place. 

(/)  Genito-urinary  System.. — The  urine  presents  no  special  peculiari- 
ties in  amount  or  constituents.  Fever,  however,  has  a  marked  influence 
upon  it.  Albumin  is  met  with  frequently,  and  may  be  associated  with 
the  fever  or  is  the  result  of  definite  changes  in  the  kidneys.  In  the 
latter  case  it  is  more  abundant  and  more  curdlike.     Amyloid  disease  of 

1  Lancet.  1888,  i. 


cnnosic  rLcHHATiVF.  rri'.EncrLosis  nr  rni:  j.r\<;s.    803 

tlie  kiiliioys  is  not  uiicdininoii.  It>  |)r('sci)cc  is  sliowii  Wy  ;ill)iiiiiiii  ami 
tube  oasts  in  the  urine,  and  sometimes  l»ya  a.reat  inci-casc  in  tlie  amount 
of  the  urini'.  In  other  instanees  there  is  dropsy,  and  tlie  ])atients  liave 
all  the  characteristic  features  of  ehrouie  liriolit's  disease. 

P^.s  ///  the  urine  may  be  due  to  disease  of  tlie  bladder  or  of  the  pelves 
of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  involved. 
In  jnilmonarv  phthisis,  iiowever,  extensive  tubt'reulous  disease  is  rarely 
foiuul  in  the  urinary  or<iaus.  liaeilli  may  be  detected  in  the  pus. 
Htematuria  is  not  a  very  common  symjitom.  It  may  occur  occasionally 
as  a  result  of  congestion  of  the  kidneys,  which  passes  off  and  leaves  the 
urine  albuminous.  In  other  instances  it  results  from  disease  of  the 
pelvis  or  of  the  bladder,  and  is  associated  either  with  early  tul)erculosis 
of  the  mucous  membranes  or  more  commonly  with  ulceration.  In  any 
medical  clinic  the  routine  inspection  of  the  testes  for  tubercle  will  save 
two  or  three  mistakes  a  year. 

(g)  Cutaneous  Si/steni. — The  skin  is  often  dry  and  harsh.  Local 
tubercles  occasionally  develop  on  the  hands.  There  may  be  pigmentary 
staining,  the  chloa^'^ma  phthisicorum,  Avhich  is  more  common  when  the 
jieritoneum  is  involved.  Upon  the  chest  and  back  the  brown  stains  of 
the  jjiti/riusi><  vcr><icolor  are  very  frequent.  The  hair  of  the  head  and 
beard  may  become  dry  and  lanky.  The  terminal  phalanges,  in  chronic 
cases,  become  clubbed  and  the  nails  incurvated — the  Hippocratic  fingers. 

DiAGXOSis. — AVhen  well  advanced  there  is  rarely  any  doubt  as  to 
existence  of  tuberculous  phthisis,  for  the  sputum  gives  positive  infor- 
mation and  the  physical  signs  of  local  disease  are  well  marked.  The 
bacilli  give  an  inlallible  indication  of  the  existence  of  tuberculosis,  and 
may  be  found  in  the  sputum  before  the  physical  signs  are  at  all  definite. 
On  the  other  hand,  it  must  be  remembered  that  there  are  cases  in  which, 
even  with  tolerably  well  defined  physical  signs,  the  sputum  is  extremely 
scanty,  and  many  exaiuinatious  may  be  required  to  detect  tubercle  bacilli. 
Early  detection  is  of  vital  importance,  as  successful  treatment  depends 
upon  the  measures  taken  before  the  lungs  are  extensively  involved. 

The  presence  of  elastic  fibres  in  the  sputum  is  an  indication  of 
destruction  of  the  lung  tissue.  In  a  large  proportion  of  cases  it  is 
indicative  too  of  tuberculous  disease.  It  also  may  be  found  early, 
before  the  physical  signs  are  well  marked.  Its  detection  is  easy  by  the 
above  mentioned  method,  not  requiring  high  powers  of  the  microscope. 
In  cases  of  early  haemoptysis,  before  there  is  marked  constitutional  dis- 
turbance or  even  local  signs,  it  is  very  important  to  make  a  thorough 
examination  of  the  sputum,  from  which  mucoid  and  purulent  portions 
may  be  picked  out  for  examination.  With  localized  and  persistent  signs 
in  one  lung,  cough,  fever,  and  loss  of  flesh,  the  diagnosis  is  rarely 
dubious.  It  is  remarkable,  however,  to  what  extent  the  local  process 
may  sometimes  proceed  without  disturbance  of  health  sufficient  to  excite 
the  alarm  of  the  physician  or  friends.  There  are  puzzling  cases  with 
localized  physical  signs  at  one  apex,  chiefly  moist  rales,  rarely  any  per- 
cussion changes,  perhaps  slight  fever,  and  a  glairy  expectoration  con- 
taining numerous  alveolar  cells.  I  have  seen  several  cases  of  this  kind 
which  have  been  for  a  time  very  obscure,  and  in  which  repeated  exam- 
inations failed  to  detect  either  bacilli  or  clastic  tissue.  They  seem  to  be 
instances  of  localized  catarrh  of  the  smaller  tubes. 


804  TUBERCULOSIS. 

ni.   Fibroid  Phthisis. 

As  already  mentioned,  sclerosis  is  in  some  degree  a  constant  accom- 
paniment of  tuberculosis.  There  are  cases  in  which  this  process  domi- 
nates the  picture  from  the  very  outset.  Fibroid  phthisis  may  follow  a 
chronic  tuberculous  pleurisy  or  it  may  supervene  upon  an  ordinary  ulcer- 
ative tuberculosis.  All  grades  are  met  with  between  cases  which  resem- 
ble, in  almost  every  respect,  the  non-bacillary  cirrhosis  of  the  lung  and 
instances  of  ulcerative  tuberculosis  with  cavity  formation  and  extensive 
shrinkage  from  associated  sclerosis.  Every  case  of  arrested  pulmonary 
tuberculosis  is  an  epitome  of  fibroid  phthisis.  In  the  process  of  healing 
which  goes  on  in  a  section  of  the  apex  the  fibroid  transformation,  the 
pigmentation,  and  the  dilatation  of  the  bronchi  form  a  miniature  picture 
of  what  may  go  on  in  an  entire  lobe  or  in  an  entire  lung. 

Morbid  Ax  atomy. — So  shrunken  may  be  the  lung  that  no  trace  of 
any  natural  appearance  of  the  organ  is  seen.  In  the  case  of  a  physician 
who  had  been  for  twenty-five  years  under  the  observation  of  Palmer 
Howard,  and  who  had  left  instructions  that  his  lungs  should  be  sent  to 
the  museum  at  McGill  College,  the  medical  men  who  performed  the 
autopsy  sent  one  enormously  hypertrophied  lung,  and  stated  that  the 
other  could  not  be  found,  as  it  was  shrivelled  to  a  jelly-like  substance. 
The  pleural  layers  are  enormously  thickened,  and  it  is  only  with  the  great- 
est difficulty  that  the  parts  can  be  separated  from  the  chest  wall.  The 
entire  mass  of  the  lung  may  not  be  much  larger  than  a  spleen.  In  other 
instances  the  process  may  be  confined  chiefly  to  the  upper  lobe  or  to  the 
upper  and  middle  lobes.  On  section  there  may  be  no  evidence  whatever 
of  lobes.  The  pleura  is  from  1  to  3  cm.  in  thickness.  The  normal 
parenchyma  of  the  lung  may  be  everywhere  substituted  by  fibrous  tissue. 
In  cases  which  have  originated  in  the  pleura  bands  may  be  seen  passing 
into  the  substance  from  the  thickened  membranes.  At  the  apex,  some- 
times throughout  the  entire  lung,  there  are  old  puckered,  thick-walled 
cavities,  some  of  which  represent  greatly  dilated  bronchi ;  others  are  in 
communication  with  them.  About  the  cavities  and  throughout  the 
fibrous  tissue  there  is  much  pigmentation,  which  gives  a  marbled  appear- 
ance to  the  section.  Encapsulated  cheesy  or  calcareous  nodules  may  be 
present.  This  picture  of  the  advanced  grade  of  chronic  fibroid  tuberculosis, 
in  which  the  whole  lung  is  involved,  is  hardly  to  be  distinguished  from 
non-tuberculous  cirrhosis  of  the  lung,  but  in  the  former  bacilli  will  be 
found  in  the  walls  of  the  cavities,  and  cheesy  or  calcareous  masses  are 
present.  Even  more  typical  are  those  cases  in  which  the  process  is 
confined  for  a  long  period  of  years  to  the  upper  portion  of  the  lung. 
The  shrinkage  then  is  remarkable,  and  an  entire  upper  lobe  may  form  a 
mass  not  half  the  size  of  the  fist,  shrunken,  puckered,  and  composed  of 
dense,  deeply  pigmented  connective  tissue,  with  contracted,  thick-walled 
cavities  and  dilated  bronchi.  In  such  instances  the  lower  lobe  usually 
is  the  seat  of  chronic  tuberculosis  with  cavities  and  old,  hard  tubercles 
and  encapsulated  cheesy  and  calcareous  masses.  The  unaffected  lung  is 
usually  very  voluminous  and  emphysematous.  It  may  present  local 
signs  of  tuberculosis  at  the  apex,  or  fresh  tuberculosis  which  has 
proved  fatal.  The  heart  is  usually  enlarged,  particularly  the  right 
ventricle. 


Fllilioil)  I '11  Til  IS  IS.  805 

Clinical  History. — The  onset  and  early  features  are  in  a  niaj<»rity 
of  cases  those  of  chronic  nleerative  phthisis,  and  for  a  year  or  more  the 
])atient  may  present  all  the  featnres  of  that  form.  After  variations  in  the 
course  all  activity  in  the  process  sui)sides  and  the  case  enters  upon  the 
chronic  sta<ic.  'riic  follow! lit;  is  a  ^^*hh\  descrij)ti<)n  iriven  by  C'hirU,  Had- 
ley,  and  C'hai)lin  :  ' 

"The  temperature,  which  before  ^\■as  always  raised  in  the  evening, 
is  now  often  normal ;  the  sweating  becomes  less  and  the  patient  regains 
much  of  his  wonted  strength  and  flesh.  If  one  keeps  the  case  under 
observation  all  this  time,  it  will  be  seen  that  the  affected  side  becomes 
more  and  more  flattened,  the  rib  spaces  fall  in,  and  the  movement  be- 
comes appreciably  diminished  ;  at  the  same  time  the  impairment  of  note 
becomes  increasingly  marked,  until  absolute  dulness,  extending  over  a 
great  part  of  the  lung,  can  be  made  out.  The  displacement  of  organs 
now  makes  its  appearance.  The  heart  is  drawn  toward  the  affected  side  ; 
the  stomach  may  be  drawn  up  if  the  disease  is  left-sided.  The  lung 
least  diseased  becomes  affected  with  compensatory  hypertrophy  or  with 
emphysema,  and  extends  across  the  sternum  to  the  most  diseased  side. 
If  the  heart  be  now  examined,  often  some  hypertrophy  can  be  made 
out  and  the  beats  of  the  organ  are  much  altered ;  instead  of  being  quick 
and  frequent,  they  are  slow,  measured,  and  infrequent.  The  sounds 
heard  over  the  diseased  lung  also  become  gradually  altered.  In  the 
place  of  the  sharp,  fine,  moist  crepitations  which  could  be  noticed  when 
the  case  was  first  seen,  there  are  now  coarse  bubbling  rales,  rhonchi,  and 
fine  superficial  rustling  crepitations.  The  bronchial  breathing  and  bron- 
chophony are  intense,  and  often  pectoriloquy  can  be  heard.  The  fingers 
may  become  much  clubbed,  and  sometimes  the  urine  becomes  albuminous. 
Even  the  countenance  can  sometimes  be  observed  to  wear  a  congested 
appearance.  The  dyspnoea  remains  very  much  what  it  was  at  first,  but 
the  cough  and  expectoration  undergo  a  change.  The  cough  is  now 
paroxysmal,  often  bad  in  the  morning  on  waking,  and  attended  Anth 
gushes  of  expectoration,  which  suggest  the  emptying  of  dilated  tubes. 
After  lasting  some  time  in  this  condition  the  patient  generally  succumbs 
to  a  fresh  eruption  of  tubercles  in  the  least  affected  lung  or  to  an  attack 
of  htemoptysis.  Owing  to  the  altered  condition  of  the  bloodvessels, 
and  especially  to  their  diminished  elasticity,  haemoptysis  is  sometimes 
more  prolonged  and  severe  in  these  cases  than  in  cases  of  ordinary 
tuberculosis." 

The  clinical  course  of  tuberculo-fibroid  disease  of  the  lung  is  ex- 
tremely varied.  There  are  instances  in  which  after  a  year  or  two  the 
patient  has  little  or  no  further  troulde,  and  he  would  consider  himself 
quite  well  except  for  the  morning  cough  with  a  slight  amount  of  ex- 
pectoration. In  other  cases  there  are  periodical  slight  rises  in  tempera- 
ture with  aggravation  of  the  cough,  and  for  years  there  may  be  alter- 
nations of  these  outbreaks  with  prolonged  periods  of  quiescence.  Recur- 
ring hemorrhages  form  a  verv  striking  feature  in  some  of  the  cases. 

An  important  change  proceeds  in  the  condition  of  the  heart  and 
arteries.  In  consequence  of  the  gradual  obliteration  of  a  large  area  of 
the  pulmonary-  circulation  there  is  hypertrophy  of  the  right  heart,  and 
the  area  of  cardiac  pulsation  is  usually  extensive.     The  peripheral  arte- 

1  On  Fibroid  Phthigis,  London,  li;94. 


806  TUBERCULOSIS. 

ries  be(3ome  gradually  sclerotic,  and  there  may  be  well  marked  phlebo- 
sclerosis.  Three  dangers  threaten  cases  of  fibroid  tuberculous  disease  : 
(1)  hemorrhage,  which  is  usually  profuse,  and  comes  either  from  an 
eroded  vessel  in  the  "wall  of  the  cavity  or  from  the  rupture  of  a  small 
aneurysm ;  (2)  extension  or  generalization  of  the  tuberculosis  ;  (3)  failure 
of  the  hypertrophied  heart.  Of  these  the  last  is  perhaps  the  most  im- 
portant. A  certain  number  of  patients  succumb  with  gradual  dilata- 
tion of  the  right  heart  and  anasarca.  There  are  instances  in  which  this 
has  been  combined  with  amyloid  disease  of  the  kidney — not,  in  my  ex- 
perience, a  very  common  sequel  of  the  disease.  There  are  other  in- 
stances in  which  there  is  more  acute  dilatation  of  the  heart  and  the 
patient  dies  with  urgent  orthopnoea  and  cyanosis. 

Diagnosis. — It  is  not,  as  a  rule,  difficult  to  distinguish  cases  of 
tuberculo-fibroid  disease  from  cirrhosis  of  the  lung  due  to  other  causes. 
The  history  is  of  importance,  as  the  latter  disease  usually  follows  a 
pleurisy,  a  pneumonia,  a  broncho-pneumonia,  or  a  prolonged  bronchitis, 
so  that  the  mode  of  onset  and  preliminary  features  are  very  different 
in  the  two  conditions.  Once  established,  cirrhosis  of  the  lung  is  very 
much  less  liable  to  be  interrupted  by  febrile  outbreaks  and  the  general 
health  and  vigor  are  of  a  very  much  higher  standard.  In  the  mono- 
graph just  referred  to  the  authors  very  justly  lay  considerable  stress 
upon  the  very  different  as])ect  of  the  patients :  "  A  case  of  tuberculo- 
fibroid  disease,  however  fibroid  it  may  become,  always  bears,  in  the 
general  aspect  of  the  patient,  evidence  of  its  tubercular  origin.  The 
cast  of  countenance  is  not  of  that  heavy  kind  so  often  observable  in  thp 
pure  fibroid  variety.  The  lips  are  not  thick  and  congested,  the  com- 
plexion has  not  the  muddy  look,  the  hair  remains  lank,  and  the  eye- 
lashes long.  The  whole  appearance  of  the  face  suggests  tubercle  and 
frail  health.  It  is  true  that  one  does  meet  with  tuberculo-fibroid  disease 
in  which  the  fibroid  characters  are  somewhat  clearly  marked  in  the  face, 
but  never,  so  far  as  we  are  aware,  to  the  extent  of  its  being  mistaken 
for  pure  fibroid  disease." 

The  presence  of  tubercle  bacilli  is  a  very  important  point  in  the 
diagnosis.  It  is  surprising,  indeed,  how  they  persist  in  long  stand- 
ing cases  in  which  the  symptoms  have  been  quiescent  for  years.  When 
not  evident  during  life  the  tuberculous  character  of  the  lesions  may  be 
determined  sometimes  post-mortem  by  the  presence  of  encapsulated 
caseous  masses. 

Chronic  syphilis  of  the  lung  occasionally  produces  conditions  which 
may  simulate  this  form  of  pulmonary  tuberculosis.  The  special  points 
which  would  favor  the  former  are  the  pronounced  history  of  syphilis, 
the  coexistence  of  syphilitic  lesions,  the  chronic  course,  often  with  very 
slight  or  no  fever.  The  local  signs  are  more  commonly  in  the  middle 
regions  of  the  lungs  toward  tlie  root,  and  are  associated  with  chronic 
fibroid  changes.  The  dulness  may  be  very  wooden  in  quality  and 
clearly  defined.  The  apex  of  the  lung  is  often  spared.  The  most  im- 
portant of  all  is  the  existence  of  a  chronic  lesion  of  the  lung  in  a 
syphilitic  person  "svithout  tubercle  bacilli  in  the  expectoration.  It  some- 
times happens  that  a  syphilitic  lung  becomes  infected  with  tuberculosis. 

Concurrent  Infections  in  Pulmonary  Tuberculosis. — The 
complex  anatomical  and  clinical  picture  of  pulmonary  tuberculosis  is 


I'liiiinii)  riiruisis.  807 

not  the  outcoiiu'  of  the  action  ol'  tlic  l):icillii.<  tiihcrciilosis  alone.  Jt  is 
well  known  that  (ttlicr  oruanisms  play  an  important  i-olc.  The  ohscrva- 
tions  ot"  Balx's,  Cornet,  Ortner,  and  others  have  shown  the  very  lVe(inent 
association  of  the  niicroe(X'eus  laneeohitus,  the  streptoeoecns  pyoj^enes, 
the  staphyloeoeens  aureus,  and  the  bacillus  pyoeyaneus.  Their  work 
lias  been  confirmed  by  many  subsequent  observers,  and  in  the  stage  of 
liectie  the  pvoiicnic  oi-<2,anisms  have  even  been  isolated  from  the  blood. 

PrntUlen,  who  has  very  carefully  studied  this  (|uestion,  arrives  at  the 
following-  eonehisions  :  The  j)ulnionary  lesions  of  tubereidosis  are  sub- 
ject to  variations  depending  largely  on  the  different  modes  of  distribu- 
tion of  the  bacilli,  whether  by  the  bloodvessels  or  through  the  bronchi, 
and  also  whether  a  concurrent  infection  with  other  organisms  has  taken 
place.  The  pneumonia  eomplicating  tul>erculosis  may  be  the  direct 
result  of  the  tuberele  l)aeillus  or  its  toxins,  or  it  may  follow  secondary 
infection  with  other  germs,  particularly  the  strej>tococcus  pyogenes,  the 
micrococcus  lanceolatus,  and  the  staphylococcus  pyogenes.  The  fre- 
quency of  this  secondary  infection  and  the  relative  significance  of  these 
germs  are  not  yet  fully  decided.  The  introduction  of  the  tubercle 
bacilli  into  the  lungs  of  a  rabbit  through  the  trachea  induces  the 
various  phases  of  pulmonary  tuberculosis,  but  cavity  formation  is  rare. 
If,  on  the  other  hand,  into  the  lungs  of  a  rabbit  which  are  the  seat  of 
extensive  consolidation  the  streptococcus  pyogenes  is  introduced,  then 
cavities  form  rapidly,  and  the  anatomical  picture  is  very  similar  to  that 
of  chronic  ulcerative  tuberculosis  in  man.  It  is  very  probable  that  in 
man,  too,  the  effect  of  contamination  with  these  pus  organisms  is  a  very 
important  one  in  hastening  necrosis  and  softening,  and  also  in  the 
chronic  cases  they  doubtless  produce  in  large  amounts  the  toxins  which 
are  responsible  for  many  of  the  symptoms  of  the  disease. 

Diseases  Associated  with  Pulmoxary  Tuberculosis. — Lobar 
pneumonia,  as  already  mentioned,  is  a  not  uncommon  complication  which 
carries  off  a  certain  number  of  cases.  It  may  be  difficult  to  distinguish 
from  an  acute  tuberculous  pneumonia.  In  chronic  ulcerative  tubercu- 
losis, however,  this  form  is  not  so  common,  and  rapid  consolidation  of 
the  lower  lobe,  with  rusty  expectoration  and  high  fever,  is  much  more 
likely  to  be  a  simple  croupous  pneumonia.  With  tuberculosis,  either 
in  the  acute  or  chronic  form,  typhoid  fever  may  coexist.  In  4  cases  of 
80  autopsies  in  typhoid  fever  tuberculous  lesions  were  present.  There 
are  cases  on  record  also  of  acute  miliary  tuberculosis  and  typhoid  fever 
present  in  the  same  subject.  There  is  a  widespread  opinion  that  typhoid 
fever  predisposes  to  tuberculosis,  and  "Wilson  Fox  in  his  treatise  on 
diseases  of  the  lungs  gives  references  to  a  number  of  cases.  In  my 
experience  it  has  been  very  rare.  I  have  no  recollection  of  an  instance 
in  which  tuberculosis  has  developed  either  during  convalescence,  or 
immediately  after  recovery,  from  typhoid  fever. 

Erysipelas  sometimes  attacks  the  subjects  of  chronic  phthisis,  who 
are  not,  however,  specially  liable  to  the  disease.  There  are  a  number 
of  cases  on  record  in  which  an  attack  of  erysipelas  has  been  beneficial, 
and  after  recovery  the  severity  of  the  pulmonary  symptoms  has  miti- 
gated, and  there  are  cases  in  which  cure  has  been  reported.  On  the 
other  hand,  I  have  known  cases  in  which  the  attack  has  proved  rapidly 
fatal  in  persons  far  advanced  in  the  disease. 


TUBERCULOSIS. 

The  eruptive  fevers  rarely  develop  in  the  course  of  pulmonary  tu- 
berculosis. Malaria  was  formerly  thought  to  antagonize  tuberculosis, 
a  view  for  which  there  is  no  special  warrant.  The  early  chills  and  fever 
of  developing  pulmonary  tuberculosis  are  very  apt  to  lead  to  error  in 
diagnosis,  and  cases  are  often  treated  for  weeks  or  months  as  malarial 
intermittent  fever. 

Heart  Diseases. — Endocarditis  is  not  verv^  infrequent  in  pulmonary 
tuberculosis.  It  was  present,  as  already  mentioned,  in  12  of  my  post- 
mortems and  in  27  of  Percy  Kidd's  500  autopsies.  The  subject  has 
been  considered  in  a  monograph  by  Teissier  (Paris,  1894).  The  endo- 
cardial lesions  are,  as  a  rule,  vegetative,  rarely  caseous,  and  due  com- 
monly to  the  associated  micro-organisms,  but  in  a  few  instances  the 
tubercle  bacillus  has  been  present  alone.  Ulcerative  lesions  are  rare. 
Both  Louis  and  Rokitansky  held  that  there  was  a  certain  antagonism 
between  valvular  disease  and  pulmonary  tuberculosis — a  view  which 
has  not  been  borne  out  by  subsequent  studies.  Certainly  stenosis  of 
the  pulmonary  artery  and  aneurysm  of  the  aorta  predispose  to  tubercu- 
losis pulmonum.  A  terminal  acute  tuberculosis  is  a  common  event  in 
all  forms  of  cardio-vascular  disease.  The  relation  of  mitral  stenosis 
to  pulmonary  tuberculosis  is  still  a  matter  of  debate.  In  9  of  54  cases 
of  stenosis  Potain  found  pulmonary  tuberculosis  present.  Teissier  con- 
cludes that  it  is  antagonistic  to  the  progress  of  the  disease.  In  long 
standing  cases  of  the  disease  arterio-sclerosis  is  very  common.  Phlebo- 
sclerosis  is  also  not  infrequently  met  with.  The  frequency  of  the  renal 
changes  may  possibly  be  correlated  with  this  arterio-sclerosis.  Ormerod 
noted  30  cases  of  chronic  renal  disease  in  100  autopsies. 

The  association  of  gout  and  rheumatism  with  pulmonary  tuberculosis 
has  often  been  referred  to,  particularly  by  the  older  writers,  among 
M'hom  Morton  described  a  species — phthisis  de  arthritide.  In  institu- 
tion life,  particularly  in  the  almshouses,  the  subjects  of  chronic  joint 
troubles  are  very  often  attacked  by  tuberculosis,  and  it  is  probably  a 
matter  entirely  of  greater  liability  to  infection. 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Ex- 
tremes OF  Life. — (a)  Infancy. — Tuberculosis  is  a  widespread  aflPec- 
tion  in  the  early  periods  of  life.  AVhile  extremely  rare  in  the 
newborn,  and  not  at  all  prevalent  in  the  first  three  months  of  life, 
the  cases  increase  rapidly  throughout  the  latter  half  of  the  first  year 
and  during  the  second  year.  In  the  statistics  of  the  late  Professor 
Parrot,  of  219  cases  in  children  under  three  years  there  were  from  one 
day  to  three  months  23  cases ;  from  three  to  six  months,  35  cases ; 
from  six  to  twelve  months,  53  cases — a  total  of  111  cases  under  one 
year.  Pulmonary  cavities  were  present  in  57  of  the  cases,  and  in  50 
the  lung  disease  was  the  only  manifestation.  Of  125  cases  at  the  Xew 
York  Foundling  Hospital,  reported  b}'  Xorthrup,  in  34  cases  the 
disease  was  extensive  and  the  seat  of  the  primary  infection  was  not 
clear,  but  the  bronchial  glands  were  large  and  cheesy.  In  42  cases  of 
general  tuberculosis  the  only  caseous  masses  were  in  the  bronchial 
glands.  In  9  cases  the  tubercles  were  limited  to  these  glands  and  to 
the  lungs,  the  latter  containing  only  miliary  tubercles,  while  the  bron- 
chial glands  were  in  a  state  of  advanced  caseation.  In  13  cases  there 
was  tuberculosis  of  the  bronchial  glands  only.     These  extremely  sug- 


Finn'fin  I'lnnisfs.  809 

gestivc  figures  slmw  the  lii^cat  prcN  nlciicf  dl"  iiircctioii  tlinmuh  tlic 
bronchial  ])ass:iu'('s.  On  the  othci'  hand,  of  127  I'atal  eases  ot"  tiihereii- 
losis  in  ehildren  nol<'(l  hy  Wdodhead,  the  niesenterie  glands  were 
tuheretdoiis  in  100.  \\'alter  C'arr  in  the  examination  of"  the  bodies 
of  120  tuberculous  children  concludes  that  the  disease  starts  much 
more  frequently  in  the  thoracic  than  in  the  mesenteric  glands.  Of  500 
auto|)sies  in  children  at  the  Mmiich  Pathological  Institute,  in  loO 
tul)ereulosis  was  present,  and  in  over  92  per  cent,  of  these  the  lungs 
were  involved. 

[/))  Old  Age. — The  prevalence  of  tuberculosis  in  the  aged,  i)articu- 
larly  in  institutions,  has  been  long  known.  The  physicians  to  the 
large  hospitals  for  old  people,  as  at  the  Chelsea,  the  Bicetre,  and  the 
8alpetriere,  have  long  recognized  the  great  frequency  of  tuberculosis 
as  a  cause  of  death.  In  the  post-mortem  room  of  the  Philadelphia 
Hospital,  to  which  the  bodies  of  aged  persons  were  sent  from  the 
iilmshouse  department,  it  was  extremely  common  to  find  old  or  re- 
cent tuberculosis.  An  important  study  of  the  subject  has  been  made 
recently  by  Barie.^  In  the  year  1891  there  were  in  Paris  10,649 
<leaths  from  pulmonary  tuberculosis.  In  641  of  these  the  individuals 
were  above  the  age  of  sixty.  In  the  decennial  period  1884  to  1893 
there  died  of  pulmonary  tuberculosis  in  the  ten  large  hospitals  or  alms- 
houses of  Paris  2202  persons  between  the  ages  of  sixty  and  ninety- 
two.  Among  the  special  peculiarities  of  the  pulmonary  tuberculosis 
of  the  aged  is  its  latency  and  slow  course.  In  very  many  instances 
there  are  found  only  puckered  cicatrices  at  the  apices  or  calcified  masses 
or  fibroid  areas.  In  other  instances  there  is  extensive  bronchiectasis 
with  senile  emphysema,  with  which  form  and  tuberculosis  there  is  no 
antagonism,  as  believed  by  Rokitanskv.  The  more  acute  forms  of 
the  disease  are  also  met  with,  and  Barie  gives  a  number  of  cases  of 
the  acute  pneumonic  as  well  as  the  acute  miliary  forms  of  tubercu- 
losis. 

Modes  of  Death  ix  Pulmoxary  Tuberculosis. —  (a)  By 
Asthenia. — In  a  majority  of  the  cases  the  patient  sinks  gradually,  with 
progressive  failure  of  the  strength  in  a  septicaemia.  As  a  rule,  the 
end  is  quiet  and  undisturbed.  Consciousness  may  be  retained  until  the 
close. 

(6)  Bi/  Asphi/.via. — This  is  rarely  met  with  apart  from  the  develop- 
ment of  an  acute  miliary  tuberculosis  or  a  rapid,  widespread  bronchitis 
of  the  smaller    tubes. 

(c)  By  Syncope. — This  is  not  very  common,  but  patients  in  the 
advanced  stag-es  of  the  disease  during  sudden  exertion  or  Avhile  on  a 
journey  may  drop  dead.  It  will  be  remembered  that  Branwell  Bronte 
insisted  upon  keeping  up,  and  died  standing. 

(f?)  From  Hemorrhage. — The  fatal  bleeding  in  chronic  phthisis  may 
come  from  the  lungs  or  from  the  intestine.  Rupture  of  an  aneurysm 
in  the  walls  of  a  cavity  or  erosion  of  a  large  vessel  is  the  common 
cause  of  the  fatal  haemoptysis.  The  importance  of  this  lesion  may  be 
judged  from  the  fact  that  in  35  cases  collected  by  Percy  Kidd  aneurysm 
was  present  in  30.  In  the  case  of  very  large  cavities  the  bleeding  may 
prove  fatal  before  any  haemoptysis  occurs.     In  the  body  of  a  man  very 

^  Revue  de  Medecine,  October,  1895. 


810  TUBERCULOSIS. 

far  advanced  in  phthisis,  who  died  quite  suddenly  in  the  Philadelphia 
Hospital,  I  found  a  very  large  cavity,  occupying  almost  the  upper 
two  thirds  of  the  lung,  which  was  filled  with  blood  which  had  come 
from  an.  eroded  vessel  in  the  w^all  of  a  small  cavity  in  the  lower  lobe. 
The  patient  had  not  had  heemoptysis.  Severe  and  fatal  hemorrhage 
may  follow  ulceration  of  the  colon,  less  frequently  of  the  ileum.  On 
several  occasions  I  have  known  death  to  occur  in  chronic  pulmonary 
tuberculosis  from  this  cause. 

(e)  With  Cerebral  Symptoms. — The  tuberculous  meningitis  may  cause 
coma  or  convulsions.  Uraemia  as  a  cause  of  death  is  rare.  Occasion- 
ally in  very  lingering  cases  a  sudden  coma  may  be  due  to  thrombosis 
in  the  cerebral  sinuses. 


V.  TUBERCULOSIS   OF  THE   ALIMENTARY  SYSTEM. 

Tuberculosis  of  the  Alimentary  Canal. 

{a)  Lips. — Tuberculosis  of  the  lips  is  very  rare.  It  occurs  occasion- 
ally in  the  form  of  an  ulcer,  either  alone  or  more  commonly  in  associa- 
tion with  laryngeal  or  pulmonary  disease.  The  process  may  result  from 
extension  of  a  focus  of  ulceration  in  the  mouth,  as  in  a  case  reported 
by  Lord  in  1892.  In  addition  to  a  tuberculous  ulceration  of  the  right 
tonsil,  the  patient  presented  a  small  irregular  ulcer  on  the  inside  of  the 
left  cheek.  This  gradually  extended,  until  eighteen  months  later  it 
involved  both  lips,  which  became  very  much  swollen.  A  report  of  two 
cases  and  an  analysis  of  the  literature  is  given  in  tome  iii.  of  Verneuil's 
Etudes.  The  ulcer  is  usually  very  sensitive,  and,  owdng  to  the  compara- 
tive frequency  of  epithelioma  and  of  chancre  of  the  lip,  may  be  mis- 
taken for  these.  The  diagnosis  in  doubtful  cases  may  be  made  by  inocu- 
lation experiments  or  the  examination  of  a  portion  for  tubercle  bacilli. 

(6)  Tongue. — In  1858,  Sir  James  Paget  gave  a  description  of  tuber- 
culous ulceration  of  the  tongue,  and  he  is  credited  with  having  been  the 
first  to  recognize  this  condition.  Mr.  Arthur  Barker  ^  reviewed  the  sub- 
ject and  gave  an  analysis  of  15  cases.  The  disease  is  nearly  always 
associated  with  tuberculosis  of  some  other  organ.  It  occurs  most  com- 
monly on  the  dorsum  or  edge,  although  the  tip  is  quite  frequently 
involved.  When  it  is  associated  with  tuberculosis  of  the  larynx  or 
lungs  the  ulceration  is  usually  found  on  the  same  side  as  the  most 
advanced  lesions  in  these  parts.  The  organ  may  be  involved  by  direct 
extension  of  a  tuberculous  ulcer  of  the  pharynx  or  epiglottis,  in  which 
case  the  posterior  portion  will  be  first  attacked.  The  condition  is  found 
much  more  commonly  in  males  than  in  females.  Of  the  15  cases  col- 
lected by  Barker,  11  were  in  males  and  4  in  females.  In  the  earliest 
stages  an  aggregation  of  small  tubercles  appears  beneath  the  mucous 
membrane.  The  epithelium  is  finally  shed  and  a  point  of  superficial 
ulceration  remains.  By  the  coalescence  of  these  small  areas  a  definite 
ulcer  is  formed,  which  is  characterized  by  having  an  irregular  outline, 
distinct,  uneven  margin,  and  a  rough  base  covered  with  a  grayish  case- 
ous detritus.     The  disease  extends  slowly,  rarely  if  ever  heals,  and  may 

^  Trans.  Path.  Soc,  Lon.,  xxxv.,  1884. 


TUBKRCrLOSIS   OF   Till-:   M.IMKXTA  IIY    ('ASM..  Si  1 

form  an  ulcer  of  coiisidcrnlilc  size.  In  loii^'  st;ni<liiiu'  ca.-cs  the  hasc  of 
tlio  ulcer  heconics  indurated  and  the  condition  may  he  mistaken  iur  epi- 
thelioma. Until  the  <lisease  heeomes  very  far  advanced  hnt  little  incon- 
venience is  oci'asioned  beyond  a  slight  inei'ease  in  the  secretion  of  saliva. 
Unlike  epithelioma,  very  little  pain  is  complained  of,  and  the  movements 
of  the  tongue  are  not  impeded  until  tiie  late  stao-es.  In  two  cases  of 
tuberculous  ulceration  of  the  tongue  reported  by  Frerichs  the  submaxil- 
lary lymph  olands  were  enlar<>:ed  and  caseated  in  both  instances.  From 
syphilitic  ulceration  the  condition  would  be  recoi>;ni/ed  by  the  historvof 
the  ease  and  the  absence  of  any  impntvement  under  treatment  with 
iodide  of  potassium.  In  doubtful  eases  inoculation  tests  should  be  made 
or  a  portion  excised  for  inicrosco})i(;al  examination. 

(c)  Palate. — Tuberculosis  of  the  hard  and  soft  palate  nearly  alwavs 
results  from  an  extension  of  the  disease  from  nei<2jhborin<>'  parts.  Barker 
records  a  case  in  a  <>'irl  of  fifteen  years  in  whom  there  had  })een  such  an 
extensive  destruction  of  the  hard  and  soft  palate  and  the  alveolar  process 
that  many  of  the  teeth  iiad  become  loosened  and  several  had  fallen  out. 
The  disease  had  extended  into  the  nasal  cavity. 

{d)  The  saUcarij  glands  belong  to  that  small  group  of  organs  of  the 
body  which  seem  to  possess  an  immunity  against  tuberculous  infection 
— an  immunity,  however,  which  in  their  case  is  relative,  not  absolute. 
The  literature  contains  only  a  very  few  accounts  of  such  a  condition. 
Von  Stubenrauch,'  in  reporting  a  case  of  tuberculosis  of  the  parotid 
gland  had  been  unable  to  find  records  of  a  previous  case  after  a  careful 
search  of  the  literature.  Frerichs,  however,  had  previously  recorded  an 
instance  in  which  both  parotid  glands  contained  four  or  five  caseous  foci, 
each  about  the  size  of  a  lentil.  The  submaxillary  and  sublingual  glands 
were  normal,  although  the  patient  presented  advanced  tuberculous  lesions 
in  various  organs  of  the  body.  Leguen  and  Marien  have  recently  re- 
ported a  case  resembling  that  of  Stubenrauch,  in  both  of  which  the  gland 
presented  a  distinct  localized  swelling,  the  skin  remaining  normal  in 
appearance  and  freely  movable  over  it.  The  tubercles  develop  in  the 
interacinous  connective  tissue,  and  the  writers  agree  in  considering  that 
infection  occurs  by  way  of  Steno's  duct.  Dmochowski  claims  to  have 
found  the  sublingual  gland  tuberculous  in  6  instances  out  of  15  autopsies 
on  patients  with  pulmonary  tuberculosis. 

(e)  The  tonsil  has  in  recent  years  been  shown  to  be  much  more  com- 
monly the  seat  of  tuberculosis  than  was  formerly  supposed.  The  appar- 
ent infrequency  no  doubt  was  due  to  the  fact  that  in  many  instances  the 
disease  simulates  very  closely  the  ordinary  hypertro])hied  tonsil,  for 
which  it  is  often  mistaken.  Cohnheim  in  1878  advanced  the  theory  that 
the  majority  of  the  cases  of  tuberculosis  of  the  lips,  buccal  mucous  mem- 
brane, and  pharynx  were  surface  infections  due  to  the  ingestion  of  food, 
particularly  milk,  containing  tubercle  bacilli.  In  1884,  Strassmann, 
working  under  Cohnheim  and  Weigert,  found  the  tonsils  involved  in  13 
instances  out  of  21  autopsies.  Dmochowski  found  them  tuberculous  in 
all  of  his  15  cases,  and  demonstrated  tubercle  bacilli  in  the  lymphatics 
between  the  tonsils  and  the  cervical  lymph  glands.  The  latter  observa- 
tion is  interesting  in  connection  with  the  views  of  Schlenker,-  who  claims 
that  the  majority  of  the  cases  of  tuberculous  cervical  glands  result  from 

^  Archiv  fixr  Chirurgie,  1894.  '^  Virchoiv's  Archiv,  1893,  Bd.  cxxxiv. 


812  TUBERCULOSrS. 

infection  with  tubercle  bacilli  which  gain  admission  by  way  of  the  tonsil. 
A  large  number  of  his  cases  of  tuberculous  cervical  adenitis  Avere  defi- 
nitely of  a  descending  variety  and  associated  with  tuberculosis  of  these 
glands.  The  majority  also  had  pulmonary  tuberculosis,  and  he  regards 
surface  infection  of  the  tonsil  by  tuberculous  food  and  sputum  far  more 
common  than  infection  by  way  of  the  circulation.  The  disease  may 
occur  as  a  superficial  ulceration.  More  commonly  there  is  an  infiltra- 
tion of  the  tonsil  with  miliary  tubercles,  which  produces  a  greater  or 
less  hypertrophy  which  it  is  practically  impossible  to  distinguish  from 
an  ordinary  enlarged  tonsil  without  a  microscopical  examination.  Case- 
ous foci  occasionally  develop. 

(/)  Pharynx. — In  extensive  laryngeal  tuberculosis  an  eruption  of 
miliary  tubercles  on  the  posterior  pharyngeal  wall  is  not  uncommon. 
In  chronic  phthisis  an  ulcerative  pharyngitis,  due  to  the  extension  of 
the  disease  from  the  epiglottis  and  larynx,  is  one  of  the  most  distressing 
of  complications  and  renders  deglutition  extremely  painful  and  difficult. 
Adenoids  of  the  nasopharynx  may  be  tuberculous,  as  shown  by  Lermoyez. 
Macroscopically,  they  do  not  differ  from  the  ordinary  vegetations  found 
in  this  situation.  He  records  a  case  in  which  pulmonary  tuberculosis 
set  in  soon  after  the  removal  of  adenoid  vegetations  which  were  shown 
to  be  tuberculous,  and  thinks  that  in  such  instances  the  tuberculous 
focus  in  the  adenoids  may  be  the  point  of  departure  of  general  infec- 
tion. Verneuil  points  out  the  risk  of  infection  which  is  run  in  curette- 
ment  of  ordinary  pharyngeal  vegetations,  especially  since  Straus  has 
demonstrated  the  frequency  of  tuberculosis  in  the  nasal  cavities  of 
men. 

{g)  The  Oesophagus. — Tuberculosis  of  the  oesophagus  is  a  compara- 
tively rare  occurrence.  It  is  only  since  the  appearance  of  Weichsel- 
baum's  and  Beck's  articles  in  1884  that  this  affection  of  the  oesophagus 
has  attracted  attention.  In  1893,  Flexner,  in  reporting  a  case  which 
occurred  in  my  wards,  was  able  to  find  in  the  literature  records  of  only 
19  well  authenticated  cases.  Frerichs  examined  30  cases  of  acute  and 
250  cases  of  chronic  tuberculosis.  Of  the  acute  cases,  8  had  tubercu- 
losis of  the  pharynx,  tonsils,  or  tongue  without  any  involvement  of  the 
oesophagus.  Of  the  chronic  cases,  only  1  case  of  oesophageal  tubercu- 
losis occurred.  The  cases  may  be  classed  under  three  headings  :  The 
first  includes  those  which  result  from  direct  extension  of  the  tuberculous 
process  from  some  of  the  neighboring  structures,  and  constitutes  the 
largest  percentage  of  the  cases.  A  group  of  caseous  bronchial  glands 
may  become  united  by  adhesions  to  the  oesophagus,  and  finally  ulcerate 
through  into  the  latter.  Penzolt  has  reported  3  cases  of  oesophageal 
tuberculosis  resulting  from  the  rupture  into  it  of  abscesses  due  to  caries 
of  the  vertebrse.  Slight  ulceration  of  the  upper  part  of  the  oesophagus 
following  pharyngeal  tuberculosis  occasionally  occurs.  The  second  class 
of  cases  embraces  those  instances  in  which  there  is  a  history  of  a  previ- 
ous lesion  of  the  oesophageal  mucous  membrane,  and  which  must  be  con- 
sidered as  a  predisposing  factor  to  tuberculous  infection.  Breus  records 
a  case  in  which  tuberculosis  of  the  oesophagus  followed  a  stricture  due 
to  the  swallowing  of  a  caustic  alkali,  and  Eppinger  an  instance  in  which 
it  followed  a  stricture  which  he  attributed  to  the  oi'dium  albicans. 
Finally,  in  the  third  class  must  be  placed  those  cases  which  occur  in  the 


TUBERCULOSIS  OF  THE  ALIMENTARY  CANAL.  «13 

course  of  an  aciilc  (lisscmiiiatcd  niiliai'v  tul)ci'('iil()>is,  and  lliosc  instances 
in  which  there  has  appai'ently  heen  an  infection  of  the  iniicons  menihi-ane 
with  tiil)en'nh)us  s[)utuni,  without  the  jiresenee  of  any  previous  })re(ns- 
posing  lesion.  The  case  which  occurred  in  my  wards  behjuged  to  this 
class.  On  tiie  anterior  wall  of  the  cesopiiagus  there  were  two  tuV)er- 
culous  ulcers,  measuring  4  and  7.5  mm.  respectively,  one  of  which 
had  perforated  into  the  left  pleural  cavity,  causing  a  purulent  |)1(  n- 
risy. 

The  disease  is  not  associated  with  any  very  definite  symptoms.  The 
occurrence  of  pain,  difficulty  in  swallowing,  and  evidence  of  stricture  in 
the  course  of  chronic  lung  and  lymph  tuberculosis  or  caries  of  the 
vertebroe  should  lead  one  to  suspect  involvement  of  the  (jesophagus. 

(/()  Stoiiach. — Miliary  tubercles  in  the  wall  of  the  stomach  are  not 
uncommon;  tuberculous  ulcers  of  the  organ  are  very  rare.  Many  of 
the  reported  cases  are  doubtful.  Marfan^  in  1887  in  reviewing  the 
subject  was  able  to  collect  only  14  authentic  cases.  Letorey^  quite 
recently  reported  a  case  and  gave  an  analysis  of  21  cases.  Nearly  all 
writers  are  agreed  that  the  disease  is  secondary.  It  is  commonest  in  the 
middle  period  of  life,  although  occasionally  children  are  aifected.  The 
condition  is  found  more  frequently  in  males  than  in  females.  Of  19 
cases  collected  by  Letorey  in  which  the  sex  was  mentioned,  it  occurred 
16  times  in  males  and  3  times  in  females.  In  the  great  majority  of  in- 
stances the  ulcers  are  single,  although  occasionally  they  may  be  multi- 
ple. In  a  recent  case  in  one  of  my  wards  there  were  numerous  ulcers 
of  various  sizes.  As  a  rule,  the  ulcers  are  associated  Avith  tuberculous 
ulceration  of  the  intestines.  Litten,  however,  has  reported  1  case  and 
Frerichs  has  noted  2  instances  in  which  the  stomach  was  the  only  part 
of  the  alimentary  tract  which  showed  ulceration.  The  pyloric  extremity 
and  the  greater  curvature  are  usually  involved.  The  ulcers  vary  in  size 
from  a  pin's  head  to  3  or  5  cm.  in  diameter.  In  the  case  reported  by 
Musser,  how^ever,  there  was  a  large  tuberculous  ulcer  three  by  one  and 
a  half  inches  in  extent.  Cheesy  tubercles  as  large  as  a  pea,  both  ulcer- 
ated and  non-ulcerated,  have  been  found  in  the  stomach,  but  they  are 
very  rare.  In  Oppolzer's  case  an  ulcer  of  the  colon  perforated  the 
organ.  Perforation  of  the  stomach  is  not  an  infrequent  occurrence.  It 
occurred  six  times  in  Marfan's  cases,  three  times  by  a  tuberculous  gland. 
As  a  rule,  the  condition  is  latent;  in  8  of  Letorey's  cases  the  ulceration 
was  suspected  during  life  and  was  verified  at  autopsy.  Occasionally 
severe  ha3matemesis  follows  erosion  of  a  bloodvessel  by  the  ulcerative 
process.  It  has  been  the  immediate  cause  of  death  in  at  least  2  in- 
stances. Death  sometimes  results  from  a  peritonitis  occasioned  by  the 
perforation,  as  in  Paulicky's  case,  although  it  generally  occurs  as  a  re- 
sult of  advanced  tuljcrculosis  in  other  organs. 

(i)  Infesfincs. — Tuberculosis  is  by  far  the  most  common  cause  of 
intestinal  ulceration.  No  part  of  the  intestinal  tract  enjoys  an  immunity 
against  tuberculous  infection.  The  disease  may  be  (1)  primary  in  the 
mucous  membrane,  or  more  commonly  (2)  secondary  to  disease  of  the 
lungs,  or  in  rare  cases  the  aifection  may  (3)  extend  from  the  peritoneum. 

(1)  Primary  intestinal  tuberculosis  occurs  most  frequently  in  children 
in  association  with  enlargement  and  caseation  of  the  mesenteric  glands 
1  Paris  Thesis,  1887.  ^  Ibid.,  1895. 


<S14  TUBERCULOSIS. 

or  with  peritonitis,  or  with  both.     It  may  be  verv  difficult  to  state  at 
the  time  of  the  autopsy,  with  any  degree  of  certainty,  whether  the  pri- 
mary lesion  has  been  intestinal  or  peritoneal.     The  very  great  frequency 
of  infection  through  the  bowel  is  shown  in  Woodhead's  analysis  of  127 
cases  of  fatal  tuberculosis  in  children,  100  of  which  showed  involve- 
ment of  the  mesenteric  glands.     Primary  tuberculosis  in  adults  is  very 
rare,  occurring  in  but  1  instance  in  1000  autopsies  upon  tuberculous 
subjects  at  the  Munich  Pathological  Institute.     Occasionally  cases  occur 
in  which  the  disease   sets  in  with  irregular  diarrhoea,  moderate  fever, 
and  colicky  pains.     In  a  few  instances  hemorrhage  has  been  the  initial 
symptom.     The  cases  at  first  are  apt  to  be  regarded  as  chronic  intestinal 
catarrh,  and  it  is  not  until  the  patient  becomes  markedly  emaciated  or 
that  signs  of  disease  in  the  lungs  appear  that  the  true  nature  of  the 
disease  becomes  apparent.     More  deceptive  still  are  the  cases  in  Avhich 
the  tuberculous  process  begins  in  the  csecum  with  symptoms  suggestive 
of  appendicitis — tenderness  in  the  right  iliac  fossa,  consti])ation,  or  an 
irregular  diarrhoea  and  fever.     Owing  to  the  fact  that  in  certain  instances 
there  may  be  a  temporary  alleviation  of  symptoms,  with  a  recurrence  at  a 
later  period,  the  diagnosis  may  be  further  complicated.  In  several  of  my 
cases  death  has  been  occasioned  by  hemorrhage.     Perforation  may  occur 
with  the  formation  of  pericsecal  abscess,  or  in  less  fortunate  cases  per- 
foration into  the  peritoneal  cavity  may  occur,  causing  death  from  general 
peritonitis.     In  rare  instances  there  is  partial  healing  of  the  ulcer,  with 
great  thickening  of  the  walls  and  narrowing  of  the  lumen  of  the  bowel. 
(2)  Secondary  tuberculosis  of  the  hoicel  is  veiy  common  in  chronic 
pulmonary  tuberculosis.     It  was  present  in  566  of  the  1000  Munich 
autopsies  in  tuberculosis  already  referred  to.     Only  3  of  these  cases 
tailed  to  show  involvement  of  the  lungs.     In  Frerichs'  series  of  250 
cases  of  chronic  tuberculosis  the  intestines  showed  tuberculous  ulcera- 
tion in  83  per  cent,  of  the  cases.     The  lesions  are  found  chiefly  in  the 
lower  part  of  the    ileum,  in  the   csecum,  and  in  the  colon.     Frerichs 
found  the  ileum  involved  in  200,  the  colon  in  115,  and  the  rectum  in  18 
oases.     The  colon  was  alone  diseased  in  8  instances.     There  was  exten- 
sive ulceration  of  the  duodenum  in  1  case,  which  also  showed  tuberculous 
ulceration  of  the  stomach.     In  a  second  instance  the  duodenal  mucous 
membrane  presented  several  tuberculous  ulcers  closely  set  together  near 
the  pyloric  orifice.     In  this  latter  instance  the  stomach  was  free  from 
ulceration,  and  the  remainder  of  the  small  intestines  was  healthy,  but  the 
colon  showed  extensive  tuberculous  ulceration.     The  disease  begins  with 
an  eruption  of  miliary  tubercles  in  the  solitary  or  agminated  glands  or 
on  the  surface  of  or  within  the   mucous  membrane.     In  the  solitary 
follicles,  owing  to  caseation  and  necrosis  of  the  tubercles,  a  loss  of  sub- 
stance is  produced,  with  the  production  of  a  crater-like  ulceration.     In 
the  case  of  Peyer's  patches  all  the  individual  follicles  are  not  simul- 
taneously attacked,  so  that  their  surfaces  are  irregular,  a  portion  having 
undergone  destruction  by  ulceration,  whilst  in  the  early  stages  islands 
of  the   normal   gland  still   remain.     This  differs  from   the   ulceration 
found  in  Peyer's  patches  in  typhoid,  where  the  destruction  is  much  more 
uniform  throughout  the  surface  of  the  gland.     The  edges  of  the  ulcers 
are  thickened  and  infiltrated  with  tubercles  which  are  constantly  under- 
going caseation  and  necrosis,  thus  producing  a  more  or  less  wormeaten 


TUBERCULOSIS  OF   Till':  AIAMKSTMIY   CAXAL.  815 

:ij)[)t'araiici'  aiul  irn\<:iilar  oiitliiu'  to  the  ulcers.  In  the  ilciiin,  in  wliicli 
IVvcr's  pati'lu's  are  c-hiclly  iinolvcd,  tlu'  ulcers  may  Ik;  ovoid.  In  the 
jejiimuii  and  colon  they  may  he  round,  hut  one  of  the  characteristic 
t'catures  of  tiie  intestinal  tuherculous  ulcer  is  its  tendency  to  increase  in 
size  in  a  direction  at  rii>ht  angles  to  the  long  axis  of  the  intestine,  so 
that  nlcers  are  finally  formed  which  entirely  encircle  the  bowel,  the  so- 
called  girdle  ulcer.  This  direction  of  spreading  is  due  to  the  fresh 
tubercles  developing  along  the  lines  of  the  bloodvessels  and  Ivmphatics, 
which  run  transversely  to  the  long  axis  of  the  intestine.  Such  ulcers 
mav  be  simulated  by  embolic  ulcers  due  to  the  plugging  of  a  vessel 
supplying  a  portion  of  the  mucous  membrane  with  nourishment,  but 
would  be  distinguished  by  the  presence  of  tubercles  about  the  edges  and 
on  the  base  of  the  ulcer.  By  the  coalescence  of  adjoining  ulcers  the 
greater  part  of  the  mucous  membrane  of  the  large  and  small  intestine 
may  become  destroyed.  The  process  is  not  confined  to  the  mucosa  and 
submucosa  alone,  but  invades  the  muscular  layers,  and  very  frequently 
extends  to  the  serous  coat,  which  often  presents  numerous  miliary 
tubercles  over  an  area  corresponding  to  the  situation  of  the  ulcer.  From 
these  there  may  sometimes  be  seen  rows  of  tubercles  extending  along 
the  lymphatics  which  lead  from  the  diseased  area  to  the  mesenteric 
glands,  which  are  usually  caseous  and  considerably  enlarged.  The 
tuberculous  ulcer  then  has  the  following  characteristics  :  (a)  It  is 
irregular,  rarely  ovoid  or  in  the  long  axis,  more  frequently  girdling  the 
bowel ;  (6)  the  edges  and  base  are  infiltrated,  thickened,  and  often 
caseous ;  (e)  the  submucosa  and  muscularis  are  usually  involved ;  and 
(<J)  on  the  serosa  may  be  seen  colonies  of  young  tubercles  or  a  well 
marked  tuberculous  lymphangitis.  The  mucous  membrane  surrounding 
the  ulcers  is  generally  the  seat  of  more  or  less  intense  catarrhal  inflam- 
mation, leading  to  a  club-shaped  or  polyp-like  hypertrophy  of  the  villi 
of  the  small  intestine  and  giving  the  mucous  surface  of  the  affected  area 
a  velvety  appearance.  Perforation  and  peritonitis  are  not  infrequent 
events  in  the  secondary  ulceration.  As  a  result  of  cicatrization  of  the 
ulcers  stenosis  of  the  bowel  may  occur,  and  in  some  instances  a  series  of 
constrictions  may  be  found. 

Localized  chronic  tuberculosis  of  the  ileo-csecal  region  is  of  great 
importance.  The  esecum  frequently  presents  extensive  ulceration  of  the 
raucous  membrane,  which  not  uncommonly  extends  into  the  appendix. 
As  a  consequence  of  the  changes  produced  a  definite  tumor-like  mass 
develops  in  the  right  iliac  fossa.  The  tumor  varies  in  size,  is  usually 
elongated  in  a  vertical  direction,  hard,  slightly  movable,  or  bound  down 
by  adhesions  and  very  sensitive  to  pressure.  The  disease  simulates 
more  or  less  closely  a  true  neoplasm  of  this  region,  particidarly  car- 
cinoma. The  condition  is  characterized  by  gradual  constriction  of  the 
lumen  of  the  bowel,  periodic  attacks  of  severe  pain,  and  alternating 
diarrhcea  and  constipation.  In  a  few  cases  extirpation  of  the  caecum 
has  been  performed  with  fairly  successful  results.  In  a  second  form  of 
this  disease,  occurring  less  frequently  than  the  former,  there  is  no 
definite  tumor  mass  to  be  felt,  but  a  general  induration  and  thickening 
in  the  right  iliac  fossa  similar  to  the  local  changes  produced  by  a  recur- 
ring appendicitis.  In  this  variety  a  fistula  discharging  fecal  matter 
occasionally  results.     Both  forms  may  be  distinguished  from  the  diseases 


816  TUBERCULOSIS. 

they  simulate  by  the  finding  of  tubercle  bacilli  in  the  stools  or  in  the 
discharge  from  the  fistula  when  such  exists. 

Tuberculosis  of  the  rectum  possesses  special  interest  in  connection 
with  fistula  in  ano.  According  to  Spillman's  statistics,  this  complication 
occurs  in  about  3.5  per  cent,  of  cases  of  pulmonary  tuberculosis. 
Hartmann  comparatively  recently  reviewed  this  subject  and  found  the 
percentage  even  higher.  In  626  patients  suffering  from  pulmonary 
tuberculosis  fistula  in  ano  was  present  in  33  cases  or  in  4.91  per  cent. 
He  also  found  that  the  condition  varied  with  sex,  being  more  frequent 
in  males.  In  447  males  it  was  present  in  27  instances,  or  6  per  cent., 
whilst  it  occurred  in  only  6  cases  out  of  179  females,  or  3.35  per  cent. 
He  also  believes  that  the  disease  is  due  to  a  surface  infection  by  fseces 
containing  tubercle  bacilli,  and  states  that  tuberculous  diarrhoea  appears 
to  play  an  important  part  as  an  etiological  factor.  Fistula  in  ano  was 
present  8  times  in  114  individuals  who  had  diarrhcea.  The  lesion  has 
in  many  instances  been  shown  to  be  tuberculous.  It  is  very  rarely 
primary,  but  if  the  tissue  on  removal  contains  bacilli  and  is  infective, 
the  lungs  are  almost  invariably  found  to  be  involved.  There  is  a 
general  opinion  that  pulmonary  symptoms  may  develop  rapidly  after  the 
fistula  is  cut,  but  Hartmann  thinks  this  view  is  exaggerated.  There 
may  be  some  foundation  for  the  statement  if  the  operation  consists  only 
in  laying  open  the  tract  without  freely  excising  the  diseased  area.  Many 
of  the  cases  of  iscnlo-rectal  abscesses  are  tuberculous  and  secondary  in 
origin  to  a  tuberculous  rectal  ulcer.  More  or  less  extensive  ulceration 
of  the  rectal  mucous  membrane  is  often  met  with,  and  one  has  to  bear 
in  mind  the  possibility  of  cicatricial  contraction  arising  therefrom. 

(3)  Secondary  tuberculous  ulceration  of  the  intestines  may  be  excited 
by  extension  of  the  disease  from  the  peritoneum.  The  affection  may  be 
primary  in  the  peritoneum  or  extend  from  tuberculous  Fallopian  tubes 
in  women  or  from  the  mesenteric  glands  in  children.  Owing  to  the 
tuberculous  process  in  the  peritoneum  the  intestines  become  matted 
together,  caseous  and  suppurating  foci  develop  between  the  folds,  and 
perforation  into  the  lumen  of  the  intestine  may  take  place  between  the 
coils. 

Tuberculosis  of  the  Liver. 

This  affection  of  the  liver  is  manifested  in  several  different  forms. 
Orth  believes  that  the  parenchyma  of  the  liver  cannot  be  a  favoring 
soil  for  the  development  of  the  bacilli,  as  one  rarely  sees  in  this  organ 
such  extensive  destructive  changes  as  are  met  with  elsewhere  in  the 
body.     The  organ  is  very  constantly  involved  in — 

(a)  General  tuberculosis.  The  miliary  granulations  are  very  small, 
and  in  acute  cases  scarcely  to  be  recognized  with  the  naked  eye.  Occa- 
sionally a  few  small  tuberculous  foci  are  found  in  the  liver  in  chronic 
pulmonary  tuberculosis.  In  such  cases  the  tubercles  are  distributed 
throughout  the  substance  of  the  organ,  suggesting  strongly  that  infec- 
tion has  occurred  by  the  way  of  the  blood.  The  liver  is  pale  and  very 
often  fatty. 

(6)  A  very  interesting  condition  of  the  organ  is  produced  by  the 
development  of  tubercles  in  the  finer  bile  vessels.  According  to  Orth, 
such  a  condition  may  be  found  in  association  with  general  tuberculosis 


TUBERCULOSIS  OF  THE  PAXCREAS.  Si 7 

of  the  liver  or  it  may  occur  indepeiidciitly,  Tlic  tubercles  may  attain 
a  considerable  size,  at  times  as  larjre  as  liazchnits.  Tlie  centres  soften 
and  cavities  are  formed  which  are  usually  lilicd  with  a  yellowish  brown 
or  greenish  i)ilc-stained  caseous  material.  The  organ  may  Ix'  jjcjuey- 
combed  with  these  tubercular  abscesses.  Consideraijle  diH'erence  of 
opinion  ap})ears  to  exist  as  to  whether  infection  in  this  form  is  through 
the  blood  or  by  way  of  the  excretory  ducts.  Simmonds  is  inclined  to 
think  that  tubercles  develop  in  the  outer  part  of  the  bile  ducts,  and 
then  open  later  into  them.  Pillet  thinks  that  biliary  tuberculosis  in  all 
its  forms,  from  the  small  granulation  to  the  true  cavity,  is  an  ulcerative 
process,  the  infective  agent  being  carried  l)y  the  excretory  channels. 
He  states  that  it  differs  anatomically  from  the  most  common  form  of 
tuberculosis  of  the  liver,  in  which  the  infection  is  carried  by  the  blood 
current,  and  that  a  complete  analogy  exists  between  this  form  of  tuber- 
culosis and  that  found  in  the  lung. 

(e)  Occasionally,  large  coarse  caseous  masses  are  found  in  the  liver 
in  association  with  perihepatitis  or  tuberculous  peritonitis.  They  may 
attain  the  size  of  an  orange  or  larger. 

(f/)  With  the  eruption  of  miliary  tubercles  there  may  be  slight 
increase  in  the  connective  tissue,  producing  a  tuberculous  cirrhosis, 
which  is  often  obscured  bv  the  fattv  change.  In  all  the  chronic  forms 
of  tubercle  in  the  liver  there  may  be  an  overgrowth  of  fibrous  tissue. 
Hanot  has  described  several  varieties,  and  believes  that  the  condition 
may  be  primary.  Practically,  it  is  an  extremely  rare  condition,  except 
in  connection  with  chronic  tuberculous  peritonitis  and  perihepatitis,  when 
the  organ  may  be  much  deformed  by  sclerosis  invohang  the  portal 
canals.  A  few  cases  of  nodular  diffuse  hejjatitis  have  been  recorded  in 
which  the  condition  was  associated  with  caseous  pulmonary  tuberculosis, 
without  there  being  any  evidences  of  localized  tuberculous  lesions  in  the 
liver  itself.  In  such  instances  it  has  been  suggested  that  the  tuberculous 
toxin  circulating  in  the  blood  acts  as  an  irritant  on  the  liver,  thus  pro- 
ducing an  increase  in  the  connective  tissue.  In  this  group  svmptoms 
of  ascites  may  appear. 

(e)  It  is  now  believed  by  some  that  localized  areas  of  necrosis  of  the 
liver  substance  occur  in  tuberculosis  similar  to  those  found  in  this  organ 
in  typhoid  fever  and  diphtheria.  Hanot  (in  1893)  called  attention  to 
a  peculiar  lesion  observed  by  him  in  the  liver  of  several  tuberculous 
patients  in  the  form  of  small  yellowish  knots.  They  did  not  present 
the  structure  of  tubercles,  and  no  giant  cells  were  to  be  found  in  them. 
In  these  areas,  however,  he  was  able  to  demonstrate  tubercle  bacilli,  and 
he  thinks  that  they  constitute  a  pecuHar  form  of  hepatic  tuberculosis. 

Tuberculosis  of  the  Pancreas. 

According  to  Becourt,  the  first  account  of  tuberculosis  of  the  ])an- 
creas  was  given  in  1812  by  Harles,  Avho  described  the  affection  under 
the  name  of  "  pancreatic  phthisis."  The  disease  is  very  rare,  alwavs 
secondary,  and  generally  associated  with  tuberculosis  of  the  lungs,  intes- 
tines, or  mesenteric  glands.  A  number  of  cases  have  been  described  as 
tuberculosis  of  the  pancreas  that  were  really  due  to  tuberculous  involve- 
ment of  the  lymph  glands,  either  partially  or  wholly  imbedded  in  the 
Vol.  I.— 52 


818  TUBEBCUL  OSIS. 

interstitial  connective  tissue  of  the  pancreas.  Lombard  found  tubercu- 
losis of  the  pancreas  5  times  in  100  autopsies  on  infants  who  died  of 
tuberculosis.  Klebs  has  claimed  that  disseminated  miliary  tubercles  of 
the  gland  do  not  occur  in  general  miliary  tuberculosis.  Orth,  however, 
admits  the  occurrence,  but  says  that  it  is  exceptional.  More  frequently, 
he  says,  a  partial  miliary  tuberculosis  is  seen  in  the  vicinity  of  large 
caseous  foci  in  the  pancreas.  In  the  pancreas  of  a  child  twenty-three 
months  old,  dead  of  general  miliary  tuberculosis,  Barlow  found  tuber- 
cles whitish  in  color,  the  size  of  a  pin's  head,  which  showed  commen- 
cing caseation  in  the  centre. 

Apart  from  the  eruption  of  miliary  tubercles,  jDancreatic  tuberculosis 
presents  itself  in  two  forms  :  First,  the  infiltrated  gland  presents  mul- 
tiple foci.  Infection  in  this  variety  takes  place  by  the  general  circula- 
tion. The  gland  is  enlarged  and  presents  nodular  masses  which  are 
often  caseous.  The  gland  substance  between  the  foci  may  be  healthy 
or  it  may  show  the  presence  of  miliary  tubercles  for  some  distance  about 
the  diseased  area.  In  the  second  variety  the  gland  presents  definite 
tuberculous  abscess  cavities,  as  in  Aran's  2  cases,  where  the  abscesses 
were  about  the  size  of  a  hen's  egg.  In  these  cases  infection  is  supposed 
to  occur  by  way  of  the  pancreatic  duct  from  the  intestine. 

There  is  no  definite  symptomatology,  as  the  disease  is  invariably 
associated  with  tuberculosis  of  other  organs.  Aran  states  that  salivation 
and  eructation  of  fluid  resembling  saliva  are  symptoms  which  are  very 
suggestive  of  pancreatic  tuberculosis.  Pemberton  claims  that  emaciation 
is  more  marked  in  this  affection  than  in  any  other  disease.  Bouillaud 
records  a  case  where  there  was  an  enormous  dilatation  of  the  gall  bladder, 
produced  by  compression  on  the  common  duct  by  a  tubercular  mass 
situated  in  the  head  of  the  pancreas. 


VI.  TUBERCULOSIS  OF  THE  GENITO-URINARY  SYSTEM. 

Any  organ  of  the  genito-urinary  system  may  be  invaded ;  in  com- 
parativelv  rare  instances  one  part  only  is  found  tuberculous,  while  in 
the  majority  of  cases  the  process  involves  two  or  more  parts  of  the  tract. 
The  successive  involvement  of  the  organs  may  be  so  rapid  that  unless 
the  case  has  been  seen  early  it  may  be  impossible  to  state  with  any 
degree  of  certainty  which  has  been  the  primary  seat  of  infection.  Espe- 
cially is  this  the  *  case  when  the  disease  is  secondary  to  a  tuberculous 
focus  elsewhere  in  the  body.  There  may  be  simultaneous  involvement 
of  various  portions  of  the  tract.  While  clinical  and  pathological  ex- 
perience has  taught  us  that  tuberculosis  of  the  genito-urinary  system 
may  be  primary,  one  always  has  to  bear  in  mind  the  possibility  of 
latent  disease  elsewhere  in  the  body.  Thus,  as  Bollinger  says,  tubercle 
bacilli  may  gain  admission  at  some  part  of  the  respiratory  tract  without 
producing  any  lesion  at  the  point  of  entrance,  and  finally  reach  a  bron- 
chial gland,  where  they  set  up  a  tuberculous  process  of  extremely  slow 
development  without  producing  any  symptoms.  From  this  point  bacilli 
may  enter  the  blood  stream  and  lodge  in  the  epididymis  or  testicle 
proper,  and  produce  nodules  which  are  readily  discovered,  owing  to  the 
ease  with  which  these  parts  are  examined.     Such  a  case  might  be  quite 


TUBERCULOSIS  OF  THE  (,' EX ITO- URINARY  SYSTEM.  819 

oasih'  inistakcM  tor  one  of  pi-iiiinry  i;('iiit;il  liilxTciilosis,  whereas  the  true 
primary  tiilKM-ciiloiis  Ini-iis  is  llir  distant.  riiiis  it  is  practically  iiii])()s- 
sihlc,  without  the  iiiibriiiati<ni  allordcd  l»y  an  aiito|)sy,  to  state  positively 
whether  or  not  one  is  dealint;-  with  a  true  primary  ui"o-<;'enital  tuhei'- 
ciilosis. 

Inl'eetion  of  the  geni to- urinary  tract  occurs  in  various  ways : 

1.  Bj/  Ilnrdiftiri/  'frnnf^nii.ssioti. — It  has  been  met  Avith  in  the  foetus. 
The  comparative  fre(jncncy  of  tuberculosis  of  the  testicle  in  very  young 
children  suggests  very  strongly  that  the  uro-genital  organs  may  l)e 
involved  as  a  result  of  direct  transmission  of  the  disease  from  the 
parents.  If  one  accepts  I]ainngarten's  vie^vs  of  hereditary  transmission 
of  tubercidosis,  this  method  of  infection  would  seem  quite  probable. 

2.  B(/  infection  from  areas  of  tuberculosis  already  existing  in  the 
patient. 

{(()  Infection  tltroiu/Ii,  the  Blood. — Owing  to  the  fact  that  many  cases 
of  uro-genital  tuberculosis  are  found  at  autopsy  associated  wdth  disease 
of  some  distant  organ,  particularly  the  lungs,  it  would  appear  most 
probable  that  in  these  cases  infection  has  been  through  the  bloodvessels. 
Jani's  observations,  wdiich  were  published  by  Weigert  after  the  author's 
death,  strongly  support  this  theory.  In  studying  sections  of  the  geni- 
tal organs  of  patients  who  died  of  pulmonary  tuberculosis  he  found 
tubercle  bacilli  in  5  out  of  8  cases  in  the  testicle,  and  in  4  out  of  6 
cases  in  the  prostate,  without,  in  any  instance,  finding  microscopical 
evidences  of  tubercles  in  these  organs.  The  bacilli  lay,  in  the  testis, 
partly  within  and  partly  close  beside  the  cellular  and  granular  contents 
of  the  seminal  tubules,  whilst  in  the  prostate  they  were  always  situated 
in  the  neighborhood  of  the  glandular  epithelium. 

(6)  Infection  from  the  Peritoneum. — This  source  of  infection,  in 
both  men  and  women,  is  much  more  frequent  than  is  commonly  sup- 
posed. The  intimate  relationship  between  the  peritoneum  and  bladder 
in  both  subjects  and  with  the  vesiculse  seminales  and  vasa  deferentia 
in  the  male  allow^s  of  a  ready  means  of  invasion  of  these  organs  by 
direct  extension  of  the  disease.  The  peritoneum  is  a  frequent  source 
of  genital  tuberculosis  in  the  female.  No  doubt,  many  cases  of  tuber- 
culosis of  the  Fallopian  tubes  originate  from  this  source.  The  fact 
that  the  fimbriated  extremity  of  the  tubes  is  often  most  seriously  in- 
volved points  rather  strongly  in  this  direction,  although  this  might  be 
taken  as  a  point  in  favor  of  blood  infection,  owdng  to  its  greater  vas- 
cularity. Various  observations  go  to  show^  that  the  action  of  the  cilia 
lining  the  lumina  of  the  Fallopian  tubes  tends  to  attract  particles  intro- 
duced into  the  peritoneal  cavity.  Jani's  observation  is  very  interesting 
in  this  connection,  as  showing  the  possibility  of  tubercle  bacilli  enter- 
ing the  tubes  from  the  peritoneal  cavity  without  there  being  any  tuber- 
culous peritonitis.  He  found  typical  tubercle  bacilli  in  the  lumen,  in 
sections  of  a  normal  Fallopian  tube,  in  a  woman  wdio  died  of  pulmonary 
and  intestinal  tuberculosis.  The  explanation  advanced  was  that  the 
bacilli  made  their  way  through  the  thin  peritoneal  coat  from  one  of  the 
intestinal  ulcers,  thus  reaching  the  peritoneal  cavity,  and  thence  being 
attracted  into  the  Fallopian  tube  by  the  current  produced  by  the  action 
of  the  cilia  lining  the  lumen.  The  intimate  relationship  between  tuber- 
culous peritonitis  and  tuberculosis  of  the  Fallopian  tubes  is  shown  in 


820  TUBERCULOSIS. 

the  fact  that  the  latter  are   affected  in  from  30  to  40  per  cent,  of  the 
cases. 

(c)  Infection  from  Other  Organs  hy  Direct  Extension. — The  occur- 
rence of  direct  extension  from  the  peritoneum  has  already  been  mentioned. 
In  tuberculous  ulceration  of  the  intestine  or  rectum  adhesions  to  the 
bladder  in  the  male  or  to  the  uterus  and  vagina  in  the  female  may 
occur,  with  fistulse  and  a  direct  extension  of  the  disease  resulting. 
Perirectal  tuberculous  abscesses  may  lead  to  secondary  involvement  of 
some  portion  of  the  genito-urinary  tract.  It  must  not  be  forgotten  that 
tuberculosis  of  the  vertebrae  may  be  followed  by  tuberculosis  of  the 
kidney  as  a  result  of  direct  extension  of  the  disease. 

3.  By  Infection  from  Without. — "Whether  uro-genital  tuberculosis 
may  occur  as  a  result  of  the  entrance  of  tuljercle  bacilli  into  the  urethra 
or  vagina  is  still  a  disputed  question.  That  bacilli  gain  admission  to 
these  passages  during  coitus  with  a  person  the  subject  of  uro-genital 
tuberculosis,  or  by  the  use  of  foul  instruments  or  syringes,  seems  quite 
probable.  The  possibility  of  genital  tuberculosis  occurring  in  the 
female  as  a  result  of  coitus  with  a  male  the  subject  of  tuberculosis  in 
some  portion  of  the  genito-urinar\"  system  was  first  suggested  by  Cohn- 
heim,  who  stated,  however,  that  it  rarely  if  ever  occurred.  Gartner 
obtained  important  results  from  his  experiments  in  animals.  He  found 
in  experimenting  with  rabbits  and  guinea-pigs  that  a  certain  percentage 
of  the  females  develojied  genital  tuberculosis  as  a  result  of  consorting 
with  male  animals  with  artificially  produced  tuberculosis  of  the  testes 
and  whose  semen  contained  tubercle  bacilli.  The  experiments  of 
Oncarani  and  of  Williams  are  directly  opposed,  however,  to  those  of 
Cornil  and  of  Dobrolansky,  who  claimed  to  have  produced  tuberculous 
endometritis  by  the  injection  of  pure  cultures  of  tubercle  bacilli  into 
the  vagina  of  rabbits. 

In  a  patient  with  intestinal  tuberculosis  the  tubercle  bacilli  might 
accidentally  reach  the  urethra  or  vagina  from  the  rectum. 

Uro-genital  tuberculosis  is  commonest  between  the  ages  of  twenty 
and  forty  years — that  is,  during  the  period  of  greatest  sexual  activity. 
Males  are  aifected  much  more  frequently  than  females,  the  proportion 
being  3  to  1.  This  great  difPerenee  is  no  doubt  partly  due  to  the  more 
intimate  relationship  between  the  urinary  and  genital  systems  in  the 
former  than  in  the  latter.  In  the  male  the  urethra  forms  the  common 
outlet  for  the  two  systems,  whilst  in  the  female  there  is  a  separate  out- 
let for  each. 

Once  the  uro-genital  tract  has  been  invaded,  the  disease  is  likely  to 
spread  rapidly,  and  the  method  of  extension  is  an  important  one. 
Quite  frequently  there  is  direct  extension,  as  when  the  bladder  is  in- 
volved secondarily  to  the  kidney  by  passage  of  the  disease  along  the 
ureter,  or  where  the  tuberculous  process  extends  along  the  vas  deferens 
to  the  vesiculffi  seminales.  No  doubt  surface  inoculation  occurs  in  some 
instances,  and  to  this  cause  may  be  attributed  a  certain  percentage  of 
cases  of  vesical  and  prostatic  disease  following  tuberculosis  of  the 
kidney.  Although  this  probability  is  acknowledged,  there  is  an  ele- 
ment '  of  doubt  as  to  the  possibility  of  the  kidney  becoming  affected 
secondarily  to  the  bladder  or  prostate  by  the  direct  passage  of  the  bacilli 
up  the  lumen  of  one  ureter  ;  for  in  such  a  case  we  have  to  suppose  that 


TUBERCULOSIS  OF  THE  KIDNEYS.  821 

a  non-motile  l)at'illiis,  contrary  to  the  laws  of  gnivity,  ascends  against 
an  almost  constant  current  of  urine  Howing  in  the  opposite  direction. 
The  lymphatics  may  afford  a  means  for  tlie  spreading  of  the  disease, 
but  in  a  greater  number  of  cases  than  is  generally  supposed  the  dis- 
ease s[)reads  by  way  of  the  bloodvessels.  Cystoscopic  examinations 
of  the  bladder  not  infrequently  show  the  presence  of  tubercles  be- 
neath the  mucous  membrane  before  there  is  any  evidence  of  super- 
Hcial  ulceration — a   fact  suggesting  strongly  a  blood  infection. 

The  discovery  of  tubercle  bacilli  in  the  urine  and  the  obtaining 
of  tuberculous  lesions  in  animals  as  a  result  of  inoculation  with  the 
urinarv  sediment  aiford  us  the  only  positive  evidence  of  genito-uri- 
narv  tuberculosis.  So  far,  there  are  no  authentic  accounts  of  tubercle 
bacilli  having  been  found  in  the  semen  of  men  with  tuberculosis  of  the 
testicle  or  vesiculae  semiuales.  Owing  to  the  fact  that  the  smegma 
bacillus  has  the  same  staining  reaction  as  the  tubercle  bacillus,  and, 
morphologically,  is  practically  indistinguishable  from  it,  the  greatest 
care  must  be  used  in  obtaining  the  specimen  of  urine  for  examination, 
to  eliminate,  if  possible,  all  chances  of  contamination.  Thus  the  urine 
examined  must  be  a  catheterized  specimen,  and  even  then  one  runs  the 
risk  of  carrying  back  into  the  bladder  on  the  end  of  the  catheter  a  few 
bacilli  which  may  be  w^ashed  out  in  the  stream  of  urine  and  be  mistaken 
for  tubercle  bacilli  in  the  sediment.  Repeated  examinations  should  be 
made  if  the  first  specimens  are  negative,  for,  as  Koch  and  Baumgarten 
have  shown,  the  bacilli  are  not  situated  on  the  surface  of  an  ulcer,  but 
just  beneath  the  portion  which  is  undergoing  coagulation  necrosis,  so 
that  the  chances  are  not  great  for  the  bacilli  to  be  washed  off  in  large 
numbers  by  the  current  of  urine.  Grethe  ^  recommends  a  method  for 
differentiating  between  tubercle  and  smegma  bacilli,  which  depends 
upon  the  fact  that  the  latter  decolorize  in  alcohol  much  more  readily 
than  the  former.  The  cover-slip  preparations  are  stained  in  the  usual 
way  with  carbol  fuchsin.  They  are  then  treated  for  two  minutes  in  a 
20  per  cent,  solution  of  nitric  acid,  and  afterward  washed  for  ten  min- 
utes in  alcohol  (the  strength  of  which  is  not  mentioned).  Any  red 
stained  bacilli  left  in  the  preparation  must  be  tubercle  bacilli,  because 
smegma  bacilli  are  completely  decolorized  by  the  use  of  the  alcohol  for 
a  period  of  only  five  minutes.  For  practical  use,  Grethe  recommends 
very  highly  Weichselbaum's  method  of  staining  tubercle  bacilli.  The 
preparation  is  first  stained  in  carbol  fuchsin,  and  then  counterstained  in 
a  concentrated  alcoholic  solution  of  methylene  blue.  By  this  method, 
with  the  exception  of  the  tubercle  bacilli,  the  whole  preparation,  in- 
cluding the  smegma  bacilli,  is  stained  blue,  the  tubercle  bacilli  appear- 
ing as  red  rods  on  a  blue  background.  Inoculations  of  guinea-pigs  with 
the  urinarv  sediment  will  occasionally  produce  typical  tubercular  lesions 
when  repeated  examinations  of  the  sediment  for  bacilli  have  given  nega- 
tive results. 

Tuberculosis  of  the  Kidneys  (Phthisis  Renum). 

Xot  infrequently  at  autopsies  on  persons  who  have  died  of  general 
tuberculosis  the  kidneys  are  found  to  contain  miliary  tubercles  scattered 
1  Fortschritte  der  Medicin,  May  1,  1896. 


822  TUBERCULOSIS. 

throughout  the  substance  of  the  organs.  When  death  has  occurred  from 
pulmonary  tuberculosis  it  is  also  quite  common  to  find  a  few  tubercles, 
or,  in  rarer  instances,  there  may  be  a  tuberculous  pyelitis.  In  primary 
tuberculosis  of  the  kidney,  which  is  not  very  rare,  tubercles  usually 
first  appear  beneath  the  mucous  membrane  of  the  pelvis  and  in  the 
papillae.  In  secondary  tuberculosis,  occurring  as  a  result  of  infec- 
tion through  the  bloodvessels,  the  tubercles  at  first  may  be  more  or  less 
generally  scattered  throughout  the  substance  of  the  organ,  or  they  may 
be  localized  either  in  the  cortex  near  the  capsule  or  beneath  the  mucous 
membrane  of  the  pelvis.  Where  the  kidney  is  involved  as  a  result  of 
direct  extension  of  the  disease  along  the  ureter  from  some  focus  lower 
down  in  the  urinary  tract  the  mucous  membrane  of  the  pelvis  and  the 
adjacent  kidney  substance  are  first  attacked.  Occasionally  renal  tuber- 
culosis follows  tuberculous  disease  of  the  testicle,  and  infection  may 
occur  by  the  roundabout  route  of  the  lymph  channels.  The  lymphatics 
of  the  testicle  on  their  way  to  empty  into  the  lumbar  glands  accompany 
.  the  spermatic  veins  to  their  termination,  and  receive  collateral  branches 
from  the  ureters,  and,  not  infrequently,  trunklets  which  drain  the  peri- 
renal fat  and  the  capsule  of  the  kidney.  This  permits  of  a  direct  route 
for  the  bacilli  to  reach  the  kidney  from  the  testicle,  in  which  instance 
the  cortex  would  be  first  most  seriously  involved.  In  the  majority  of 
cases  of  renal  tuberculosis  the  process  also  involves  the  pelvis  and  ure- 
ter, and  sometimes  the  bladder  and  prostate.  In  advanced  cases,  in 
which  the  bladder,  prostate,  and  vesiculse  seminales  are  also  involved,  it 
may  be  almost  impossible  to  state  whether  the  disease  has  crept  from 
below  upward  along  the  ureters  or  whether  it  has  started  in  the  kidneys 
and  proceeded  downward.  In  the  majority  of  instances  I  believe 
the  latter  is  the  case,  and  that  infection  takes  place  through  the 
blood. 

Renal  tuberculosis  is  most  common  during  the  middle  period  of  life, 
although  it  may  occur  at  the  extremes  of  age.  It  is  about  twice  as  fre- 
quent in  men  as  in  women.  One  kidney  alone  may  be  involved,  and 
the  disease  may  creep  down  the  ureter  and  extend  a  few  millimetres 
on  the  vesical  mucosa,  as  in  a  man  with  aortic  insufficiency  in  whom, 
at  autopsy,  a  localized  patch  of  tuberculosis  was  found  in  the  pelvis  of 
the  kidney,  involving  a  pyramid,  while  the  ureter  five  centimetres  from 
the  bladder  and  at  its  orifice  was  thickened  and  tuberculous.  The 
prostate  showed  an  area  of  caseation :  there  was  no  lung  disease. 

Taking  as  a  type  of  the  disease  a  case  in  which  the  tuberculous  pro- 
cess begins  in  the  vicinity  of  the  pelvis  of  the  kidney,  the  tubercles  will 
first  be  found  beneath  the  mucous  membrane  of  the  calyces  and  in 
the  pyramids.  The  colonies  of  tubercles  rapidly  extend  on  the  mucous 
membrane  of  the  pelvis  and  spread  throughout  the  substance  of  the 
pyramids.  Necrosis  and  caseation  proceed  rapidly,  and,  as  a  rule,  from 
the  first  it  is  a  tuberculous  pyo-nephrosis.  The  process  extends  from 
the  medullary  portion  of  the  kidney  to  involve  the  cortex,  and  the 
whole  kidney  becomes  converted  into  a  series  of  cysts  which  correspond 
more  or  less  accurately  with  the  pyramids  and  the  portions  of  the  cor- 
tex corresponding  to  them.  These  cysts  may,  for  a  considerable  time, 
remain  separate,  but  eventually  they  communicate,  owing  to  the  thin 
portion  of  kidney  substance   between  them  being  destroyed.     The  cap- 


TUBERCULOSIS  OF  THE  h'ri).\EY'S  823 

sule  of  the  kidiu'v  becomes  greatly  thickened.  The  cysts  generally  con- 
tiiin  a  cheesy  sul)staiice  resenibliiig  putty,  which  may  eventually  become 
impreguateil  with  lime  salts.  In  other  instances  the  walls  of  the  pelvis 
are  thickened  and  cheesy,  the  pyramids  erodeil,  and  caseous  nodules  are 
scattered  throughout  the  substance  of  the  organ,  even  to  the  capsule, 
which  may  be  thickened  and  adherent.  In  the  rarer  cases,  in  which  the 
tuberculous  process  begins  in  the  jK'riphery  of  the  kidnev,  the  cortex 
may  slu>w  ipiite  advanced  changes  before  the  mucous  menil)rane  of  the 
pelvis  is  involved  to  any  extent.  The  disease  may  be  confined  to  one 
kidney  or  progress  more  extensively  in  one  than  in  the  other.  The  less 
seriously  aifected  kidney  may  only  show  a  pyelitis  or  a  superficial  necro- 
sis of  one  of  the  pyramids.  On  the  other  hand,  one  kidney,  although 
not  showing  a  tuberculous  process,  may  be  the  seat  of  a  serious  nephri- 
tis, prol)ably  an  advanced  amyloid  degeneration.  The  ureters  are  usu- 
ally thickened  and  the  mucous  membrane  ulcerated  and  caseous.  In- 
volvement of  the  bladder,  vesicular  seminales,  and  testes  is  not  uncom- 
mon in  males. 

The  symptoms  of  renal  tuberculosis  are  variable,  but  they  are  prac- 
tically those  of  pyelitis.  The  condition  is  for  many  years  compatible 
with  fair  health.  The  urine  may  be  purulent  for  a  long  period,  and 
yet  the  patient  may  have  little  or  no  distress.  With  our  present  know- 
ledge it  is  impossible  to  distinguish  accurately  cases  in  which  the  erup- 
tion of  tubercles  first  occurs  in  the  vicinity  of  the  pelvis  from  those  in 
which  the  cortex  is  first  attacked.  Fenwick,  however,  claims  that  in 
the  pelvic  form  blood  and  pus  appear  in  the  urine  in  small  amounts, 
either  coincidentally  with  renal  pain  or  soon  after  its  appearance ;  that 
renal  colic  appears  relatively  earlier  than  in  the  cortical  form  ;  that  the 
stages  of  the  disease  are  passed  through  more  rapidly ;  and  that  the 
bladder  is  earlier  involved.  When,  however,  the  tuberculosis  primarily 
attacks  the  cortex,  it  must  first  break  into  the  pelvis  before  very  charac- 
teristic symptoms  are  prodticed.  Polyuria,  resulting  from  the  irritating 
effect  of  the  minute  tubercles,  would  probal)ly  be  the  first  svmpt(^m 
complained  of,  even  before  any  aching  in  the  kidney  is  experienced.  The 
urine  would  be  of  low  specific  gravity,  and  would  contain  more  albumin 
than  could  be  accounted  for  by  the  presence  of  the  trace  of  pus.  Hemor- 
rhage from  the  two  situations  also  varies.  In  the  early  stage  of  the 
pelvic  form  the  bleeding  is  usually  slight  and  intermittent,  whereas 
when  a  cortical  deposit  sloughs  out  suddenly  into  the  pelvis  there  mav 
be  profuse  but  transient  hematuria.  In  renal  tuberculosis,  when  the 
bladder  becomes  involved,  or  even  earlier,  micturition  is  frequent,  and 
many  cases  are  mistaken  for  cystitis.  The  possibility  of  nature  afiect- 
ing  a  cure  is  shown  by  the  accidental  discovery  of  the  so-called  scrofu- 
lous kidney,  in  which  the  organ  has  become  converted  into  a  series  of 
cysts  filled  with  a  putty-like  substance.  When  the  disease  becomes  ad- 
vanced and  both  organs  are  affected  constitutional  symjitoms  are  more 
marked.  There  is  irregular  fever,  -with  rigors  and  loss  of  weight  and 
strength.  Recurrent  chills  are  common.  General  tuberculosis  is  fre- 
quent. In  only  one  of  my  cases  were  the  limgs  uninvolved.  Occa- 
sionally a  cyst  may  perforate  and  cause  general  peritonitis.  The  pain 
suffered  varies  greatly :  it  may  be  of  a  dull,  aching  character,  situated 
over  the    region  of  the  affected   kidney,  or,  as   occasionally  happens, 


824  TUBERCULOSIS. 

severe  and  colicky,  owing  to  the  plugging  of  the  ureter  by  some  of  the 
caseous  material. 

Physical  examination  may  detect  special  tenderness  on  one  side,  or 
the  kidney  may  be  palpable  in  front  on  deep  pressure ;  but  tuberculous 
pyelo-nephritis  seldom  causes  a  large  tumor.  Occasionally  the  pelvis 
becomes  enormously  distended,  but  this  is  rare  in  comparison  with  cal- 
culous pyelitis.  The  urine  presents  changes  similar  to  those  of  ordinary 
calculous  pyelitis — pus  cells,  blood,  epithelium,  and  occasionally  definite 
caseous  masses,  and  even  moulds  of  the  pelvis.  Albumin  is  present  in 
considerable  quantity,  but  tube  casts  are  not  commonly  seen.  Care- 
ful and  persistent  examination  of  the  urinary  sediment  for  tubercle 
bacilli  will  usually  demonstrate  their  presence. 

The  very  close  resemblance  between  calculous  pyelitis  and  renal 
tuberculosis,  both  in  the  gross  pathological  changes  and  in  the  symptoms 
produced,  renders  it  in  many  instances  extremely  difficult  to  distinguish 
between  the  two  affections.  Hsematuria  occurs  in  both,  but  in  tuber- 
culous disease  it  occurs  less  frequently,  is  not  so  profuse,  and  is  less 
influenced  by  exercise  than  is  the  hsematuria  of  calculous  pyelitis.  Renal 
colic  is  not  so  frequent  as  in  the  latter  affection.  The  presence  of 
tuberculosis  elsewhere  in  the  body,  particularly  in  a  testis  or  the  pros- 
tate, and  the  discovery  of  tubercle  bacilli  in  the  urine,  should  leave 
little  doubt  as  to  the  true  nature  of  the  disease. 

Tuberculosis  of  the  Ureters,  Bladder,  and  Urethra. 

It  is  doubtful  whether  primary  tuberculosis  of  a  ureter  ever  occurs. 
It  is  almost  invariably  involved  secondarily  to  some  other  part  of  the 
genito-urinary  system,  particularly  the  pelvis  of  the  kidney.  The  dis- 
ease usually  occurs  as  a  result  of  a  direct  extension  of  the  tuberculous 
23rocess  from  the  kidney,  or  in  rarer  instances  from  the  bladder  by  ex- 
tension upward.  Surface  inoculation  by  bacilli  contained  in  the  urine 
from  a  tuberculous  kidney  no  doubt  often  occurs.  In  advanced  cases 
the  whole  of  the  mucous  membrane  of  the  ureter  may  be  extensively 
ulcerated  and  the  walls  thickened  and  caseous.  In  such  a  case  it  is 
quite  possible  on  deep  palpation  to  feel  the  ureter  as  a  thickened,  more 
or  less  irregular  cord. 

Tuberculosis  of  the  bladder  is  quite  common.  It  may  be  primary,  but 
is  generally  secondary  to  tuberculosis  elsewhere  in  the  uro-genital  tract. 
Extension  of  the  disease  from  the  kidney  may  occur  in  various  ways  : 

First,  by  surface  inocculation.  The  urine  coming  from  a  tubercu- 
lous kidney  is  laden  with  irritating  products,  which  finally  cause  swell- 
ing and  congestion  of  the  vesical  mucous  membrane,  particularly  over 
the  trigone.  This  leads  to  frequency  of  micturition,  owing  to  irritation 
of  the  vesical  neck.  Later  excoriation  of  the  surface  occurs  or  an 
abrasion  of  the  mucous  membrane  is  produced  by  needless  instrumenta- 
tion. The  soil  having  been  thus  favorably  prepared  and  a  means  of  en- 
trance for  the  bacilli  produced,  infection  readily  takes  place.  In  such 
cases,  therefore,  if  the  mucous  membrane  remains  intact,  the  chances  of 
infection  are  much  diminished,  so  that  every  possible  means  of  ascertain- 
ing the  true  cause  of  the  bladder  trouble  should  be  adopted  before 
sounding  for  stone  is  performed. 


TUBERCULOSIS  OF  TIIK   rilETERS,  BLADDER,  AND    URETHRA.   825 

Secondly,  the  l)l;i(M(i-  may  he  involved  as  a  ivsnlt  of  direct  exten- 
sion of  the  disease  alonii;  the  line  of  the  ureter.  The  mucous  mem- 
brane about  the  oritiee  of  the  urethra  becomes  swollen  and  congested, 
and  this  is  followed  by  ulceration,  whicii  gradually  extends  along  the 
corres))()ndinii'  trigonal   limi). 

'riiinllv,  in  a  yrcat  many  more  instances  than  is  generally  supposed 
th(>  bladder  is  involved  secondarily  to  renal  tuberculosis  as  a  result  of 
infeetit)n  through  the  bloodvessels.  Cystoscopic  examination  of  the 
bladder  in  suspected  cases  quite  frequently  shows  the  presence  of  tuber- 
cles beneath  the  mucous  membrane  without  there  being  any  superficial 
ulceration — a  point  strongly  suggesting  a  blood  infection. 

The  disease  sometimes  extends  from  the  prostate,  the  infection 
creeping  rather  uniformly  up  from  the  anterior  angle  of  the  trigonum. 
The  spread  of  the  disease  probably  takes  place  along  the  lymphatics  of 
the  submucous  coat.  Occasionally  the  bladder  is  invaded  from  an 
infected  seminal  vesicle.  Not  infrequently  there  is  a  direct  extension 
of  the  disease  from  the  recto-vesical  fold  of  peritoneum  in  cases  of 
tuberculous  peritonitis.  Tuberculous  ulcerations  of  the  intestine  may 
lead  to  adhesions  to  the  bladder  with  secondary  involvement  of  the 
latter.  In  the  female,  invasion  may  be  from  a  tuberculous  uterus  or 
vagina. 

The  extent  to  Avhich  the  tuberculous  process  may  have  advanced 
varies  considerably.  In  primary  vesical  tuberculosis  the  middle  coat 
alone  may  be  found  involved  if  the  disease  has  not  become  too  far 
advanced.  Other  cases  may  show  only  a  slight  localized  ulceration,  or 
the  whole  of  the  vesical  mucous  membrane  may  present  irregular,  deep 
ulcerations,  the  bases  of  which  are  covered  wdth  a  caseous  exudate. 
The  bladder  is  usually  contracted  and  the  walls  very  much  thickened. 
The  urine  is  purulent  and  contains  particles  of  caseous  material. 

In  primary  tuberculosis  of  the  bladder  the  symptoms  produced  may 
not  appear  until  some  considerable  time  after  involvement.  When  they 
do  present  themselves,  however,  the  resemblance  to  those  caused  by 
•calculus  may  be  quite  marked,  especially  when  the  tuberculosis  begins 
in  the  posterior  wall.  Frequency  of  micturition  and  pain  in  the  glans 
or  mid-penis,  particularly  in  the  latter  situation,  are  usually  the  first 
symptoms  which  attract  the  patient's  attention.  Fenwick  found  these 
to  be  the  earliest  symptoms  in  76  per  cent,  of  his  cases,  whilst  in  many 
of  the  remainder  hemorrhage  was  the  first  symptom.  The  frequency 
of  micturition  is  at  first  most  marked  during  the  day,  but  later  the 
night  is  also  disturbed  by  repeated  calls  to  empty  the  bladder — a  point 
which  would  be  strongly  against  the  probability  of  the  symptoms  being 
due  to  a  calculus.  These  symptoms  are  followed  in  from  a  few  days  to  a 
few  months,  according  to  the  acuteness  of  the  disease,  by  the  appearance 
of  blood  in  the  urine.  This  varies  in  amount,  and  may  consist  of  a  few 
drops  at  the  end  of  micturition.  The  hemorrhages  are  usually  transi- 
tory, and  are  not  specially  influenced  by  rest,  as  are  those  of  vesical 
calculus.  Pus  is  usually  present  in  the  urine  from  the  beginning,  at 
first  in  small  amounts,  but  increasing  in  quantity  as  the  disease  advances. 
During  the  act  of  micturition  the  stream  is  often  suddenly  arrested,  the 
patient  checking  it  voluntarily,  owing  to  the  severe  pain  and  spasm. 
This  differs  from  the  stoppage  of  the  stream  by  a  calculus  engaged  in 


826  TUBERCULOSIS. 

the  mouth  of  the  urethra,  which  is  beyond  the  patient's  control  and 
which  usually  increases  the  pain.  The  frequency  of  micturition,  which 
was  at  first  due  to  the  vesical  irritability  and  exaggerated  "  distention 
reflex,"  is  later  partially  produced  by  the  diminished  capacity  of  the 
bladder,  o^dng  to  the  gradual  contraction. 

In  advanced  stages  of  vesical  tuberculosis  the  symptoms  are  much 
the  same  whether  the  infection  is  primary  or  secondary.  Protracted 
cvstitis,  which  has  come  on  without  apparent  cause,  is  always  suggestive 
of  tuberculosis.  The  renal  regions,  the  testes,  and  the  prostate  should  be 
examined  with  care.  The  judicious  and  careful  use  of  the  cystoscope  is 
of  infinite  value  in  arriving  at  the  true  nature  of  the  disease  if  repeated 
examinations  of  the  urinary  sediment  have  given  negative  results. 

Tuberculosis  of  the  urethra,  as  a  primary  infection,  is  extremely 
rare.  Secondary  tuberculosis,  which  is  more  common,  may  result  from 
direct  invasion  from  the  prostate  by  continuity  or  by  surface  inoculation 
or  bv  blood  infection  from  a  focus  higher  up.  ^Miliary  tubercles  in  the 
urethra  are  not  uncommon  in  patients  who  die  of  general  miliary  tuber- 
culosis. The  chief  symptoms  of  urethral  tuberculosis  are  excessive 
pain  on  urination  or  instrumentation  and  a  marked  tendency  to  bleeding 
on  slight  manipulation.  When  definite  ulceration  occurs  the  first  ounce 
or  two  of  urine  passed  nearly  always  contains  tuberculous  detritus. 
Primary  tuberculosis  of  the  urethra  may  strongly  simulate  stricture, 
but  the  extraordinary  amount  of  pain  caused  by  the  most  delicate 
instrumentation,  even  after  the  use  of  a  strong  solution  of  cocaine, 
should  lead  one  to  suspect  tuberculosis. 

Tuberculosis  of  the  Prostate  and  Vesicul-^  Seminales. 

The  prostate  is  frequently  involved  in  tuberculosis  of  the  uro-genital 
tract,  some  writers  claiming"  that  it  never  escapes.  In  Krzyincki's  cases 
it  was  affected  in  14  out  of  15  males.  In  37  males  Orth  found  the 
prostate  involved  in  17  cases. 

The  disease  may  occur  as  a  primar}'  infection,  but  more  commonly 
results  from  extension  from  some  adjacent  or  distant  organ.  Many 
cases  of  primarv  tuberculosis  of  the  prostate  follow  chronic  folhcular 
inflammation  of  the  gland.  The  lowered  resistance  produced  by  such 
an  inflammation  seems  to  be  an  important  determining  factor.  In 
certain  instances  prostatic  tuberculosis  appears  to  date  from  an  attack 
of  gonorrhoea.  The  involvement  of  the  posterior  urethra  in  the  gonor- 
rhceal  inflammation  excites  into  acti\'ity  any  slumbering  tubercular 
focus  which  mav  be  already  existent  in  the  prostate.  Secondary  infec- 
tion generallv  follows  tuberculous  involvement  of  the  testes,  bladder,  or 
kidney.  That  following  testicular  disease  is  commonest  of  all.  More 
marked  changes  occur  in  primary  tuberculosis  of  the  prostate  and  in 
cases  in  which  the  disease  is  secondary  to  involvement  of  adjacent  parts 
than  in  those  in  which  it  is  secondary  to  pulmonary  tuberculosis,  for  in 
the  latter  case  death  is  likely  to  occur  "before  the  prostatic  disease  becomes 
far  advanced. 

In  primary  tuberculosis  of  the  organ  the  tubercles  generally  first 
appear  about  "the  acini  of  the  glands,  although  occasionally  the  sub- 
mucous tissue  of  the  prostatic  urethra  may  be  invaded.     In  the  latter 


TUBERCULOSIS  OF  PROSTATE  AND   VESICULJE  SEMINALES.     827 

instance  tlu'  deposit  uiulcrgoi's  caseation,  aiul  lc:i<ls  linally  to  :i  super- 
ficial ulceration  of  the  mucous  membrane,  thus  permittinf;  of  a  mixed 
infection,  owing;  to  contamination  with  pus  organisms,  after  which  the 
destructive  process  is  likely  to  advance  more  rapidly.  In  some  instances 
the  entire  ])rostate  may  i)e  eouverted  into  an  abscess  cavity  which  may 
open  into  the  urethra,  and  this  is  followed  sometimes  l)v  extravasation  of 
urine.  Secondary  prostatic  tuberculosis  begins  in  the  |)eriprostatic  lym- 
phatics and  bloodvessels.  In  both  primary  and  secondary  infections 
extension  of  the  disease  into  the  surrounding  tissues  frequently  occurs, 
and  quite  often  sinuses  burrow  in  various  directions.  The  commonest 
situation  for  these  sinuses  to  open  is  on  the  perineum  just  in  front  of 
the  anus,  or  they  may  burrow  backward  and  open  into  the  rectum. 
Occasionally  one  sees  evidences  of  a  spontaneous  cure  in  the  occurrence 
of  calcareous  and  libro-sclerotic  changes  in  the  cavity  wall,  M'ith  a 
resorption  of  their  contents  and  a  contraction  of  the  entire  mass. 

Enlargement  of  the  prostate  is  more  or  less  marked  from  the  com- 
mencement of  the  disease.  In  primary  infections  the  enlargement  is 
general,  and  in  a  majority  of  cases  uniform.  AVhere  the  infection  is 
secondary  to  tuberculosis  of  the  testicle  on  one  side,  the  corresponding 
half  of  the  prostate  is  usually  considerably  larger  than  the  other.  The 
enlargement  is  partly  due  to  the  growth  of  tubercles,  and  partly  to 
secondary  inflammation  and  hypertrophy  of  the  interstitial  connective 
tissue. 

If  the  disease  begins  in  the  periphery  of  the  prostate  or  in  the  peri- 
prostatic tissue,  the  symptoms  may  be  for  a  long  time  delayed.  Com- 
plaint is  not  likely  to  be  made  until  the  urethra  or  neck  of  the  bladder 
is  invaded.  Frequent  and  painful  micturition,  increasing  in  severity  as 
the  vesical  neck  becomes  involved,  is  the  most  uniform  symptom.  There 
may  be  haematuria,  which  is  usually  slight,  however,  excepting  in  rare 
instances.  The  urine  contains  some  pus,  which  may  be  markedly 
increased  for  a  time,  when  a  prostatic  abscess  opens  suddenly  into  the 
urethra.  Agonizing  pain  is  experienced  on  catheterization.  A  rectal 
examination  gives  valuable  information,  and,  next  to  finding  tubercle 
bacilli  in  the  urinary  sediment,  affords  the  most  positive  e\*idence  of 
the  true  nature  of  the  disease.  In  the  early  stages  only  a  few  small 
tubercles  may  be  felt,  but  in  more  advanced  cases  hard,  irregular 
nodules,  varying  in  size  from  a  pea  to  a  bean,  and  occasionally  areas 
of  softening,  may  be  easily  detected.  If  the  vesiculse  seminales  are 
also  enlarged  and  nodular,  the  e^'idence  will  point  still  more  strongly 
toward  tuberculosis.  The  importance  of  a  rectal  examination  in  all 
cases  of  suspected  genito-urinary  tuberculosis  cannot  be  overestimated, 
o^ving  to  the  frequency  with  which  the  prostate  is  involved,  no  matter 
in  what  part  of  the  tract  the  primary  focus  may  be  situated. 

Involvement  of  the  vesiculffi  seminales  is  quite  common  in  uro-genital 
tuberculosis.  They  M-ere  involved  in  11  out  of  15  males  in  KrzA-incki's 
series  of  cases.  Primary  infection  rarely  if  ever  occurs.  The  disease 
is  usually  secondary  to  tuberculosis  of  the  testicle  or  prostate,  the  former 
source  of  infection  being  the  commonest.  Direct  extension  from  a 
tuberculous  peritonitis  occurs.  The  seminal  vesicles  become  enlarged, 
hardened,  and  the  nodular  character  can  be  quite  readily  made  out  on 
rectal  examination.     Xot  infrequently  the  tuberculous  deposit  breaks 


828  TUBERCULOSIS. 

down  with  the  formation  of  distinct  cavities  within  the  seminal  vesicle 
— a  condition  occasionally  seen  at  autopsy. 

Tuberculosis  of  the  Testes. 

This  is  a  somewhat  common  affection,  and  may  be  primary,  or, 
more  frequently,  is  secondary  to  tuberculosis  elsewhere.  It  occurs 
quite  frequently  in  young  children,  many  cases  occurring  before  the 
second  year.  It  is  also  stated  to  have  been  found  in  the  foetus. 
In  infants  it  is  serious,  and  usually  associated  with  tuberculosis  in 
other  parts.  A  general  infection  was  present  in  every  one  of  the  9 
cases  reported  by  Hutinal  and  Deschamps.  In  20  cases  reported  by 
Jullien  6  were  under  one  year,  and  6  between  one  and  two  years  of 
age.  In  5  cases  both  testicles  were  affected.  Koplik  holds  that  a 
majority  of  the  cases  of  this  kind  are  congenital  in  Baumgarten's  sense. 
Many  cases  also  occur  about  puberty  and  in  young  adult  life.  In  primary 
tuberculosis  of  the  testicle  and  in  cases  in  adults  which  are  secondary 
to  tuberculosis  of  adjacent  parts,  the  epididymis  is  generally  first  in- 
volved, and  the  process  usually  begins  in  the  globus  major.  Where 
the  testicle  is  involved  as  a  part  of  a  general  miliary  tuberculosis  the 
tubercles  may  appear  simultaneously  in  the  epididymis  and  testicle 
proper.  In  children  the  tunica  albuginea  is  first  affected,  but  in  adults 
the  disease  commences  in  the  substance  of  the  organ,  the  gray  miliary 
tubercles  appearing  in  the  lymphoid  intertubular  tissue  of  the  epidid- 
ymis, and  often  later  working  their  way  through  the  mediastinum  testis 
and  infecting  the  lymphoid  tissue  around  the  tubuli  seminiferi. 

The  beginning  of  the  disease  is  rarely  noticed.  A  hard  nodule, 
already  of  some  size,  is  usually  discovered  accidentally  at  the  back  of 
the  gland.  When  both  testicles  are  involved  the  process  in  one  is 
usually  more  advanced  than  in  the  other.  As  the  disease  progresses 
the  nodules  increase  in  size,  and  eventually  some  may  undergo  caseation 
and  softening.  Occasionally  in  this  way  the  whole  testicle  may  become 
destroyed.  The  skin  at  one  point  may  become  adherent,  reddened,  and 
inflamed,  finally  giving  w^ay  and  allowing  the  tuberculous  abscess  to 
discharge.  Where  such  a  condition  occurs  over  the  body  of  the  gland 
a  hernia  testis  may  follow.  Caseation,  however,  does  not  always  occur, 
but  in  rare  instances  the  gland  undergoes  calcification  and  fibroid  degen- 
eration with  complete  healing. 

The  disease  not  infrequently  extends  along  the  vas  deferens,  and 
finally  involves  the  vesiculse  seminales,  prostate,  and  bladder.  When 
involvement  of  the  vas  occurs  it  will  be  found  distinctly  thickened  and 
nodular. 

Tuberculosis  of  the  testicle  is  only  slightly  painful  and  there  is  very 
little  tenderness  on  palpation.  Excepting  in  very  advanced  stages  of 
the  disease  testicular  sensation  is  retained.  Hydrocele  very  rarely 
occurs.  The  disease  is  most  likely  to  be  confounded  with  syphilis.  In 
the  latter,  however,  the  body  of  the  gland  is  often  affected.  There  is 
no  pain  nor  tenderness,  but  the  testicular  sensation  is  lost  early.  The 
outlines  of  the  growth  are  more  nodular  and  irregular.  The  vas  is 
never  affected  in  syphilitic  disease  of  the  testicle.  It  is  not  uncommon 
to  have  tuberculosis  of  the  testicle  associated  with  peritoneal  tuber- 


TUBERCULOSIS  OF  Till-:  FILM  ALE  GENERATIVE  ORGANS.     829 

culosis,  and  in  an  ohscui'c  peritoneal  alTeetion  the  detection  ol'  iiodides 
in  the  testicle  has  often  led  to  a  correct  dia<;'nosis.  General  intection 
niav  follow  tuherenlosis  of  the  testicle,  and  also,  in  some  instances,  may 
result  from  remo\al  of  a  diseased  gland. 

Tuberculosis  of  the  Female  Generative  Organs. 

Tlu>  reproductive  organs  of  the  female  have  for  a  long  time  been 
known  to  be  occasionally  the  seat  of  tuberculosis,  but  it  is  only  within 
the  last  few  years  that  tuberculous  att'ections  of  these  parts  have  been 
recognized  as  comparatively  frecjuent  occurrences.  Laparotomy  in  tuber- 
culous peritonitis  has  revealed  the  fact  that  in  very  man\^  instances  in 
women  the  Fallopian  tubes  are  also  involved.  This  discovery  has  ex- 
cited interest  in  the  subject,  owing  to  the  strong  probability  that  the 
tubes  may  be  in  many  instances  the  source  of  origin  of  the  peritoneal 
disease. 

The  careful  and  systematic  microscopic  examination  of  specimens 
from  the  operating  room  and  autopsy  table  has  shown  that  primary 
tuberculosis  of  the  tubes  is  not  at  all  uncommon,  and  that  many  cases, 
which  macroscopically  would  appear  to  be  of  a  simple  inflammatory 
character,  are  really  tuberculous  (J.  Whitridge  Williams). 

Genital  tuberculosis  in  the  female,  as  has  already  been  stated,  is 
much  less  frequent  than  in  the  male,  the  proportion  being  1  to  3.  The 
disease  is  most  common  between  the  ages  of  twenty  and  forty  years — 
that  is,  during  the  period  of  greatest  sexual  activity.  Cases  have 
occurred  as  early  as  ten  weeks  and  as  late  as  eighty-three  years  of  age. 
Although  statistics  vary  considerably,  the  frequency  of  genital  tuber- 
culosis may  be  judged  from  the  fact  that  various  pathologists  have 
found  it  present  in  from  1  to  8.5  per  cent,  of  all  autopsies  on  phthisical 
women.  Kelly  had  found  tuberculosis  present  in  1  out  of  every  12 
operations  for  the  removal  of  tubes  and  ovaries  which  were  the  seat  of 
past  or  present  inflammatory  disease.  Certain  portions  of  the  genital 
tract  are  attacked  much  more  frequently  than  others,  the  order  of  fre- 
quency being  as  follow^s :  tubes,  uterus,  ovaries,  vagina,  cervix,  and 
vulva. 

Vulva. — Tuberculosis  of  the  vulva  is  a  rare  occurrence,  only  3 
authenticated  cases,  in  which  tubercle  bacilli  w^ere  found  or  in  which 
inoculation  experiments  gave  positive  results,  having  been  reported  up 
to  1893  (Williams).  The  vagina  is  practically  always  involved.  The 
lesion  produced  exhibits  all  the  characters  of  an  ordinary  tubercular 
ulcer.  The  presence  of  tubercle  bacilli  in  the  secretions  or  of  tubercles 
in  the  scrapings  from  the  ulcer  would  differentiate  the  disease  from  car- 
cinoma or  syphilis,  for  which  it  might  be  mistaken. 

Vagina. — The  vagina  is  usually  involved  secondarily  to  a  tubercu- 
losis of  some  portion  of  the  genital  tract  higher  up,  particularly  the 
uterus.  It  may,  however,  be  the  only  seat  of  tuberculosis  in  the  geni- 
talia, and  Friedliinder  claims  that  it  may  be  the  primary  focus  of  the 
disease  in  the  body.  Occasionally  it  becomes  involved  secondarily  to 
disease  of  the  bladder  or  rectum  by  direct  extension,  in  which  case 
vesico-vaginal  or  recto-vaginal  fistula  not  infrequently  result.  The 
upper  third  of  the  posterior  wall  of  the  vagina  is  usually  involved,  as 


830  TUBERCULOSIS. 

this  is  the  area  with  which  the  exudate  from  tuberculous  foci  higher 
up  usually  comes  in  contact.  The  disease  may  occur  either  as  an  erup- 
tion of  miliary  tubercles  or  as  an  ulcerating  surface.  Tuberculosis  of 
the  vagina  might  be  mistaken  for  granular  vaginitis,  hard  or  soft 
chancre,  carcinoma,  or  papular  and  ulcerative  syphilides.  Here,  again, 
the  microscope  is  of    invaluable  service  in  clearing  up  the  diagnosis. 

Uterus. — Tuberculosis  of  the  body  of  the  uterus  is  very  rare  and 
is  nearly  always  secondary.  It  is  generally  associated  with  tuberculosis 
of  the  tubes,  from  which  the  process  extends.  The  uterus,  however, 
may  be  the  only  seat  of  tuberculous  disease  in  the  body.  Rarely  does 
the  process  extend  beyond  the  internal  os  to  involve  the  cervix.  It 
may  occur  as  a  miliary  tuberculosis,  with  or  without  the  formation  of 
ulcerations.  In  nearly  all  cases  there  is  at  first  an  eruption  of  miliary 
tubercles  in  the  endometrium,  a  form  of  the  disease  met  with  par- 
ticularly at  autopsies  on  women  who  have  died  of  some  other  disease, 
the  condition  never  having  been  suspected  during  life.  A  few  minute 
ulcerations  may  be  present.  The  endometrium  between  the  tubercles 
may  be  reddened  or  may  appear  normal.  The  form  of  uterine  tuber- 
culosis generally  met  with,  however,  is  the  chronic  diffuse  tuberculosis 
(caseous  endometritis).  Here  the  entire  uterine  cavity  is  filled  with 
caseous  material ;  the  surface  of  the  endometrium  is  covered  with  exu- 
date, and  presents  irregular  and  jagged  ulcers,  the  floors  of  which  are 
studded  with  tubercles  in  various  stages  of  development.  Later  the 
muscular  wall  of  the  uterus  becomes  infiltrated  with  tubercles  and 
undergoes  hypertrophy.  The  cervical  canal  may  become  obstructed  by 
caseous  exudate,  and  the  latter,  accumulating  in  the  uterine  cavity, 
produce  a  pyometra. 

The  cervix  of  the  uterus  is  much  less  frequently  involved  than  the 
body.  It  is  seldom  associated  with  disease  of  the  latter,  but  not  com- 
monly occurs  along  with  vaginal  tuberculosis.  Friedlander  reported  a 
case  in  which  it  was  the  only  seat  of  tuberculosis  in  the  body.  The 
disease  generally  presents  itself  in  the  form  of  an  eruption  of  miliary 
tubercles  or  as  an  ulcerating  surface.  In  advanced  cases  the  condition 
might  be  mistaken  for  carcinoma  of  the  cervix,  but  the  examination  of 
sections  of  a  minute  portion  of  the  diseased  area  would  reveal  the  true 
nature  of  the  disease. 

Fallopian  Tubes. — The  Fallopian  tubes  are  by  far  the  most  frequent 
seat  of  genital  tuberculosis.  In  a  large  percentage  of  cases  the  disease 
is  associated  with  tuberculosis  of  the  uterus  or  ovaries  or  both.  The 
special  attention  which  has  been  paid  to  local  affections  of  these  parts 
by  gynecologists  during  the  last  decade  has  taught  us  that  primary 
tuberculosis  of  the  tubes  is  not  at  all  uncommon.  The  disease  may 
produce  a  most  characteristic  form  of  salpingitis,  in  which  the  tubes  are 
enlarged,  the  walls  thickened  and  infiltrated,  and  the  contents  cheesy. 
The  fimbriated  extremity  is  usually  closed,  and  the  fimbrise  are  frequently 
bound  down  to  the  ovary.  When  both  ends  of  the  tube  become  occluded 
a  very  large  pus  sac  may  result.  Between  this  and  the  mildest  cases, 
in  which  only  a  few  visible  tubercles  are  studded  over  the  mucosa,  all 
grades  exist.  The  condition  is  usually  bilateral.  It  may  occur  in  quite 
young  children. 

Although,  as  a  rule,  the  disease  is  evident  on  macroscopic  examina- 


tubP.rculosis  of  the  brain  and  cord.  831 

tion,  yet  there  are  specimens  wliit-li  to  the  iiakt-d  eye  appear  to  be 
ordinary  cases  of  salpingitis,  but  which  on  microscopic  examination 
show  tlie  mucosa  to  be  studded  Avith  numerous  miliary  tubercles  (Welch 
antl  \\'illiams).  These  cases  of  "  unsuspected  tuberculosis"  constitute 
75  per  cent,  of  all  the  cases  of  tuberculosis  of  the  Fallopian  tubes 
which  have  l)een  operated  on  in  the  <rynee<)los>:ical  department  of  the 
Johns  Hopkins  Hospital. 

Tuberculous  salpiui^itis  may  cause  serious  local  disease  with  abscess 
formation,  and  it  may  be  the  starting  point  of  peritonitis. 

It  is  practically  impossible  to  make  an  absolute  diagnosis  of  tuber- 
culosis of  the  tubes.  The  association  of  a  thickened  tube  with  an  ill 
delined  mass  in  the  abdominal  cavity  should  arouse  one's  suspicions. 

Ovarii. — Although  comparatively  rare,  tuberculosis  of  the  ovary  is 
more  common  than  was  formerly  supposed.  It  may  be  the  only  seat 
of  tuberculosis  in  the  genital  tract,  as  is  sometimes  the  case  when  found 
associated  with  tuberculous  peritonitis.  Primary  tuberculosis  of  the 
ovary  probably  never  occurs.  The  disease  may  manifest  itself  as  an 
eruption  of  tubercles  over  the  surface  of  the  ovary,  or  there  may  be 
more  extensive  involvement  with  the  production  of  an  ovarian  abscess. 


YII.  TUBERCULOSIS  OF  THE  BRAIN  AXD  CORD. 

In  connection  vdx\\  acute  miliarv  tuberculosis  a  few  scattered  g'ran- 
iiles  may  be  met  with  on  the  meninges.  One  of  the  special  forms  of 
acute  tuberculosis  affects  the  meninges,  and  has  already  been  described. 
(See  Acute  Tuberculous  Meningitis,  page  754.) 

The  disease  occurs  in  two  forms  in  the  brain — namely,  a  localized 
chronic  meningo-eucephalitis,  in  which  there  is  thickening  of  the  mem- 
branes and  small  nodular  tubercles ;  and  the  larger  tuberculous  tumor, 
which  may  attain  the  size  of  a  walnut  or  larger,  and  which  is  often 
solitary.  These  forms  develop  slowly,  are  essentially  chronic,  and  have 
the  clinical  characters  of  a  tumor. 

The  tuberculous  brain  tumor  is  met  with  most  commonly  in  children. 
Of  148  cases  collected  by  Bribram,  118  were  under  fifteen  years  of  age. 
Tubercles  are  usually  found  in  other  organs  as  well,  particularly  the 
lungs  and  the  bronchial  glands.  In  a  few  rare  cases  the  brain  alone  is 
involved.  They  are  frequently  mnltiple — in  100  out  of  183  cases, 
according  to  Gowers ;  in  20  per  cent.,  according  to  Starr.  The  growths 
range  in  size  from  a  pea  to  a  walnut ;  occasionally  larger,  somewhat 
diffuse  masses  are  found.  They  are  almost  always  attached  to  the  me- 
ninges ;  rarely  are  deep  in  the  brain  substance.  The  masses  may  really 
look  imbedded  in  the  white  matter  of  the  cerebrum,  but  on  section  are 
found  to  be  attached  to  the  pia  mater  at  the  bottom  of  a  sulcus.  They 
occur  most  frequently  in  the  cerebellum,  next  in  the  cerebrum,  and  then 
in  the  pons.  The  tuberculous  tumor  is,  as  mentioned,  usually  attached 
to  the  meninges,  is  grayish  yelloAV  in  color,  firm,  hard  on  section,  cheesy, 
yellow,  and  is  often  surroimded  by  a  translucent  connective  tissue.  The 
centre  of  the  growth  may  be  semi-diffluent.  In  other  cases  lime  salts 
are  deposited.  The  tuberculous  growth  may  produce  symptoms  by 
causing  destruction  of,  or  pressure   upon,  the    contiguous   brain    sub- 


832  TUBERCULOSIS. 

stance,  or,  growing  about  the  arteries  of  the  meninges,  maA^  block  the 
blood  current  and  cause  areas  of  softening.  Growing  about  the  longi- 
tudinal fissure,  it  may  compress  the  sinus  and  lead  to  thrombus  forma- 
tion ;  and,  lastly,  it  not  infrequently  excites  a  tuberculous  meningitis. 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of 
tumor.  The  occurrence  in  children,  the  coexistence  of  tuberculous 
lesions  elsewhere,  or  the  presence  of  a  healed  gland  or  joint  disease 
are  among  the  features  which  would  suggest  the  tuberculous  character 
of  the  growth. 

Tuberculosis  of  the  spinal  cord  occurs  in  the  same  forms  as  in  the 
brain.  Acute  tuberculous  meningitis  is  very  rarely  confined  to  the 
cord ;  it  is  almost  always  cerebro-spinal.  A  tuberculous  tumor  in  the 
cord  is  rare.  Of  130  tumors  of  the  cord  collected  by  Lloyd,  15  were 
tubercle.  Herter  has  reported  3  cases,  and  collected  24  instances  from 
the  literature,  in  all  of  which  save  1  the  condition  was  secondary. 


VIII.  TUBERCULOSIS  OF  THE  MAMMARY  GLA^'D. 

Excellent  descriptions  of  tuberculosis  of  the  breast  were  given  by 
Astley  Cooper  in  1829,  by  Nelaton  in  1839,  and  by  Velpeau  in  1854. 
For  nearly  three  decades  following  the  latter  date  very  few  cases  were 
recorded,  and  it  was  not  until  the  appearance  of  Dubar's  monograph  in 
1881  that  mammary  tuberculosis  became  generally  recognized.  With 
the  exception  of  histological  details,  Velpeau's  account  has  never  been 
surpassed.  Tuberculosis  of  the  breast  is  much  more  common  than  has 
hitherto  been  generally  supposed.  Mandy^  has  collected  40  cases,  only 
1  of  which  occurred  in  the  male.  Other  cases  of  mammary  tuberculo- 
sis in  the  male  have  been  reported  by  Horteloup  and  Poirier.  The 
disease  is  commonest  between  the  fortieth  and  sixtieth  years.  It  is 
said  never  to  occur  in  children,  but  Payne  observed  a  case  in  an  infant 
which  was  also  the  subject  of  general  tuberculosis.  Traumata  and  con- 
ditions associated  with  the  puerperal  state  seem  to  favor  its  development. 
The  majority  of  cases  occur  in  women  who  have  borne  children.  Of 
35  cases  collected  by  Powers,^  22  were  in  married  women,  and  of  these 
21  had  borne  children.  The  right  breast  appears  to  be  oftener  affected 
than  the  left.     In  only  1  of  Powers'  cases  were  both  glands  diseased. 

Velpeau  recognized  that  the  disease  may  be  either  primary  or  sec- 
ondary, and  subsequent  investigations  have  borne  out  his  views.  In 
primary  cases  it  seems  likely  that  infection  takes  place  through  the 
milk  ducts,  although  the  bacilli  may  enter  from  infected  fissures  by 
way  of  the  lymphatics.  The  great  majority  of  cases  are  secondary  to 
some  other  focus  in  the  body,  usually  the  lungs. 

Mammary  tuberculosis  occasionally  occurs  in  the  form  of  scattered 
nodules  throughout  the  gland,  resembling  often,  in  the  early  stages, 
alveolar  hypertrophy.  Both  the  parenchyma  and  the  stroma  of  the 
gland  are  involved,  and  the  nodules  may  undergo  caseation.  A  second 
variety  of  the  disease  occurs  in  the  form  of  rather  large  caseous  tumors, 
which  on  section  closely  resemble  tuberculous  lymph  glands.  These 
soften  and  break  down,  and    frequently  involve    the    skin.      Fistulse 

'  Brima'  Beitrdge,  viii.  "  Annals  of  Surgery,  1894. 


TUBERCULOSIS   OF  Till':  ARTERIES.  833 

which  discharge  ;i  thin  caseous  matter  rrc(jtiently  (leveh)i).  These, 
together  with  the  idcers,  present  a  characteristic  tuhereuh)us  aspect. 
The  nipple  is  quite  often  retracted  in  the  aho\'e  forms.  Mammary 
tuberculosis  not  infrequently  takes  the  form  of  a  cold  abscess.  The 
axillary  glands  are  involved  in  about  two  thirds  of  the  cases.  The 
dangers  to  which  children  are  exposed  by  sucking  Momen  who  are  the 
subject  of  tuberculosis  of  the  breast  is  shown  in  a  ease  i'e])orted  bv 
Niepce/  in  which  a  nurse  whose  milk  contained  tubercle  bacilli  su(dcle"d 
a  child  born  of  healthy  parents,  with  the  result  that  the  child  soon 
afterward  died  of  tuberc;ulous  meningitis. 

The  disease  runs  a  chronic  course,  lasting  months  or  vears.  The 
diagnosis  can  be  made  by  the  general  appearance  of  the  fistuke  and 
ulcers  and  by  the  iinding  of  tubercle  bacilli.  Simple  opening  of  the 
abscesses,  with  scraping  of  the  cells,  is  not  sufficient.  With  a  radical 
operation,  in  which  the  breast  and  axillary  glands  are  thoroughly 
removed,  the  chances  against  secondary  local  recurrence  are  good. 

The  skin  of  the  breast  is  occasionally  the  seat  of  lupus,  which  mav 
affect  either  the  areolar  region  or  the  skin  elsewhere. 

In  1836,  Bodor  described  an  interesting  condition  of  the  l^reast  in 
subjects  who  suffered  from  pulmonary  tuberculosis,  in  which  the  gland 
became  temporarily  enlarged,  without  there  being  any  local  tuberculous 
lesions.  The  condition  has  been  quite  frequently  observed  since  that 
date.  The  enlargement  is  only  temporary,  disappearing  in  a  few  weeks. 
It  is  commonest  in  men,  and  usually  only  one  gland  is  affected.  The 
condition  is  usually  found  on  the  same  side  as  the  most  advanced  pul- 
monary changes.  The  breast  is  firm  to  the  touch,  and  is  often  quite 
sensitive  to  pressure.  Thomas^  has  collected  several  cases,  and  reports 
1  himself  in  which  the  histological  examination  showed  the  enlargement 
to  be  due  to  the  development  of  fibrous  tissue  about  the  acini,  which 
were  considerably  atrophied. 


IX.  TUBERCULOSIS  OF  THE  ARTERIES. 

In  chronic  tuberculous  disease  of  the  lungs  and  other  organs  the 
arteries  are  often  involved  in  an  acute  infiltration  ;  tubercles  mav  develop 
in  the  walls  and  proceed  to  caseation  and  softening,  which  mav  be  fol- 
lowed by  the  formation  of  a  thrombus,  or  hemorrhage  mav  occur.  The 
recent  observations  of  Hektoen,  referred  to  under  Tuberculous  Men- 
ingitis (page  756),  show  that  there  may  be  the  production  of  tubercles  of 
the  intima,  and  a  diffuse  subendothelial  proliferation  due  to  the  implan- 
tation of  bacilli  direct  from  the  blood.  By  direct  extension  into  vessels 
the  bacilli  are  widely  distributed.  Tuberculosis  of  the  smaller  arteries 
plays  a  very  important  role  in  meningitis,  in  which  from  the  adventitia 
the  tuberculous  disease  may  invade  the  media  and  intima  and  lead  to 
occlusion  or  thrombus  formation. 

Primary  tuberculosis  of  the  larger  bloodvessels  is  almost  unknown. 
Occasionally  the  aorta  is  invaded  from  a  cheesy  mass  in  a  lymph  gland 
outside  the  vessel.  In  a  case  reported  by  Flexner  a  patient  with 
chronic    tuberculosis  presented  a    nodular  mass  in    the  aorta  2.5  cm. 

1  Paris  Thesis,  1886.  -  Ibid.,  1893. 

Vol.  I.— 53 


834  TUBERCULOSIS. 

below  the  origin  of  the  left  subclavian  artery.  It  was  pale,  translucent, 
apparently  made  up  of  several  smaller  masses.  It  was  found  to  be  a 
tubercle  seated  directly  upon  the  intima,  and  consisted  of  several  masses 
with  caseous  centres.  The  most  interesting  feature  was  that  both  media 
and  adventitia  were  perfectly  normal.  There  were  no  caseous  glands  in 
the  vicinity  of  the  aorta. 

Prognosis  in  Tuberculosis. 

At  one  time  or  another  tubercle  bacilli  effect  a  lodgement  in  a  con- 
siderable proportion  of  all  individuals,  justifying  the  old  German 
axiom  :  "  Jedermami  hat  am  Ende  ein  bischen  TubereuloseJ'  Infection 
with  the  bacilli  does  not  necessarily  mean  the  establishment  of  a  pro- 
gressive and  fatal  disease.  The  subject  is  a  wide  one,  and  there  are 
several  aspects  in  which  it  may  be  considered  : 

(a)  The  Natural  or  Spontaneous  Cure  of  Tuberculosis. — The  spon- 
taneous healing  of  local  tuberculosis  is  an  every-day  aifair.  Disease  of 
the  bones,  of  the  joints,  and  adenitis  may  heal  without  the  aid  of  the 
knife  or  of  medicines.  The  percentage  of  persons  with  evidence  of 
tuberculous  lesions,  active  or  obsolete,  is  remarkably  high.  It  is 
stated  that  in  the  autopsies  at  the  Paris  Morgue,  made,  as  a  rule,  upon 
the  bodies  of  persons  who  have  committed  suicide  or  who  have  been 
killed  accidentally,  nearly  75  per  cent,  show  tuberculous  foci — either 
calcareous  or  cheesy  nodules  in  the  mesenteric  or  bronchial  glands,  or 
puckering  Avith  caseous  or  calcareous  nodules  at  the  apices.  The  per- 
centage in  observations  which  have  been  made  of  late  years  on  this 
point  in  hospitals  has  been  very  striking,  as  showing  the  widespread 
prevalence  of  the  disease.  In  1000  autopsies  at  the  Montreal  General 
Hospital,  excluding  the  216  cases  dead  of  pulmonary  tuberculosis,  there 
were  59  cases  which  presented  tuberculous  lesions  in  the  lungs.  This 
estimate  is  low,  as  I  excluded  (which  I  really  should  not  have  done) 
the  solitary  cheesy  nodule  unless  there  were  colonies  of  tubercles  in  the 
vicinity.  These  59  cases  died  of  various  diseases  and  at  various 
ages,  a  majority  of  them  between  forty  and  sixty  years.  My  experience 
tallies  closely  with  the  larger  figures  of  Heitler,  taken  from  the  Vienna 
post-mortem  records,  in  which,  of  16,562  cases  in  which  the  death  was 
not  directly  due  to  pulmonary  tuberculosis,  there  were  780  instances  of 
obsolete  tubercle.  The  more  recent  observations  have  shown  a  much 
higher  percentage  :  thus,  Bollinger  found  traces  at  autopsy  of  former 
tuberculosis  in  27  per  cent.  ;  Massini  in  39  per  cent.  •  and  Harris  in 
38.8  per  cent.  The  spontaneous  arrest  of  pulmonary  tuberculosis  is, 
after  all,  a  very  common  affair.  Clinically  it  is  shown  by  the  complete 
recovery  of  patients  in  whose  sputa  elastic  tissue  and  bacilli  have  been 
found,  and  anatomically  by  the  presence  of  lesions  in  all  stages  of 
repair.  A  clear  distinction  should  be  drawn  between  arrest  and  heal- 
ing. The  latter  term  may  be  applied  when  in  the  granulation  products 
and  associated  pneumonia  a  scar  tissue  develops  and  the  caseous  areas 
become  cretaceous.  When  the  fibroid  change  encapsulates,  but  in- 
volves the  entire  tuberculous  area,  the  tubercle  may  be  called  involuted 
or  quiescent,  but  it  is  not  harmless,  as  may  be  shown  by  the  fact  that 
usually  about  such  apparently  quiescent  areas  there   are  small  colonies 


rjioayo^i'S  l\  tuherculosis.  835 

of  iniliarv  tubercles.  Cavities  of  any  size  rarely  heal,  in  the  proper 
sense  of  the  term.  They  may  become  ^-reatly  reduced  in  size,  and  an 
U])[)er  lobe  of  a  luui;"  with  numerous  cavities  may  be  so  contracted  by 
sclerosis  and  shrinkage  that  it  lias  not  one  third  of  its  natui-al  dimen- 
sions. Ijaennec  described  with  _ii:reat  accuracy  the  natural  process  of 
cure  in  tuberculosis,  and  suo;<2;ested  that  as  tubercles  in  the  g-lands  heal, 
the  same  could  take  place  in  the  lesions  of  the  lungs.  At  the  apices  of 
the  lungs  the  following  common  conditions  arc  held  to  signify  healed  and 
obsolete  tub(>rcuh)us  processes  :  (1)  The  thickening  of  the  ])]eura,  usually 
at  the  posterior  surface  of  the  apex,  Avith  subjacent  induration  for  a  dis- 
tance of  a  few  millimetres.  This  has,  perhaps,  no  greater  significance 
than  the  milky  patch  on  the  pericardium.  (2)  Puckered  cicatrices  at 
the  apex — cicatrices  compIMes  of  Laennec — depressing  the  pleura  and  on 
section  showing  a  large  pigmented  fibrous  scar.  The  bronchioles  in  the 
neighborhood  may  be  dilated,  but  there  are  neither  tubercles  nor  cheesy 
masses.  This  may  sometimes,  bnt  not  always,  indicate  a  healed  tuber- 
culous lesion.  (3)  Puckered  cicatrices  with  cheesy  or  cretaceous  nodules, 
and  with  scattered  tubercles  in  the  vicinity.  (4)  The  cicatrices  fistuleuses 
of  Laennec,  in  which  the  fibroid  puckering  has  reduced  the  size  of  one 
or  more  cavities  which  communicate  directly  with  the  bronchi. 

(6)  The  FcK-tors  of  Prognosis  in  Established  Pulmonary  Tuberculosis. 
— Many  years  ago  Flint  called  attention  to  the  self-limitation  and 
intrinsic  tendency  to  recover  in  well  marked  pulmonary  tuberculosis. 
Of  670  cases,  44  recovered,  and  in  31  the  disease  was  arrested.  The 
factors  upon  which  one  may  lay  stress  in  estimating  the  prognosis  in 
a  case  with  well  marked  symptoms,  say  at  one  apex,  are  as  fol- 
lows :  Previous  good  health  and  a  sound  ftimily  history  are  perhaps 
the  most  important.  A  strong  digestion  is  a  third  most  important 
favoring  factor.  A  fourth,  and  perhaps  most  essential  of  all,  is  the 
possibility  of  living  in  a  favorable  environment.  A  slow,  gradual  onset 
\vithout  high  fever  and  without  rapid  consolidation  and  caseation  is  also 
a  good  omen.  Cases  beginning  with  pleurisy  appear  to  run  a  more  pro- 
tracted and  favorable  course.  Of  the  special  symptoms  fever  is  perhaps 
the  most  valuable  element.  With  apyrexia  the  local  disease  rarely  makes 
much  progress.  The  higher,  the  more  irregular,  and  the  more  persistent 
the  fever,  cseteris  paribus,  the  more  grave  is  the  prognosis.  The  facility 
with  which  the  fever  is  reduced  by  the  open-air  treatment  is  another 
important  point,  as  are  also  the  frequency  and  severity  of  the  recur- 
rences of  the  pyrexia  which  are  so  common  in  the  chronic  forms  of  the 
disease.  Recurring  attacks  of  haemoptysis  are  unfavorable,  more  par- 
ticularly when  they  are  followed  by  spells  of  high  fever.  Not  very 
much  stress  is  to  be  laid  upon  the  number  of  bacilli  in  the  sputa,  since 
they  may  be  extraordinarily  abundant  from  a  very  small  focus  of  local 
disease.  On  the  other  hand,  persistence  for  a  long  period  in  very  large 
numbers  is  usually  an  unfavorable  element  in  prognosis,  while  a  gradual 
diminution  is  a  hopeful  feature.  In  pulmonary  tuberculosis  the  primal 
vice  control  the  situation,  and  the  better  the  digestion  and  the  more  able 
the  patient  is  to  take  a  varied  and  nourishing  diet  the  better  are  his 
prospects.  There  are  no  more  unfavorable  cases  than  those  in  which, 
early  in  the  disease,  w'itli  pronounced  gastric  symptoms,  there  is  a  marked 
chloro-anfemia. 


836  TUBERCULOSIS. 

(c)  The  Duration  of  Pulmonary  Tuberculosis. — Laennec  placed  the 
average  duration  at  two  years.  As  mentioned,  a  case  of  acute  pneu- 
monic phthisis  may  prove  fatal  within  ten  days,  whereas  in  the  chronic 
form  the  disease  may  persist  for  twenty  or  more  years.  The  probable 
duration  in  each  individual  case  must  be  estimated  according  to  the 
factors  already  mentioned.  The  large  statistics  of  different  authors 
vary  very  much ;  thus  in  Pollock's  tabulation  of  over  3500  cases  the 
mean  duration  of  the  disease  was  a  little  over  two  years  and  a  half. 
"  Williams's  returns  for  1000  patients  in  the  better  classes  give  only 
198  deaths,  and  the  mean  duration  of  life  in  the  latter  after  the  com- 
mencement of  the  disease  was  seven  years  and  eight  months,  while  only 
36  per  cent,  of  these  patients  lived  less  than  nine  years.  Of  the  survi- 
vors, the  average  duration  of  whose  life  was  eight  years  and  two  months, 
as  many  as  68  patients,  or  8  per  cent,  of  the  whole  number,  had  lived  more 
than  twenty  years  from  the  commencement  of  the  disease  "  (Wilson  Fox). 

(d)  Tuherculosis  and  Marriage. — Under  the  subject  of  prognosis 
comes  the  question  of  the  marriage  of  persons  who  have  had  tuberculo- 
sis or  in  whose  family  the  disease  prevails.  The  folloAving  brief  state- 
ments may  be  made  with  reference  to  it : 

(1)  Subjects  with  healed  lymphatic  or  bone  tuberculosis  marry  with 
personal  impunity  and  may  beget  healthy  children.  It  is  undeniable,, 
however,  that  in  such  families  scrofula,  caries  of  the  bone,  arthritis, 
cerebral  and  pulmonary  tuberculosis  are  more  common.  Which  is  it, 
"  heredite  de  graine  ou  heredity  de  terrain,"  as  the  French  have  it — 
the  seed  or  the  soil,  or  both  ?  AVe  cannot  yet  say.  The  risks,  however^ 
are  such  as  may  properly  be  taken. 

(2)  The  question  of  marriage  of  a  person  who  has  arrested  or  cured 
lung  tuberculosis  is  more  difficult  to  decide.  If  a  male,  the  personal 
risk  is  not  so  great ;  and  when  the  health  and  strength  are  good,  the 
external  environment  favorable,  and  the  family  history  not  extremely 
bad,  the  experiment — for  it  is  such — is  often  successful,  and  many 
healthy  and  happy  families  are  begotten  under  these  circumstances.  In 
women  the  question  is  complicated  with  that  of  childbearing,  which 
increases  the  risks  enormously.  With  a  localized  lesion,  absence  of 
hereditary  taint,  good  physique,  and  favorable  environment  marriage 
might  be  permitted.  When  tuberculosis  has  existed,  however,  in  a  girl 
whose  family  history  is  bad,  whose  chest  expansion  is  slight,  and  whose 
physique  is  below  the  standard,  the  j^hysician  should,  if  possible,  place 
his  veto  upon  marriage. 

(3)  With  existing  disease,  fever,  bacilli,  etc.  marriage  should  be  abso- 
lutely prohibited.  Pregnancy  and  parturition  hasten  the  process  in 
almost  every  case.  There  is  much  truth,  indeed,  in  the  remark  of 
Dubois  :  "  If  a  woman  threatened  with  phthisis  marries,  she  may  bear 
the  first  accouchment  well ;  a  second,  with  difficulty ;  a  third,  never." 
(On  this  subject  the  monograph  of  Reibmayr,  Die  Ehe  Tubercidoser, 
may  be  consulted  with  advantage.) 

Prophylaxis  in  Tuberculosis. 

The  measures  directed  to  the  prevention  of  tuberculosis  may  be  con- 
sidered under — first,  those  which  are  concerned  with  the  destruction  of 


'niOPlIYLAXIS   IS   TI'BERCULOSIS.  8:37 

the  witloprcad  livrin  ;  aiul  sccoikI,  iiieasiires  diroctetl  to  maintain  tiic 
nutrition  of  the  individual  at  its  niaxiniuni. 

General  Mcdsurcx. — ((/)  Disinfection  of  the  sputum.  The  most  com- 
mon method  of  dissemination  of  the  disease  is  with  the  ex])ectoration 
of  tubercuh)us  patients.  In  a  dried  form  it  is  spread  l)roadeast  witii  the 
dust,  and  every  patient  in  the  stage  of  eavity  is  a  focus  of  danger.  W'lien 
one  considers  that  such  a  patient  may,  as  shown  by  Xuttall,  expectorate, 
at  a  very  moderate  estimate,  from  two  to  four  billions  of  bacilli  in  the 
twenty-four  hours,  the  danger  is  by  no  means  imaginary.  The  patient 
.should  be  directed  always  to  use  a  spit-cup  or  the  handkerchief,  and 
never  to  spit  (»n  the  floor  or  on  the  ground.  The  sputum  may  be  disin- 
fected bv  tliorouii:h  boilino-  or  a  solution  of  carbolic  acid  of  the  strena-th 
of  1  :  20  may  be  put  into  the  spit-cup.  The  handkerchiefs  used  by  the 
patients  should  be  thoroughly  boiled.  It  should  be  explained  frankly 
to  the  patient  that  the  risk  practically  is  from  this  source  alone,  and  the 
friends  should  be  given  to  understand  that  with  due  precautions  the 
danger  of  nursing  and  caring  for  a  consumptive  is  very  s/igJit  indeed. 
The  patient  should  occupy  a  single  bed  in  a  well-ventilated,  airy  room. 

In  the  advanced  stages,  when  the  diarrhoea  is  present,  the  stools 
should  be  carefully  disinfected. 

The  disgusting  habit  of  expectorating  in  public,  which  is  so  common 
in  this  country,  should  be  tabooed,  and  in  public  conveyances,  such  as 
street-cars,  should  be  strictly  forbidden.  It  is  no  hardship  to  ask  a  con- 
sumptive to  carry  some  convenient  form  of  spit-cup. 

As  already  mentioned,  the  public  has  already  been  pretty  widely 
instructed  as  to  the  importance  of  care  in  dealing  with  tuberculosis. 
Hospital  authorities  and  health  boards  could  issue  with  advantage  a 
leaflet  such  as  that  which  Cornet  has  prepared,  which  reads  as  follows : 

"  Protection  from  Consumption. 

"  The  most  destructive  disease  of  the  human  race  is  consumption 
(tuberculosis ).  It  carries  off  a  seventh  of  the  population.  In  Germanv 
alone  there  die  yearly  of  consumption  wellnigh  150,000  people. 

"  It  has  now  been  discovered  that  this  disease  is  caused  by  the  inhala- 
tion of  a  germ,  a  so-called  bacillus.  It  is  infectious — that  is,  it  can  be 
given  by  any  person  to  another.  But  neither  the  breath  nor  the  per- 
spiration of  the  patient  is  at  all  dangerous,  as  used  to  be  supposed. 
Infection  generally  takes  place  through  the  spit,  and,  according  to  the 
latest  inquiries,  especially  when  the  spit  is  discharged  by  the  consump- 
tive upon  the  floor  or  in  a  handkerchief,  where  it  dries  and  becomes 
dust,  and  some  of  the  swarm  of  germs  contained  therein  are  inhaled  by 
healthy  people. 

"  Many  other  diseases,  such  as  diphtheria,  pneumonia,  and  various 
forms  of  catarrh,  may  be  communicated  in  a  similar  wav. 

"  Consumptives  endanger  not  only  those  about  them,  but  themselves, 
through  the  drying  of  their  spit,  because  they  again  inhale  the  dis- 
charged and  dried  bacilli,  and  thus  infect  hitherto  sound  parts  of  their 
lung's. 

"  Such  infection  may  be  avoided  if  consumptives — and,  indeed,  all 
who  have  a  chronic  cough  with  expectoration — keep  this  expectoration 


838  TUBERCULOSIS. 

always  moist ;  if  they  give  up  spitting  on  the  floor  or  into  a  hand- 
kerchief, and  always  use  a  spittoon  which  is  emptied  down  the  water- 
closet. 

"  Spittoons  must  be  placed  wherever  necessary,  in  every  enclosed 
space  frequented  by  men.  They  ought  not  to  be  filled  with  sand  or 
sawdust,  but  either  left  entirely  empty  or  supplied  with  a  very  lit- 
tle water.  They  ought  to  be  at  hand  in  sufficient  numbers  in  every 
apartment  of  houses,  in  workshops  and  factories,  in  counting-houses, 
schools,  offices,  public  places,  in  corridors  and  on  stairs,  so  as  to  give 
every  one  a  convenient  opportunity  of  observing  these  injunctions. 

"  In  this  way  healthy  people  who  have  to  remain  within  the  same 
room  as  consumptives  will  be  almost  entirely  protected  from  infection. 

"  Posters  ought  to  be  put  up  in  factories,  workplaces,  etc.  forbidding 
most  strictly  spitting  upon  the  floor  or  into  a  handkerchief. 

"  On  the  street,  where  spitting  can  scarcely  be  prevented,  certain 
other  circumstances  diminish  the  risk  of  infection. 

"  Let  every  man,  even  though  suffering  from  an  ordinary  cough,  dis- 
charge his  spit,  not  on  the  ground,  not  in  a  pocket-handkerchief,  but 
always  in  a  spittoon. 

"  Milk  ought,  as  far  as  possible,  to  be  used  only  after  boiling,  espe- 
cially by  children,  invalids,  and  convalescents. 

"  By  the  strict  observance  of  these  injunctions  consumptives  are 
made  almost  harmless  to  those  about  them ;  and  all  the  more  that  the 
bacilli  can  live  outside  the  body  only  for  about  six  months,  it  may  be 
hoped  that,  if  these  rules  are  followed  out  by  the  sick,  consumption  in 
general  will  diminish." 

(6)  In  large  cities  the  health  boards  should  be  empowered  to  carry 
out  certain  regulations.  The  measures  which  have  been  adopted  by  the 
Board  of  Health  at  New  York  are  not  only  extremely  reasonable,  but 
may  be  recommended  to  other  cities  as  models  to  follow  : 

"1.  The  department  will  hereafter  register  the  name,  address,  sex, 
and  age  of  every  person  suffering  from  tuberculosis  in  this  city,  so  far 
as  such  information  can  be  obtained,  and  respectfully  requests  that  here- 
after all  physicians  forward  such  information  on  the  postal  cards  ordi- 
narily employed  for  reporting  cases  of  contagious  disease.  This  informa- 
tion will  be  solely  for  the  use  of  the  department,  and  in  no  case  will 
visits  be  made  to  such  persons  by  the  inspectors  of  the  department,  nor 
will  the  department  assume  any  sanitary  surveillantie  of  such  patients, 
unless  the  person  resides  in  a  tenement-house,  boarding-house,  or  hotel, 
or  unless  the  attending  physician  requests  that  an  inspection  of  the 
premises  be  made  ;  and  in  no  case  where  the  person  resides  in  a  tene- 
ment-house, boarding-house,  or  hotel  Avill  any  action  be  taken  if  the 
physician  requests  that  no  visits  be  made  by  inspectors,  and  is  willing 
himself  to  deliver  circulars  of  information  or  furnish  such  equivalent 
information  as  is  required  to  prevent  the  communication  of  the  disease 
to  others. 

"  2.  Where  the  department  obtains  knowledge  of  the  existence  of 
patients  with  pulmonary  consumption  residing  in  tenement-houses, 
boarding-houses,  or  hotels  (unless  the  case  has  been  reported  by  a 
physician  and  he  requests  that  no  visits  be  made)  inspectors  will  visit 
the  premises  and  family,  will  leave  circulars  of  information,  will  instruct 


PllUVllYLAXlS  AV   TlBKlirUUhSlS.  839 

till'  ptrsoii  siitl\'vin<2:  from  ('onsiini])ti()ii  luul  the  family  as  to  tlie  measures 
which  should  be  takeu  to  <2;uar(l  a<;:iiust  the  spread  of  the  disease,  and, 
if  it  is  considered  neeessarv,  will  make  sueh  rec^onimendatioiis  for  tlu; 
cleansing  or  renovation  of  the  a[)artment  as  may  he  re(|uired  to  render 
it  free  from  infections  matter. 

"3.  In  all  cases  where  it  comes  to  the  knowledge  of  the  tlepartment 
that  premises  which  have  been  occupied  by  a  consumptive  have  been 
vacated  by  death  or  removal,  an  inspector  will  visit  the  ])remises  and 
direct  the  removal  of  infected  articles,  sueh  as  carpets,  rugs,  l)edding, 
etc.,  for  disinfection,  and  will  make  such  written  reconnnendations  to 
the  board  as  to  the  cleansing  and  renovation  of  the  apartment  as  may 
be  required.  An  order  embodying  these  recommendations  will  then  be 
issued  to  the  owner  of  the  premises,  and  compliance  Avith  this  order  will 
be  enforced.  No  other  persons  than  those  there  residing  at  the  time 
will  be  allowed  to  occupy  such  apartments  until  the  order  of  the  board 
has  been  complied  with.  Infected  articles,  sueh  as  carpets,  rugs,  etc., 
will  be  removed  by  the  department,  disinfected,  and  returned,  without 
charge  to  the  owner. 

"  4.  For  the  prevention  and  treatment  of  pulmonary  tuberculosis  it 
becomes  of  vital  importance  that  a  positive  diagnosis  shall  be  made  at 
the  earliest  possible  moment,  and,  that  the  value  of  bacteriological 
examinations  of  the  sputa  for  this  purpose  may  be  at  the  service  of 
physicians  in  all  cases  not  under  treatment  in  hospitals,  the  department 
is  prepared  to  make  such  bacteriological  examinations  for  diagnosis,  if 
samples  of  the  sputa,  freshly  discharged,  are  furnished  in  clean,  Avide- 
necked,  stoppered  bottles,  accompanied  by  the  name,  age,  sex,  and 
address  of  the  patient,  the  duration  of  the  disease,  and  the  name  and 
address  of  the  attending  physician.  Bottles  for  collecting  such  sputa, 
with  blank  forms  to  be  filled  in,  can  be  obtained  at  any  of  the  drug 
stores  now  used  as  stations  for  the  distribution  and  collection  of  serum 
tubes  for  diphtheria  cultures.  After  the  sputum  has  been  obtained,  if 
the  bottle,  with  the  accompanying  slip  filled  out,  is  left  at  any  one  of 
these  stations,  it  will  be  collected  by  the  department  and  examined 
microscopically,  and  a  report  of  the  examination  forwarded  to  the  attend- 
ing physician  free  of  charge. 

"  5.  The  authorities  of  all  public  institutions,  such  as  hospitals, 
dispensaries,  asylums,  prisons,  homes,  etc.,  will  be  required  to  furnish 
to  the  department  the  name,  sex,  age,  occupation,  and  last  address  of 
every  consumptive  coming  under  observation  within  seven  days  of  such 
time." 

(e)  Inspection  of  Dairies. — A  certain  proportion  of  cases  of  tubercu- 
losis, particularly  in  children,  are  caused  by  the  drinking  of  milk  of 
tuberculous  cows.  Every  dairy  supplying  milk  to  the  city  should  be 
systematically  inspected,  and  full  power  should  be  given  to  confiscate 
and  kill  suspected  animals.  Where  this  systematic  inspection  is  not 
carried  out  the  milk  should  be  boiled. 

{d)  Skilled  veterinary  inspection  should  be  made  at  the  abattoirs  of  the 
carcasses  of  all  animals.  There  is  much  less  danger  of  infection  through 
meat  than  through  milk. 

The  widespread  diffusion  among  the  public  of  knowledge  on  the  sub- 
ject of  tuberculosis  will  undoubtedly  be  very  beneficial.     Such  societies 


840  TUBERCULOSIS. 

as  have  been  organized  in  Philadelphia  for  the  prevention  of  the  disease 
will  do  great  good  by  teaching  proper  measures  of  protection  against  the 
disease  and  by  influencing  public  opinion  in  the  right  direction.  Many 
persons,  even  among  physicians,  regard  it  as  a  great  hardship  that  a 
consumptive  should  be  under  the  surveillance  of  the  health  board,  but 
the  measures  required  to  be  carried  out  in  the  interest  of  public  safety 
are  neither  exacting  nor  irksome.  Sanitarians,  however,  must  not  be 
content  with  such  measures  as  are  directed  against  the  seed  alone.  In 
the  larger  cities,  particularly  those  with  narrow  streets  and  high  tene- 
ment-houses, these  measures  must  be  combined  with  others  directed  to 
improvement  of  the  conditions  under  which  many  of  the  people  live, 
particularly  to  obtaining  clean,  dustless  streets  and  affording  a  maximum 
amount  of  fresh  air  and  sunshine. 

Individucd  Prophylaxis. — A  mother  with  pulmonary  tuberculosis 
should  not  be  allowed  to  suckle  her  child.  An  infant  born  into  a  family 
in  which  tuberculosis  has  prevailed  or  born  of  tuberculous  parents  should 
be  watched  with  special  care,  and  guarded  particularly  against  catarrhal 
affections  of  all  kinds.  The  convalescence  from  the  fevers  of  childhood, 
more  particularly  measles  and  whooping  cough,  should  be  watched  with 
special  attention.  A  frequent  cause  of  impaired  vitality  in  young  children 
is  the  condition  of  the  tonsils.  On  the  first  indication  of  mouth-breathing 
a  thorough  examination  should  be  made  for  adenoid  vegetations,  which 
if  present  should  be  removed.  If  a  child  has  also  recurring  attacks  of 
tonsillitis  and  the  organs  are  at  all  enlarged,  it  is  best  to  have  them  cut 
out. 

The  child  should  be  clothed  in  flannel  and  live  in  the  open  air  as 
much  as  possible.  The  sleeping  room  at  night  should  be  well  ventilated. 
It  is  a  good  practice  for  the  mother  to  bathe  the  throat  and  chest  of  the 
child  every  morning  with  cold  water.  The  meals  should  be  at  regular 
hours,  the  food  plain  and  substantial,  and  the  child  should  be  encour- 
aged to  drink  milk.  Many  children  have  when  young  an  aversion  to 
fats  of  all  kinds,  but  they  should  be  encouraged  to  take  cream  and  but- 
ter and  milk.  If  the  child  becomes  anaemic  or  its  health  seems  failing, 
cod-liver  oil,  the  syrup  of  the  iodide  of  iron,  and  arsenic  are  the  best  tonics. 
If  the  thorax  is  naturally  long,  narrow,  and  contracted,  something  may 
be  done  to  improve  the  condition  by  systematic  pulmonary  gymnastics 
and  regulated  exercises.  In  the  choice  of  an  occupation  preference 
should  be  given  to  an  out-door  life.  Families  with  a  marked  pre- 
disposition to  the  disease  should,  when  jjossible,  reside  in  an  equable 
climate. 

Treatment  op  Tuberculosis. 

(a)  Dietetic  Treatment. — As  the  healing  of  a  tuberculous  process 
is  largely  dependent  upon  the  state  of  general  nutrition,  the  question  of 
diet  becomes  of  the  very  first  importance.  Persistent  failure  properly 
to  digest  food  is  an  unfavorable  feature  in  any  case.  The  variations  in 
this  respect  are  remarkable.  There  are  patients  in  whom  the  appetite 
and  digestion  are  not  disturbed  in  the  slightest  degree,  and  while,  as  a 
rule,  these  are  the  most  hopeful  subjects,  even  in  such,  in  spite  of  active 
powers  of  digestion  and  assimilation,  tuberculosis  may  make  rapid  prog- 
ress.     So  soon  as   the  disease    is    recognized    the    practitioner  should 


Ti:i:.\TMi:y'r  of  'niiKiirrLOsrs.  841 

empluisizt'  to  the  jKitieiit  and  to  tlic  friends  the  necessity  of  the  most 
carefnl  attention  to  diet,  and  his  instrnetions  shouhl  be  speeiiie,  not 
genera h 

111  the  initial  stages,  with  irregnhir  f(!ver  and  ii-ritative  cougli,  there 
is  loss  of  appetite,  at  times  nansea  or  even  a  jiositive  aversion  to  food. 
Care  should  he  taken  that  this  eondition  is  not  aggravated  hy  eongh 
mixtnres,  ereasote,  cod-liver  oil,  and  hypopiiosphites  with  which  tiie 
patient  is  too  often  at  this  period  drenched.  In  the  prononnced  gastric 
irritability  of  the  early  stages  it  is  best  to  confine  the  ])atient  to  a  liquid 
diet,  consisting  of  one  of  the  milk  preparations,  with  or  withont  egg 
albumen  and  meat  juices.  The  milk  may  be  taken  either  raw,  diluted 
with  Apollinaris  or  seltzer  water,  or  half  an  ounce  of  lime  water  is 
added  to  each  glass,  or  it  may  be  peptonized,  though,  as  a  rule,  the  dis- 
agreeable taste  is  very  objectionable  to  tuberculous  patients.  Butter- 
milk, koumyss,  or  kefir  sometimes  agrees  much  better  than  the  simple 
milk.  When  there  is  an  insuperable  objection  to  milk,  the  meat  juices 
and  scraped  meat  and  meat  cakes  may  be  used,  and  these  articles  made 
from  the  fresh  meat  are  to  be  much  preferred  to  the  beef  peptonoids  and 
other  similar  preparations  on  the  market. 

Eggs  form  a  most  important  article  of  dietary  in  early  tuberculosis. 
Patients  are  not  always  shle  to  eat  the  yolk,  but  when  the  proper  amount 
of  milk  is  not  borne  the  egg-white  is  a  useful  addition,  and  is  usually 
easily  digested.  When  there  is  much  gastric  irritability,  a  glass  of  hot 
w^ater  early  in  the  morning,  or  in  extreme  cases  lavage,  will  be  found 
useful.  It  is  rarely  necessary  to  resort  to  Debove's  method  of  forced 
feeding,  in  which,  after  lavage  of  the  stomach,  a  mixture  is  given  through 
the  tube,  containing  a  litre  of  milk,  an  egg,  and  one  hundred  grammes 
of  very  finely  minced  meat.  A  patient  will  sometimes  take  this  three 
times  a  day  without  special  disturbance.  It  is  not  often  that  one  has  to 
resort  to  rectal  alimentation  in  the  early  stages  of  tuberculosis.  When 
solid  food  can  be  taken  a  varied  diet  may  be  given,  in  which  the  albu- 
minous elements  largely  prevail,  and  to  which  are  added  the  more  easily 
digested  forms  of  vegetables.  Usually  four  or  even  five  light  meals  are 
better  borne  than  three  large  ones.  On  a  mixed  diet  the  patient  does 
not  need  so  much  milk,  and  if  plenty  of  cream  and  good  butter  is  taken 
it  is  well  not  to  insist  upon  its  use.  These  measures  may  prove  of  no 
avail  whatever  in  the  treatment  of  a  case  unless  the  patient's  surround- 
ings are  favorable,  and  improvement  in  the  digestion  may  not  occur 
until  he  removes  from  home  or  begins  an  open-air  life.  As  already 
mentioned,  very  special  care  should  be  taken  not  to  aggravate  the  dys- 
pepsia by  medicines.  As  a  rule,  the  bitter  tonics,  with  acids,  and  the 
preparations  of  malt  are  well  borne  and  are  very  useful. 

In  the  later  stages  of  tuberculosis  the  dyspeptic  symptoms  may  again 
be  the  most  troublesome  symptoms  to  combat,  and  the  patient  usually 
does  best  upon  the  albuminous  diet  referred  to  above. 

Alcohol  should  not  be  given  as  a  routine  matter  to  tuberculous 
patients.  It  is  often  beneficial  in  cases  with  feeble  digestion  and  high 
fever  and  in  the  later  stages  of  the  disease,  when  the  heart's  action  be- 
comes rapid  and  weak.  There  are  cases  in  which  three  or  four  ounces 
of  whiskey,  taken  as  milk  punches  or  given  with  the  egg  albumen,  seem 
to  promote  the  appetite  and  improve  the  general  nutrition.     Routine 


842  TUBERCULOSIS. 

administration  is  not  advisable,  and  there  is  no  evidence  to  uphold  the  old 
idea  that  the  persistent  use  of  alcohol  promotes  fibroid  changes  in  the 
tuberculous  areas. 

(6)  Pulmonary  Gymnastics. — In  incipient  cases  much  benefit  results 
from  systematically  carried  out  forced  inspiratory  movements,  which 
increase  the  chest  capacity  and  favor  particularly  expansion  of  the 
apices.  The  patient  should  be  directed  to  draw  slowly  the  fullest  possi- 
ble inspiration,  raising  at  the  same  time  the  arms  above  the  head.  At 
the  end  of  the  act  the  breath  may  be  held  for  a  few  moments.  These 
efforts  may  be  repeated  slowly  for  from  ten  to  fifteen  minutes,  morning 
and  evening.  The  practice  should  be  carried  out  systematically,  and 
intercurrent  hsemoptysis  or  high  fever  should  be  alone  regarded  as  con- 
traindications. Sometimes  pains  in  the  side  are  produced  at  first,  prob- 
ably from  stretching  of  pleural  adhesions,  but  they  usually  disappear 
with   persistence  in  the  effort. 

(c)  Climatic  Treatment. — The  essence  of  the  treatment  of  tuber- 
culosis by  climate  is  a  life  in  the  fresh  air.  A  majority  of  the  un- 
fortunate victims  of  tuberculosis  live  in  small  rooms  in  small  houses, 
and  even  the  outside  air  can  scarcely  be  called  pure ;  yet  even  in  our 
larger  cities  it  is  at  any  rate  fresh  in  comparison  with  the  quality  of 
the  air  breathed  in  rooms  heated  above  70°  and  with  all  possible  ave- 
nues of  ventilation  closed.  As  a  large  proportion  of  all  patients  are 
unable  to  seek  any  change,  the  first  duty  of  the  physician  is  to  see  what 
can  be  done  in  the  way  of  fresh-air  treatment  at  home.  The  patient 
and  friends  must  first  be  convinced  of  the  necessity  for  fresh  air  and 
their  minds  disabused  of  the  dread  of  catching  cold.  Even  in  small 
houses  the  sunshine  reaches  some  rooms  for  a  certain  period  of  the  day^ 
and  the  patient  should  be  covered  warmly  in  the  bed,  the  bed  wheeled 
in  the  sunshine,  and  the  windows  opened  ^\^dely.  In  other  instances 
the  patient  may  rest  for  hours  on  a  couch  on  the  veranda.  Even 
in  the  winter  months  no  degree  of  cold  contraindicates  this  open-air 
life.  With  plenty  of  rugs  and  clothing  this  practice  may  be  carried 
out  even  with  the  most  delicate  patients,  who,  as  a  rule,  quickly  learn  to- 
appreciate  the  benefit.  The  sleeping  room  should  have  a  southern 
exposure,  and  if  possible  an  open  fireplace.  The  patient  should  sleep 
with  the  window  partially  open,  and  it  is  an  easy  matter  even  in  small 
rooms  to  prevent  any  draught  from  blowing  directly  upon  the  bed. 

In  the  comparatively  limited  number  of  persons  who  are  able  to- 
leave  their  homes  the  doctor  is  called  upon  first  to  decide  Avhether  the 
patient  is  in  a  condition  to  travel,  and  second  to  choose  the  locality  to- 
which  to  send  him.  Patients  with  disease  localized  at  one  apex  and 
without  high  fever  or  much  constitutional  disturbance  can  be  sent  away 
with  advantage.  Cases  "svith  rapid  tuberculous  consolidation,  high  and 
irregular  fever,  and  rapid  loss  in  weight  are  better  at  home  until  some 
lull  takes  place,  or,  at  any  rate,  until  there  is  some  positive  indication 
that  the  case  is  not  one  of  phthisis  florida. 

With  well  marked  cavities,  hectic  fever,  night  sweats,  and  progres- 
sive emaciation  the  physician  should,  when  possible,  resist  the  importu- 
nities of  the  patient  and  friends  (which  are  often  under  these  circum- 
stances most  urgent)  and  keep  the  subject  at  home. 

In  deciding  upon  a  suitable  climate  there  are  many  questions  to  be 


Tin:  ATM  EST  OF   Tl'IIERCULOSIS.  843 

considered  besides  those  relatiiii:'  directly  to  the  disease,  ])articularly  tiie 
patient's  ciivinnstances,  constitution,  etc.  The  climatic  treatment  of 
tuberculosis  is,  after  all,  only  the  open-aii-  plan  under  more  favorable 
auspices.  There  arc  three  requirements  in  a  suital)le  climate :  pure 
atmosphere,  an  equable  temperature  not  subject  to  rapid  variations,  and 
a  maximum  amount  of  sunshine.  Livin<i;  an  out-door  life,  it  makes 
little  ditlerence  where  the  patient  resides  if  these  factors  are  present. 

The  purity  of  the  atmosphere  is  the  first  consideration,  and  it  is 
this  requirement  that  is  so  Avell  met  in  the  mountains  and  forests. 
Dryness  of  the  air  is  a  factor  upon  which  perhaps  too  great  stress  has 
been  laid.  Colorado  and  parts  of  Mexico  are  ideal  dry  climates  ;  for 
example,  at  Denver  the  total  rainfall  per  annum  is  rarely  more  than 
fourteen  or  fifteen  inches,  and  the  relative  humidity  is  also  very  low. 
That  dryness,  however,  is  not  an  essential  factor  is  seen  in  the  beneficial 
results  obtained  in  certain  health  resorts,  such  as  Torquay  and  Falmouth 
in  the  south  of  England,  one  of  the  most  humid  atmospheres  in  the 
world. 

Altitude  is  a  secondary  consideration.  The  rarefaction  of  the  air  is 
of  great  benefit  in  certain  cases,  and  the  increase  in  the  frequency  and 
depth  of  the  respirations  and  the  changes  in  lung  capacity  and  in  the 
size  of  the  chest  are  very  beneficial,  particularly  in  the  early  stages  of 
the  disease. 

Equability  of  the  climate  is  a  factor  of  great  importance.  Sudden 
changes  of  temperature,  particularly  when  combined  with  high  winds, 
are  very  trying  to  consurnptives.  Low  temperatures,  formerly  so 
dreaded  in  tuberculosis,  have  been  found  by  the  experience  at  the 
Adirondacks  and  at  certain  Swiss  resorts  to  be  beneficial.  Practically, 
the  division  of  Jaccoud  into  climates  of  low  and  of  high  level  is  the 
most  satisfactory,  the  former  being  more  sedative  and  soothing,  the  lat- 
ter stimulating  and  invigorating.  Of  low  level  climates  in  Europe,  the 
Riviera,  Egypt,  Algiers,  and  some  of  the  resorts  in  the  south  of  Eng- 
land are  the  most  frequented — in  America,  the  Bermudas,  the  West 
India  islands,  Florida,  and  the  coast  of  California.  They  are  most 
suitable  for  cases  of  advanced  tuberculosis  with  fever,  for  those  cases  in 
which  the  softening  is  progressive,  for  the  subjects  of  chronic  fibroid 
tuberculosis  with  emphysema,  and  for  patients  with  the  severer  com- 
plications, as  tujDerculosis  of  the  larynx  and  the  intestines.  ^lany  of 
the  most  beneficial  of  these  comparatively  low  level  resorts  are  inland, 
and  in  this  country  Aiken  in  South  Carolina  and  Thomasville  in  Georgia 
are  examples  of  warm  dry  climates  which  prove  very  beneficial  in  many 
cases  of  tuberculosis. 

The  high  altitudes  are  particularly  beneficial  in  the  early  stages  of 
the  disease,  before  cavity  formation  or  before  extensive  consolidation 
have  occurred,  and  when  there  is  not  much  fever.  Chronic  cases  with 
hectic  fever,  extensive  disease  at  both  apices,  great  cardiac  irritabil- 
ity, emphysema,  and  serious  complications,  laryngeal  or  intestinal,  are 
nnsuited  to  high  altitudes.  Many  of  the  most  favorable  of  these  re- 
sorts have  only  medium  altitudes,  from  1500  to  3000  feet.  Such  in 
Europe  are  the  -well  known  resorts  of  Falkenstein  and  Goerbersdorf, 
and  in  this  country  the  Adirondacks  and  Asheville.  Of  resorts  with 
high  altitudes,  from  3000  to  7000  feet,  in  Europe  Davoz  Platz  and 


844  TUBERCULOSIS. 

Saint-Moritz,  and  in  this  country  Colorado,  are  the  best  known.  Cases 
of  early  tuberculosis,  as  a  rule,  do  well  either  in  the  medium  or  high 
altitudes,  and  unquestionably  one  finds  a  larger  percentage  of  arrest  of 
the  disease  in  the  subjects  who  have  gone  early  either  to  the  Adiron- 
dacks  or  to  Colorado  than  among  those  who  have  gone  to  the  low  level 
climates.  From  a  medium  altitude,  such  as  the  Adirondacks,  a  patient 
after  a  residence  of  two  or  three  years  may  return  with  impunity  to  the 
sea  level.  In  a  majority  of  instances  the  patient  who  goes  to  Colorado 
must  make  up  his  mind  to  live  there.  A  permanent  return  to  the  sea 
level  is  rarely  practicable,  and  recurrence  of  the  disease  not  infrequently 
follows  the  attempt. 

{d)  Treatment  in  Sanitaria. — For  many  years  special  hospitals 
for  pulmonary  tuberculosis  have  existed,  but  of  late  the  attention  of  the 
profession  has  been  called  to  the  great  advantage  of  the  treatment  of  the 
disease  in  institutions  in  country  districts  especially  suited  to  the  purpose. 

In  Europe  the  sanitaria  of  Falkenstein  and  Goerbersdorf  are  the 
most  celebrated.  The  former,  founded  by  Dettweiler,  is  situated  in  the 
Taunus  Mountains  at  a  height  of  400  metres  above  the  level  of  the  sea. 
The  climate  does  not  differ  in  any  respect  from  that  of  Central  Ger- 
many, but  the  air  is  pure  and  free  from  dust  and  moisture.  The  insti- 
tution is  in  the  hands  of  a  company  and  has  been  very  successful.  The 
out-door  treatment  is  raised  to  a  system,  and  it  is  stated  that  the  num- 
ber of  patients  confined  to  their  rooms  is  only  about  8  per  cent,  in  the 
summer  and  9  per  cent,  in  the  winter. 

The  sanitarium  at  Goerbersdorf  in  Silesia,  founded  by  Brehmer. 
has  accommodation  for  250  patients,  and  in  it,  too,  is  carried  out  in  a 
systematic,  rigid  manner  the  open-air  treatment  of  the  disease.  The 
results  in  both  of  these  institutions  are  remarkable.  Recent  statistics, 
as  given  by  Knopf,^  show  a  recovery  of  about  25  per  cent,  and  an  im- 
provement in  from  45  to  50  per  cent.  In  this  country  the  Adirondack 
Cottage  Sanitarium,  now  in  the  twelfth  year  of  its  existence,  has  proved, 
under  the  management  of  Trudeau,  a  model  institution  of  its  kind. 
It  has  now  a  capacity  of  74  beds,  a  certain  number  of  which  are  free, 
and  in  others  the  rate  is  such  as  to  be  within  the  reach  of  persons  with 
moderate  means.  Of  91  patients  who  remained  from  three  to  forty- 
four  months,  the  average  residence  being  ten  months  and  twenty-five 
days,  19  cases  were  apparently  cured;  in  31  the  disease  was  arrested; 
in  22  the  condition  was  improved;  in  18  there  was  no  improvement; 
and  1   patient  died  of  tuberculous  peritonitis. 

The  Saranac  Sanitarium  is  not  only  an  object  lesson  of  the  greatest 
value  in  showing  how  much  may  be  done  for  the  relief  of  tuberculosis 
in  a  properly  arranged  institution,  but  it  also  demonstrates  how  the 
scientific  study  of  tuberculosis  may  be  carried  on.  The  good  example 
set  at  Saranac  has  been  followed  in  other  places,  and  the  Sharon  Insti- 
tution in  Massachusetts,  under  Vincent  Bowditch,  has  also  shown  how 
much  may  be  done  in  a  similar  way  with  less  favorable  climatic  sur- 
roundings. We  may  look  forward  within  a  few  years  to  a  rapid  ad- 
vance of  this  method  of  dealing  with  tuberculosis.  (For  further  infor- 
mation with  reference  to  sanitaria  the  reader  may  consult  the  essay  of 
Knopf,  already  referred  to.) 

^  Les  Sanataria:  Traitement  et  Prophylaxie  de  la  Phthisie  jmlmonaire,  Paris,  1895. 


TJlh'A  TMENT  OF   TUBERCULOSIS.  845 

TIu'sc  sanitaria  arc  largely  for  the  trcaimciit  and  care  of"  pav  |)atit'iits, 
hut  in  tinu'  cities  will  arrant;-c  for  |)ul>lic  institutions  in  snitaldc  localities 
not  far  distant,  to  which  cases  of  cai'ly  pulnionaiy  tiihci'cnlosis  can  be 
sent  for  systematic  treatment.  The  civic  health  board  will  in  future 
provide  for  two  classes  of  pulmonary  tuberculosis — the  early  curable 
cases,  which  will  be  sent  to  sanitaria,  and  the  chronic,  incurable  cases, 
which  will  be  cared  for  in  Avell  conducted  hospitals  in  the  immediate 
vicinity  of  the  city. 

((')  GKNKiiAii  Mkdicai.  TREATMENT. — So  far  as  wc  know,  there  are 
no  agents  wdiicli  have  a  s})ecial  and  pecidiar  action  on  the  tuberculous 
processes.  The  chief  remedies  employed  against  the  disease  influence 
the  general  nutrition,  increase  the  normal  physiological  resistance,  and 
perhaps  render  the  tissues  less  liable  to  invasion.  The  following  are 
among  the  most  important  remedies  which  act  usefully  in  this  w'av  : 

Creasofe  and  its  Dcvivdtivoi. — Under  the  use  of  these  preparations 
many  tuberculous  patients  increase  in  weight  and  present  a  general 
amelioration  of  the  local  symptoms.  The  best  beechwood  creasote 
should  be  used,  given  either  in  pill  form  or  in  capsules,  alone  or,  as 
Soramerbrodt  recommends,  with  cod-liver  oil.  If  the  pills  and  capsules 
disagree,  it  may  be  given  in  a  solution  with  tincture  of  gentian,  alcohol, 
and  sherry  wine.  Sometimes  the  carbonate  of  creasote  is  better  borne 
by  the  stomach ;  as  it  contains  over  90  per  cent,  of  creasote,  the  dose  is 
the  same.  The  good  effects  of  creasote  depend  very  much  upon  the 
amount  the  patient  is  able  to  take.  One  rarely  sees  such  good  effects 
from  the  small  doses,  though  it  is  well  to  begin  with  a  couple  of  minims 
twice  a  day.  Patients  who  are  tolerant  of  large  doses  do  better,  and 
ten,  or  fifteen,  or  twenty  minims,  or  even  half  a  drachm,  three  times  a 
day  may  be  taken.  If,  as  is  only  too  frequently  the  case,  the  drug  dis- 
turbs the  stomach,  it  may  be  given  by  the  rectum  as  an  emulsion  with 
oil  and  e^or.     Other  methods  are  by  inhalation  and  subcutaneously. 

Of  derivatives  of  creasote,  guaiacol  is  the  one  which  has  been  most 
frequently  used.  It  may  be  administered  in  pearls  of  one  or  tW'O  min- 
ims three  times  a  day,  or  it  may  be  given  hypodermically  in  doses  of 
one  minim  in  olive  oil,  and  is  very  often  for  this  purpose  combined  with 
iodoform.  The  carbonate  of  guaiacol  may  be  substituted  in  doses  of 
from  three  to  five  grains. 

Creasote  has  no  direct  action  on  the  tubercle  bacilli,  but  under  its 
use  in  some  cases  the  cough  lessens,  the  expectoration  diminishes,  the 
sweats  disappear,  and  the  general  nutrition  improves.  It  constitutes 
the  least  unsatisfactory  drug  in  the  treatment  of  the  disease. 

Arsenic  influences  very  favorably  the  nutrition,  and  may  be  used  in 
doses  of  from  three  to  five  minims  of  Fowler's  solution  three  times  a 
day,  increasing  if  it  is  well  borne.  In  pill  form,  in  doses  of  from  Jg  to 
gljy,  increasing  up  to  ^l^"  of  ^  grain,  it  is  less  apt  to  disturb  the  stomach. 
Patients  who  can  take  large  doses  for  a  considerable  period  of  time  are 
sometimes  much  benefited. 

The  hi/pophosphites,  of  \Yhich  various  ])reparations  are  on  the  market, 
are  useful  as  general  tonics.  They  have  no  specific  influence  upon  the 
tuberculous  processes.  The  hypophosphite  of  lime  and  the  syrup  of  the 
iodide  of  iron  are  sometimes  found  useful  in  c()ml)i nation. 

Cod-liver  oil  is  useful  in  many  forms  of  tuberculosis.     It  acts  better 


846  TUBERCULOSIS. 

in  children  than  in  adults.  It  may  be  given  in  teaspoonful  doses  three 
or  four  times  a  day.  When  well  borne  and  assimilated  its  use  is  often 
followed  by  a  marked  im2:>rovement  in  the  general  condition.  In  an 
emulsion  with  hypophosphites  it  is  sometimes  better  borne.  In  the 
glandular  tuberculosis  of  young  children  it  seems  particularly  bene- 
ficial. 

Iron  is  useful  in  the  anaemia  of  tuberculosis  under  certain  conditions. 
When  much  fever  is  present  or  when  digestion  is  greatly  disturbed  it  is 
useless,  but  in  the  chloro-ansemia  of  the  early  stages  there  is  no  remedy 
more  valuable.  Great  care  must  be  taken  not  to  disturb  the  stomach, 
particularly  with  the  stronger  preparations  of  iron.  Children  usually 
take  the  syrup  of  the  iodide  of  iron  readily. 

(/)  Treatment  of  Special  Symptoms  in  Pulmonary  Tuber- 
culosis.— (1)  Fever. — No  single  condition  in  tuberculosis  is  more  diffi- 
cult to  combat  than  the  pyrexia.  Wlien  high  and  j)ersistent  the  patient 
should  be  at  rest,  and  when  practicable  in  the  fresh  air  and  sunshine  for 
a  considerable  part  of  each  day.  Sponging  with  tepid  water  will  be 
found  beneficial.  Drugs  are  most  unsatisfactory.  Quinine,  digitalis, 
and  the  salicylates  may  be  tried,  and  the  combination  of  the  two  former 
drugs  is  sometimes  followed  by  good  results.  Antipyrine  and  phena- 
cetin,  if  used  at  all,  should  be  employed  with  caution,  as  in  full  doses 
both  these  drugs  are  apt  to  cause  much  depression.  The  external  appli- 
cation of  guaiacol,  fifteen  to  twenty-five  minims,  rubbed  on  the  skin,  is 
often  followed  by  a  prompt  but  transient  reduction  in  the  fever. 

(2)  Simating. — This  is  frequently  associated  with  the  fever,  particu- 
larly in  the  later  stages  of  the  disease.  It  may  occur  independently  as 
a  result  of  exhaustion.  The  sweating  is  usually  most  distressing  at 
night  and  in  the  early  morning  hours.  Sponging  at  half-past  nine  or 
ten  in  the  evening  with  tej)id  or  cold  water  will  sometimes  reduce  the 
temperature  and  prevent  the  sweating.  Of  the  few  trustworthy  rem- 
edies for  this  symptom,  atroj)ia  heads  the  list.  It  may  be  given  in 
doses  of  from  yl^  to  gl^  of  a  grain.  It  often  has  an  unpleasant  effect 
in  drying  the  mouth.  Aromatic  sulphuric  acid,  alone  or  in  combina- 
tion with  gallic  acid,  is  sometimes  beneficial.  When  the  sweat  seems 
to  be  induced  by  the  cough,  opiates  are  indicated.  Of  the  scores  of 
other  remedies  suggested  for  night-sweats  few  are  efficacious. 

(3)  Cough. — The  patient  should  be  instructed  to  restrain  the  cough  as 
much  as  possible.  The  irritative  cough  of  the  early  stages  of  the  disease 
is  best  treated  Avith  codeine  in  doses  of  from  one  sixth  to  one  third  of  a 
grain.  When  more  severe  morphine  may  be  necessary.  Sometimes  the 
combination  with  dilute  hydrocyanic  acid  is  very  beneficial.  When  the 
cough  is  associated  with  much  expectoration,  particularly  in  the  morning, 
it  is  best  treated  by  warm  alkaline  drinks,  taken  immediately  on  waking, 
warm  milk  and  Apollinaris  water,  to  which  has  been  added  a  pinch 
of  salt  and  bicarbonate  of  soda.  Inhalations  of  creasote,  terebene,  or 
the  oil  of  eucalyptus  are  very  serviceable  in  reducing  the  amount  of 
catarrh.  Some  of  the  most  distressing  forms  of  cough  rise  from  the 
laryngeal  irritation,  and  for  such  local  treatment  is  indicated. 

(4)  For  the  diarrhoea  of  chronic  phthisis  and  of  intestinal  tubercu- 
losis large  doses  of  bismuth  are  useful,  combined  with  Dover's  powder. 
Enemata  of  starch  and  laudanum  may  be  tried  or  the  acetate  of  lead 


'    Tlll'.A'l'MENT  OF  TrUKRCrLnSlS.  847 

-aud  opium  [)ill.  In  other  instanci's  tlic  ucitl  dianlKjL'a  luixturo,  contain- 
ing iu  each  dose  ten  to  twelve  minims  of  the  dihite  acetic  acid,  one 
eighth  of  a  grain  of  acetate  of  morphia,  and  a  grain  of  the  acetate  of 
lead,  may  he  tried.  It  is  usually  impossible  t<t  ari-est  the  diarrJKea  of 
the  late  stages  of  the  disease.  The  effect  of  ditfei'cnt  forms  of  diet 
shoidd  be  watched. 

(5)  Laryngeal  and  Phari/nc/eal  Complication.^. — Persistent  local  treat- 
ment may  do  much  to  relieve  the  very  distressing  symptoms  of  ad- 
vanced disease  of  these  parts.  Krause,  Heryng,  and  others  have  called 
attention  to  the  great  importance  of  active  local  treatment  directed  to 
the  healing  of  the  deep  ulcers  and  the  radical  removal  of  the  tubercu- 
lous tissues.  The  remarkable  results  which  have  been  obtained  would 
indicate  that  we  have  been  altogether  too  timid  in  dealing  Avith  these 
lesions.  While  laryngeal  tuberculosis  may  in  rare  instances  heal  by 
general  and  climatic  treatment,  in  a  large  proportion  of  all  cases  the 
condition  is  progressive,  and  when  extensive  and  severe  the  cause  of 
the  most  distressing  symptoms  to  the  patient.  Heryng's  results  should 
stimulate  laryngologists  to  more  radical  and  thorough  treatment  of  tiie 
disease. 

(6)  Hccmopfi/sis. — Early  in  the  disease  tlie  bleeding  comes  from  small 
erosions  on  the  mucosa  of  the  smaller  bronchi  or  from  areas  of  soften- 
ing which  have  communicated  with  the  bronchi ;  iu  the  later  stages  the 
blood  comes  from  eroded  vessels  in  a  rapidly  softening  caseous  area,  or 
from  a  vessel  on  the  wall  of  a  cavity,  or,  most  common  of  all  in  the 
stages  of  ca\T[ty,  from  a  rupture  in  a  small  aneurysm.  The  first  indica- 
tion is  to  quiet  the  action  of  the  heart  by  rest,  mental  and  bodily,  and 
for  this  the  soothing  influence  of  morphine,  which,  as  has  been  said,  not 
only  favors  mental  but  vascular  serenity,  is  very  benelicial.  If  the 
patient  is  vigorous  and  robust  and  the  bleeding  should  persist,  venesec- 
tion may  be  practised.  It  was  a  method  resorted  to  frequently  enough 
by  the  older  practitioners.  Sterne  somewhere  mentions  that  he  was 
bled  from  both  arms  for  bleediua;  at  the  luno^s.  Huo:o;ard  of  Davoz  has 
recently  recommended  the  renewal  of  the  practice.  An  ice  bag  may 
be  placed  over  the  chest.  Among  measures  which  may  lessen  some- 
what the  amount  of  blood  in  the  pulmonary  circtilation  are  the  nitrites, 
which  relax  particularly  the  systemic  arterioles.  Small  doses  of  salts 
or  fractional  doses  of  calomel  may  be  administered  to  divert  the  blood 
to  the  portal  system.  Hot  foot-baths  may  also  be  used.  It  is  doubtful 
if  any  drug  has  a  special  influence  in  controlling  htemoptysis.  Ergot 
is  probably  contraindicated,  as  it  is  stated  to  produce  a  distinct  rise 
in  the  pulmonary  pressure.  Aconite,  on  the  other  hand,  lowers  the 
pressure,  and  if  there  is  much  vascular  excitement  it  may  be  used. 
Aromatic  sulphuric  acid,  tannic  acid,  lead,  and  gallic  acid  are  warmly 
recommended. 

(g)  Local  Treatment  of  the  Luxgs. — Many  substances  have 
been  employed  for  direct  injection  into  the  lung  tissue,  of  which  creasote, 
a  3  per  cent,  solution  in  almond  oil,  carbolic  acid,  a  2  per  cent,  solution 
in  glycerin^  and  iodoform  in  olive  oil,  are  the  most  important.  The 
good  effects  which  surgeons  have  had  in  the  treatment  of  joint  tubercu- 
losis with  injections  of  iodoform  suggest  that  a  further  trial  be  given  to 
this  remedy  directly  injected  into  the  affected  areas.     In  a  few  instances 


848  TUBERCULOSIS. 

the  cavity  in  pulmonary  tuberculosis  is  so  favorably  situated  that  it 
could  be  laid  open  and  drained. 

One  or  two  other  special  metliods  of  treatment  of  pulmonary  tuber- 
culosis remain  for  consideration. 

The  use  of  compressed  air  in  the  pneumatic  cabinet,  which  was  so 
much  in  vogue  a  few  years  ago,  has  still  a  few  warm  advocates,  and 
meets  certain  indications  in  those  who  cannot  go  away  or  who  cannot 
live  an  open-air  life. 

Tuberculin. — The  announcement  by  Koch  that  he  had  obtained  a 
material  which  exercised  a  specific  curative  action  upon  tubercle  caused 
a  furor  of  excitement  never,  perhaps,  equalled  in  the  history  of  medi- 
cine. At  present  we  are  deep  in  the  reaction  following  the  failure  to 
substantiate  this  claim.  Tuberculin  is  a  product  of  the  growth  of  the 
tubercle  bacilli,  extracted  with  glycerin.  Its  use  has  been  almost  en- 
tirely abandoned.  A  few  enthusiastic  observers  still  claim  to  get  good 
results,  and  good  clinical  physicians  state  that  in  suitable  cases  it  may 
be  used  Avithout  risk.  If  emj)loyed,  the  dose  should  be  small,  not 
enough  to  produce  fever.  As  a  diagnostic  means  it  is  of  the  greatest 
value,  particularly  in  the  tuberculosis  of  cattle,  and  is  probably  of  equal 
importance  in  man,  in  spite  of  the  fact  that  the  reaction  sometimes  fol- 
lows in  actinomycosis  and  leprosy. 

Serum-therapy. — The  blood  serum  of  animals,  particularly  of  dogs, 
goats,  horses,  and  asses,  which  have  been  treated  with  the  toxins  of  the 
tubercle  bacilli  is  now  used  extensively  in  pulmonary  tuberculosis.  The 
employment  is  at  j^resent  largely  empirical.  Maragliauo  in  Italy  claims 
the  most  remarkable  results,  and  in  this  country  Paquin  of  St.  Louis 
has  introduced  the  method,  using  the  blood  serum  of  the  horse.  I  have 
no  personal  experience  with  the  treatment,  and  from  the  reports  which 
have  been  published  it  is  not  possible  to  speak  with  any  confidence  of 
the  results. 

In  speaking  of  the  treatment  we  have  considered  chiefly  that  of  pul- 
monary tuberculosis,  the  most  important  form.  In  the  tuberculosis  of 
other  organs  the  same  general  measures  are  to  be  carried  out ;  the  reader 
will  find  the  local  treatment  referred  to  under  the  special  sections. 

Note  on  Treatment  of  Tuberculous  Peritonitis. — The  general 
hygienic  and  dietetic  measures  are  to  be  carried  out.  Creasote,  arsenic, 
cod-liver  oil,  and  the  hypophosphites  may  be  used.  Local  treatment  is 
sometimes  advantageous.  The  tincture  of  iodine  frequently  applied 
often  relieves  the  pain,  and  some  have  recommended  mercurial  inunc- 
tions. For  the  constipation  which  is  so  common  mild  laxatives  should 
be  used.  Surgical  procedures  are  of  great  value.  In  the  ascitic  form 
repeated  aspiration  may  be  practised.  Laparotomy  offers  in  certain 
cases  the  hope  of  cure,  while  in  others  rehef  may  be  obtained.  The 
best  results  have  been  obtained  in  the  ascitic  form  or  in  the  localized 
peritonitis  with  encysted  exudation.  Where  there  are  large  nodular 
masses  and  evidence  of  the  coexistence  of  extensive  tuberculosis  in 
other  organs  the  conditions  are  not  favorable. 


SYPHILIS. 

By  W.  F.  ROBINSON,  M.  D. 


Definition. — Syphilis  is  a  elironio  infectious  disease,  of  lono;  dura- 
tioii  and  irregular  course,  produced  Ijy  a  specific  virus  capable  of 
attacking  any  and  all  tissues  of  the  body.  The  disease  manifests 
itself  in  a  multitude  of  phenomena  having  their  origin  for  the  most 
part  in  an  indolent  inflammatory  process  accompanied  by  a  new  cell 
formation  of  low  grade.  It  is  acquired  by  inoculation  with  the  blood 
or  morbid  secretions  of  an  individual  suffering  with  the  malady,  or  is 
transmitted  from  the  parent  to  the  child.  Persons  once  affected  with 
syphilis  are  usually  immune  thereafter. 

Nature  and  Course  of  Syphilis. — Syphilis  is  a  distinct  and 
independent  malady  related  etiologically  in  no  wise  to  any  other  form 
of  disease.  No  one  today  doubts  the  unicity  of  the  infecting  virus  or 
that  local  infection  with  such  virus  will  invariably  be  followed  by 
systemic  invasion  and  the  development  of  true  syphilis.  The  conten- 
tions of  the  dualists  are  ended  and  their  fallacy  is  now  only  an  interest- 
ing chapter  in  medical  history.  But  no  one  as  yet  knows  positively 
just  what  the  infecting  virus  of  syphilis  is.  It  is  unique  in  that  it  has 
thus  far  defied  the  most  skilful  and  untiring  investigators  to  unravel  its 
complexity  or  determine  its  true  nature.  While  evading  recognition, 
there  are  still  facts  enough  in  existence  to  make  it  reasonably  certain 
that  the  causative  agent  is  a  bacterium  and  that  syphilis  is  a  germ 
disease.  No  other  theory  of  its  origin  will  explain  the  symptoms 
manifested  in  its  course  so  well  as  this.  It  seems  certain  also  that  the 
isolation  and  detection  of  the  specific  element  cannot  much  longer 
be  delayed. 

Syphilis  is  a  disease  that  is  acquired  either  by  inheritance  or  by 
infection  of  a  sound  individual  with  the  virus  as  it  comes  from  a 
person  suffering  with  the  malady.  The  first  form  is  known  as  In- 
herited Syphilis,  and  the  second  as  Acquired  Syphilis.  These  two  forms 
of  the  trouble  differ  from  each  other  very  materially  in  their  course, 
their  symptoms,  and  their  gravity  as  relates  to  the  life  of  the  sufferer. 
The  acquired  form  is  a  disease  largely  amenable  to  treatment  and  sel- 
dom imperilling  the  life  of  the  individual  affected,  while  the  mortality 
in  the  inherited  form  is  extremely  great,  and  its  mutilating  effects  are 
often  made  manifest  in  every  tissue  and  organ  of  the  body  when  life 
is  spared. 

The  acquired  form  of  syphilis  is  contracted  most  frequently  in  the 
contacts  of  sexual  intercourse.  It  is  because  of  this  fact  that  syphilis 
is  classed  with  and  spoken  of  as  a  venereal  disease.     But  syphilis  is  not 

Vol.  I.— 54  S49 


850  SYPHILIS. 

always  acquired  in  this  manner.  It  is  frequently  contracted  in  ways 
other  than  by  sexual  congress.  Kissing  is  often  a  source  of  infection ; 
the  use  of  toilet  articles,  towels,  napkins,  knives,  spoons,  pipe-stems, 
and  cigar-holders  previously  contaminated  with  the  virus  of  syi^hilis 
by  persons  suffering  with  the  disease  is  a  fruitful  source  of  the  malady  ; 
the  breast  of  a  healthy  nurse  is  infected  by  the  syphilitic  child ;  sur- 
geons, physicians,  and  accoucheurs  are  infected  in  the  practice  of  their 
professions  and  in  turn  infect  others  in  like  manner.  In  all  these  ways 
and  in  many  others  syphilis  can  be  transmitted.  Syphilis  acquired  in  a 
manner  dominated  by  no  erotic  element  is  spoken  of  as  sypliilis  inson- 
tium,  or  syphilis  in  the  innocent.  Its  course  differs  in  no  wise  from 
that  pursued  by  the  disease  when  acquired  in  the  venereal  act. 

The  contagium  of  syphilis  cannot  be  carried  in  the  air  :  it  needs  a 
more  substantial  vehicle.  The  easiest  and  most  usual  form  of  trans- 
mission is  by  direct  and  close  contact  with  an  individual  suffering  with 
the  disease.  If  the  conditions  are  favorable,  there  is  then  a  direct  pas- 
sage of  the  virus  from  the  unsound  to  the  sound  individual.  Such 
method  of  acquiring  the  disease  is  said  to  be  by  immediate  infection. 
When  the  virus  is  transmitted  by  means  of  some  intervening  carrier 
the  infection  is  said  to  be  mediate.  In  order  that  the  virus  shall  make 
its  entrance  into  the  system  it  must  be  brought  into  contact  with  some 
solution  of  continuity  in  the  skin  or  in  contact  with  the  mucous  sur- 
faces. It  cannot  make  its  way  through  the  sound  integument.  The  break 
in  the  skin  may  be  exceedingly  minute  ;  it  may  be  the  merest  abrasion 
or  pin-point  opening,  but  it  is  always  there  as  an  open  door  through 
which  the  poison  may  enter.  Upon  the  mucous  and  pseudo-mucous 
surfaces  there  is  good  reason  for  believing  that  such  opening  is  not  so 
necessary.  Here  the  virus,  if  implanted  and  allowed  to  remain  undis- 
turbed, can  make  its  way  through  the  moist  epithelial  coverings  to  the 
tissues  beneath.  This  it  can  do  the  more  easily  if  it  finds  its  way 
into  a  mucous  or  sebaceous  follicle. 

If  pus  infection  of  the  wound  does  not  take  place  at  the  time  that 
the  syphilitic  virus  is  deposited,  the  wound  closes  and  the  parts  appear 
unaffected.  In  this  condition  they  remain  for  a  variable  length  of  time, 
iisually  about  three  weeks.  This  time,  in  which  there  are  no  manifes- 
tations of  any  trouble  whatever,  is  known  as  the  first  period  of  incuba- 
tion. Then  the  first  symptom  of  syphilitic  infection  makes  its  appear- 
ance. This  is  in  the  form  of  a  sore  at  the  exact  point  where  infection 
took  place.  This  sore  is  known  by  various  names,  as  the  hard  chancre, 
initial  sclerosis,  or  initial  lesion  of  syphilis.  While  this  first  lesion  of 
svphilis  is  always  strictly  circumscribed  and  definite  in  its  site,  it  is 
not  true  that  the  virus  of  the  disease  is  entirely  localized  within  it.  At 
least  partial  invasion  of  the  system  has  taken  place  before  its  appear- 
ance. Extirpation  of  the  chancre  does  not  abort  nor  in  any  way  modify 
the  course  of  the  disease. 

The  chancre  assumes  variable  and  characteristic  forms,  to  be  de- 
scribed later.  It  usually  follows  a  sluggish,  indolent  course,  lasting  from 
a  few  weeks  to  several  months,  and  then,  if  it  has  been  uncomplicated 
by  pus  infection,  disappears  completely,  leaving  no  relics  of  its  exist- 
ence behind.  At  about  the  time  that  the  chancre  appears  characteristic 
changes  take  place  in  the  neighboring  lymphatics  and  glands.     These 


NATUEK  AM)   cnrilSK   OF  SY  rill  LIS.  851 

t'iil:ir<iH',  hc'coinc  indiirMtcd  and  hard,  hut  ai'c  sclddin  paiiil'iil  and  rarely 
suppurate.      They  (•on>tituti'  the  hiiho  ot"  syphilis. 

With  the  ap|)oarancc'  oi"  the  chancre  heuins  the  ><»  called  second 
period  of  incidMifioii.  This  period  is  ill  delined  and  iudeliuite  in  its 
extent.  It  is  made  to  include  the  development  oi'  the  chancre,  the 
enlaruement  of  neiohhoriuo-  lyni])h  ii'lands,  and  that  series  of  ehantjjes 
which  takes  place  within  tlic  system  hefore  the  ai)pearanee  of  eruptions 
on  the  skin.  During'  this  time  the  patient  may  retain  the  full  vijror 
and  appearance  of  health,  or  there  may  be  jjrodromal  symptoms,  such 
as  mahiise,  inappetence,  headache,  slight  muscular  j^ains,  and  occasion- 
ally a  low  or  hio'h  temperatiu'c,  showing  that  the  system  is  slowly  being 
brought  untler  the  influence  of  the  poison.  Then  follows  the  first  exan- 
theni,  and  with  its  appearance  the  establishment  of  syphilis  within  the 
system  is  comjilete. 

Up  to  this  time  the  course  of  syphilis  is  reasonably  certain  and  un- 
varying in  different  individuals.  There  are  abont  the  same  changes  and 
they  occnr  in  abont  the  same  succession,  differing  only  in  the  length  of 
time  occupied  in  their  evolution  and  development.  After  the  appear- 
ance of  lesions  upon  the  skin  and  the  thorough  invasion  of  the  body  no 
such  orderly  succession  of  symptoms  can  be  predicted.  The  trouble 
may  end  at  once ;  it  may  become  quiescent  for  a  time  and  then  break 
out  with  added  intensity  and  vigor ;  it  may  go  through  a  series  of 
changes  increasing  in  energy  and  variety  of  expression  until  it  expends 
its  force  and  then  subsides  ;  or  it  may  enter  at  once  upon  a  malignant 
and  destructive  course  in  which  the  integrity  of  various  organs  may  be 
involved  or  life  itself  threatened. 

Syphilis  is  a  constitutional  disease  always.  The  involvement  of  the 
system  may  be  severe,  or  it  may  be  so  light  as  to  give  rise  to  scarcely 
appreciable  symptoms.  Limitation  of  all  symptoms  to  the  chancre 
means  that  the  systemic  manifestations  have  been  mild  and  the  skin 
affections  overlooked,  or  that  the  nature  of  the  local  lesion  presented  was 
misunderstood.  Syphilis  is  a  chronic  disease,  persisting  usually  for  a 
long  period  of  time  and  seldom  presenting  symptoms  that  can  be  classed 
as  acute.  Under  favorable  and  early  treatment  most  cases  recover  in 
from  two  to  four  years.  Some  cases  are  so  mild  that  all  symptoms 
vanish  after  the  expiration  of  a  few  months,  and  never  reappear.  This 
happens  at  times  with  no  treatment  at  all  or  that  only  of  the  most  in- 
different nature.  In  other  cases  the  symptoms  are  severe  from  the  be- 
ginning. Bone  and  brain  lesions  appear  with  or  precede  the  skin  erup- 
tions. The  skin  may  be  quickly  filled  with  ulcerating  gummata  instead 
of  the  more  frequent  macules  and  papules.  The  integrity  of  every 
organ  in  the  body  may  be  threatened  and  a  fatal  ending  may  ensue. 
This  malignant  form  of  the  disease  is  called  by  the  French  '^ galloping" 
or  "lightning"  syphilis,  and  the  terms  are  apt  and  appropriate.  It  is 
fortunate  that  such  cases  are  rare. 

Stages  in  Sr/philis. — Ricord  divided  the  course  of  syphilis  into  three 
periods,  designating  them,  respectively,  the  primary,  secondary,  and 
tertiary  stages.  The  primary  stage  beo;an  Avith  the  appearance  of  the 
initial  lesion  and  continued  until  the  development  of  generalized  skin 
eruptions.  The  skin  eruptions  ushered  in  the  secondary  stage.  This 
was  more  indefinite  in  course  and  extent,  but  was  made  to  include  the 


852  SYPHILIS. 

exanthemata  occurring  in  the  course  of  the  disease,  loss  of  hair,  affec- 
tions of  the  nails,  sore  throat,  and  mucous  patches  within  the  mouth 
cavity  and  elsewhere  upon  the  mucous  surfaces.  The  tertiary  stage 
followed  the  secondary,  and  was  still  more  indefinite  in  its  course.  It 
was  supposed  to  begin  at  about  the  end  of  the  first  year  and  to  continue 
until  the  termination  of  the  disease.  This  classification,  while  of  great 
service  in  the  past,  is  not  now  regarded  with  the  favor  once  accorded  it. 
Its  errors  are  becoming  more  apparent  every  day,  and  the  time  is  not 
far  distant  when  it  will  be  entirely  discarded.  Its  chief  fallacy  lies  in 
the  fact  that  it  endeavors  to  make  syphilis  conform  to  a  time  schedule 
and  a  regular,  unvarying  succession  of  changes.  Such  a  course  syphilis 
does  not  pursue,  and  any  attempt  to  make  it  appear  that  it  does  is  mis- 
leading in  the  extreme.  The  tertiary  stage  in  many  cases  never  makes 
its  appearance,  all  symj)toms  of  the  disease  ending  with  the  termiuation 
of  the  skin  eruptions.  Again,  the  secondary  stage,  as  far  as  any  of  its 
chief  manifestations  are  concerned,  may  be  wanting  entirely,  and  so 
called  tertiary  symptoms  follow  close  upon  the  appearance  of  the 
chancre.  The  primary  stage  is  the  only  one  described  by  Ricord  in 
which  the  symptoms  are  possessed  of  sufficient  constancy  and  definite- 
ness  to  warrant  their  being  grouped  as  belonging  to  one  'period  of  the 
disease. 

Syphilis  must  be  recognized  as  a  disease  not  following  any  one  defi- 
nite course  and  manifesting  itself  in  a  series  of  symptoms  appearing  at 
a  certain  time  after  the  development  of  the  chancre,  these  running  their 
course  within  specified  and  exact  limits,  then  to  disappear  and  be  suc- 
ceeded by  another  set  of  symptoms  equally  clear  and  concise ;  but  as  a 
disease  that,  starting  from  a  fixed  point,  pursues  many  different  lines  of 
evolution  and  expresses  itself  in  a  great  variety  of  symptoms.  Only 
in  such  manner  can  an  intelligent  conception  of  the  malady  be  obtained. 

Etiology. — The  belief  is  wellnigh  universal  among  scientific  and 
medical  men  that  syphilis  is  caused  by  a  living  germ.  So  many  of  the 
clinical  facts  and  manifestations  of  the  disease  can  be  given  a  ready 
and  satisfactory  explanation  by  the  assumption  of  such  an  hypothesis 
that  the  evidence  is  overwhelmingly  in  its  favor.  ^Moreover,  reasoning 
from  analogy,  we  are  able  to  reach  the  same  conclusions.  Syphilis  un- 
doubtedly belongs  to  the  infectious  granulomata.  Its  infectiousness, 
the  course  it  pursues,  the  development,  structural  anatomy,  clinical  ap- 
pearances, and  ultimate  termination  of  its  various  lesions  are  all  in 
accord  with  diseases  of  this  class.  In  this  group  of  affections  are  in- 
cluded leprosy,  tuberculosis,  glanders,  lupus  vulgaris,  mycosis  fungoides, 
and  actinomycosis.  All  of  these  diseases  are  known  to  be  inoculable  ; 
bacteria  are  found  constantly  in  their  lesions ;  and  in  some,  as  in  tu- 
berculosis, glanders,  and  actinomycosis,  certain  of  these  organisms  are 
positively  known  to  be  the  causative  agent  in  their  production.  These 
facts  furnish  good  evidence  for  our  belief  that  syphilis  originates  in  the 
same  manner. 

While  the  existence  of  a  bacterium  that  produces  and  perpetuates 
syphilis  is  highly  probable,  its  detection,  isolation,  and  thorough  demon- 
stration have  not  yet  been  accomplished.  In  1884,  Lustgarten  described 
a  bacillus  which  he  had  found  in  syphilitic  tissues  and  which  he  believed 
to  be  the  microbic  element  of  the  disease.     The  bacillus  was  from  three 


SVMrTUMS.  853 

to  sovcMi  niicroinilliiiu'trcs  in  Iciiiitli,  or  aljoiit  tlic  size  of"  the  tulxTclc 
bacillus,  had  a  sliiilitly  cui'vcd  or  S-sliapctl  a|)|)('araiu'f,  and  had  Uiioh- 
like  cnlariiciiu'iits  at  its  ends.  Since  niakin<i'  his  invcstijiations  otlu-r 
observers  have  veritied  the  existence  of"  the  bacillus  in  tissues  of  like 
nature. 

These  bacilli  have  been  found  in  the  tissues  and  secretions  of  chancres 
and  moist  ])a]ndes,  in  dry  papules,  mucous  ])atclies,  o-umniata,  condy- 
lomata, and  lymph  glands.  They  are  not  numerous,  usually  b('in<>-  ftund 
alone  or  in  tirouj)s  of  two  to  eight  within  cells  somewhat  resembling, 
but  larger  than,  white  blood  corpuscles.  They  occur  most  frecpiently 
near  the  advancing  border  of  the  lesion,  rarely  deep  within  its  substance. 

The  staining  method  employed  in  their  demonstration  is  briefly  as 
follows  :  Thin  sections  of  the  part  to  be  examined  are  made  througli 
the  border  of  the  lesion,  including,  if  possible,  sound  as  well  as  syphi- 
litic tissue.  These  sections  are  placed  in  a  solution  consisting  of 
100  parts  of  aniline  water,  and  11  parts  of  a  concentrated  alcoholic 
solution  of  gentian  violet.  In  this  they  are  allowed  to  remain  for 
twenty-four  hours.  Then  the  temperature  of  the  solution  is  raised  to 
40°  C  and  the  immersion  is  continued  for  two  hours  longer,  after  which 
the  sections  are  removed  and  placed  in  absolute  alcohol  for  five  min- 
utes. On  removal  from  this  they  are  dipped  for  ten  seconds  in  a  1|- 
per  cent,  solution  of  permanganate  of  potassium,  and  are  then  decol- 
orized in  sulphurous  acid  largely  diluted  with  distilled  water.  If  after 
a  thorough  attempt  it  is  seen  that  decolorization  of  the  specimen  can- 
not be  completely  effected,  the  process  of  washing  in  alcohol,  perman- 
ganate solution,  and  a  stronger  solution  of  sulphurous  acid  must  be 
repeated.  The  section  when  ready  for  mounting  must  be  colorless  to 
the  naked  eye.  When  decolorization  is  complete  the  section  is  washed 
in  distilled  water,  cleared  in  the  usual  way  with  oil  of  cloves,  mounted 
in  glycerin  or  Canada  balsam,  and  examined  with  a  yV  inch  oil  immer- 
sion lens. 

The  bacillus  thus  described  may  be  the  active  causative  agent  of  syph- 
ilis, but  enough  has  not  been  done  as  yet  to  prove  it  such.  Lustgarten 
did  not  carry  his  work  to  completion,  nor  has  any  other  investigator 
done  so  since.  It  is  not  enough  to  find  certain  forms  of  bacteria  present 
in  the  syphilitic  tissues.  They  must  be  found  constantly  in  all  at  least 
of  the  earlier  lesions.  They  must  be  removed  from  such  lesions,  isolated 
from  all  other  species  of  bacteria,  and  pure  cultures  must  then  be  made 
upon  suitable  media.  From  these  cultures  inoculation  experiments  upon 
individuals  free  from  any  taint  of  the  disease  must  be  made,  with  the 
result  of  producing  in  them  demonstrable  syphilis.  In  the  lesions  of 
syphilis  thus  produced  the  same  germs  must  be  found.  These  are  essen- 
tially Koch's  la\vs,  and  in  the  round  that  they  require  can  complete 
proof  alone  be  obtained.  Only  when  this  shall  have  been  accomplished 
wdll  the  bacillus  of  syphilis  be  completely  demonstrated.  One  great 
difficulty  in  the  way  of  demonstrating  the  germ  of  syphilis  is  the  fact 
that  animals  are  immune  to  the  disease.  Inoculation  experiments  have 
been  tried  repeatedly  upon  them,  but  only  in  rare  instances  with  in- 
different success.  The  help  afforded  in  the  study  of  tuberculosis  by 
animals  is  here  denied. 

Symptoms. — Syphilis  is  a   disease  that  expresses  itself  in  a  great 


854  SYPHILIS. 

variety  of  ways  and  with  a  multitude  of  symptoms.  Frequently 
it  expends  its  entire  energy  in  an  attack  on  one  organ  or  one  set  of 
organs.  Thus  the  symptoms  may  be  confined  entirely  or  in  large  part 
to  the  skin,  to  the  bones,  to  the  nervous  system,  or  to  any  one  of  the 
various  organs  or  systems  of  organs  of  which  the  body  is  composed  ;  or 
a  number  of  organs  may  be  attacked  simultaneously  or  in  succession. 
Again,  in  its  encroachment  upon  a  given  organ  it  is  not  by  any  means 
uniform  in  the  lesions  that  it  produces  or  the  effects  to  which  it  gives 
rise.  There  is  no  lesion  of  the  skin  known  to  the  physician  that  syphilis 
may  not  reproduce,  and  in  its  involvement  of  deeper  structures  it  fur- 
nishes nearly  as  extensive  a  list  of  jjathological  phenomena.  Hence 
the  study  of  symptoms  presented  by  syphilis  must  be  a  study  of  its  dif- 
ferent lesions  and  their  varying  expression  in  different  organs. 

The  First  Period  of  Incubation. — After  the  syphilitic  virus  has 
gained  entrance  to  the  system  an  interval  occurs  in  which  there  is  no 
appreciable  evidence  of  infection.  This  interval  occupies  a  period  of 
time  varying  from  ten  to  thirty  days.  At  the  expiration  of  this  incu- 
bative period  the  hard  chancre  or  initial  sclerosis  makes  its  appearance 
at  the  point  where  infection  took  place.  The  length  of  this  incubative 
period  varies  within  quite  wide  limits.  Ten  days  appears  to  be  the 
shortest  time  on  record  in  which  the  date  of  infection  was  indisputable, 
while  periods  as  long  as  sixty  and  seventy  days  have  been  noted  by 
careful  observers.  Very  long  or  very  short  periods  are  exceptional, 
however,  and  always  open  to  suspicion.  The  great  majority  of  chancres 
occur  at  about  the  end  of  the  third  week. 

The  point  at  which  the  chancre  is  situated  is  always  the  point  where 
contamination  with  the  syphilitic  virus  has  taken  place.  Infection  never 
occurs  at  a  distance  from  this  point.  Two  or  more  points  may,  how- 
ever, be  infected  at  the  same  time,  and  if  this  occurs  there  will  be  an 
equal  number  of  chancres  resulting.  Thus  it  may  happen  that  a  man 
may  get  a  chancre  of  the  lip  at  the  same  time  with  a  chancre  of  the 
penis,  the  one  acquired  by  kissing,  the  other  by  coitus  with  the  same 
woman.     But  this  is  unusual. 

During  this  incubation  period  it  is  highly  probable  that  the  virus 
does  not  remain  localized  and  latent,  but  that  it  undergoes  distribution 
with  developmental  changes  too  delicate  for  our  coarse  methods  of  ap- 
preciation. Certain  it  is  that  infection  of  the  system  occurs  within  a 
relatively  short  period  of  time  after  contamination  has  taken  place. 
This  is  shown  by  the  fact  that  if  an  abraded  surface  or  open  wound 
through  which  the  poison  is  supposed  to  have  passed  be  thoroughly  cau- 
terized or  dee^jly  extirpated  within  a  few  hours  after  inoculation  has 
taken  j)lace,  it  does  not  in  any  wise  affect  the  appearance  of  the  chancre 
or  the  course  of  the  subsequent  syphilis. 

Chancre. — A  chancre  is  that  changed  condition  of  the  normal  or  un- 
sound skin  or  mucous  membrane  produced  by  infection  with  the  virus 
of  syphilis,  and  occurring  at  the  point  where  such  infection  has  taken 
place.  It  is  characterized  by  a  varying  degree  of  induration  and  an 
accompanying  enlargement  of  the  neighboring  lymphatic  glands. 

Better  and  less  confusing  terms  for  its  designation  are  the  "  initial 
sclerosis "   and  the  "  initial  lesion "  of  syphilis. 

The  initial  sclerosis  does  not  occur  in  hereditary  syphilis,  and  is 


SYMl'TOMS.  855 

iioviM*  wantinu;  in  the  iU'(|iiir('(l  ionii.  It  may  he  so  sli<>;ht  in  its  in;miics- 
tations  as  n()t  to  attract  the  j)ati('ii('s  attciitioii,  or  it  may  \)v  liiddcti 
(looplv  beyond  the  external  o[)enin<4s  of  the  body,  siK-h  as  in  the  iiKuitli 
cavity  or  vagina,  and  thus  escape  detection,  but  its  existence'  is  none  the 
less  certain.  Cases  of  sy[)hilis  in  which  il  is  declared  to  have  been 
absent  are  simply  cases  in  which  it  was  overlooked  or  misunderstood. 
It  is  one  of  the  few  symptoms  in  syphilis  that  is  constant  and  uuvaryinj^ 
in  its  a[)])earance. 

The  initial  lesion  is  the  first  symptom  of  sy|)hilis  to  declare  itself 
after  infection,  and  it  is  also  the  first  conclusive  proof  that  infection  has 
taken  place.  The  site  of  its  appearance  is  always  definite.  It  occurs  at 
the  point  or  points  of  infection,  and  in  no  other  localities.  It  is  usually 
single,  but  if  there  has  been  coincident  infection  at  two  or  more  })()ints, 
there  will  be  a  corresponding-  number  of  initial  lesions.  This  frequently 
happens  on  the  glans  or  foreskin  when  the  rupture  of  a  number  of  her- 
petic vesicles  has  opened  different  passageways  for  the  entrance  of  the 
specific  virus.  Here  as  many  as  a  dozen  or  more  distinct- and  individual 
lesions  may  occur,  each  presenting  the  typical  characteristics  of  a  hard 
chancre. 

The  chancre  of  syphilis  is  not  auto-inoculable.  Its  virus  can  be 
deposited  npon  the  broken  skin  or  mucous  membranes  of  the  individual 
upon  which  it  occurs,  and  no  chancre  will  result.  In  this  it  differs  from 
the  chancroid,  which  can  be  freely  inoculated  at  different  sites  upon  its 
bearer.  When  the  chancre  appears  upon  a  surface  that  is  brought  con- 
stantly in  contact  with  an  opposing  surface,  it  is  apt  to  produce  a  lesion 
that  looks  as  if  auto-inoculation  had  taken  place.  This  happens  fre- 
quently upon  the  inner  surface  of  the  foreskin  and  the  glans  penis  or 
between  the  lips  of  the  vulva.  If  such  secondary  lesion  be  examined 
carefully,  it  will  be  found  to  be  superficial,  not  at  all  indurated,  and 
perhaps  slightly  ulcerated.  It  is  caused  by  the  irritation  produced  by 
the  chancre,  and  not  by  any  specific  action  of  the  syphilitic  virus.  No 
mistake  need  occur  if  careful  examination  of  all  lesions  presenting  them- 
selves be  made. 

Sites. — As  syphilis  is  acquired  most  frequently  in  the  contacts  of  sex- 
ual intercourse  the  initial  lesion  is  found  oftenest  upon  the  genital 
organs. 

In  the  male  it  occurs  upon  the  glans  penis,  in  the  sulcus  coronarius 
near  the  frsenum,  upon  the  inner  or  outer  surface  of  the  foreskin,  on  the 
skin  of  the  penis  or  scrotum,  and  at  the  meatus  urinarius  or  deep  within 
the  urethra. 

In  the  female  the  parts  oftenest  attacked  are  the  labia  majora  and 
minora,  the  fourehette,  the  preputial  covering  of  the  clitoris,  the  entrance 
to  the  vagina,  the  os  uteri,  the  perineum,  and  the  inner  surface  of  the 
thigh. 

Other  parts  of  the  body  where  chancres  may  be  met  with  are  the  lips, 
tip  of  the  tongue,  the  tonsils  and  walls  of  the  pharynx,  the  nipples  and 
breasts  in  nursing  women,  the  base  of  the  nail  and  finger  tips  in  sur- 
geons, physicians,  and  accoucheurs,  the  lobe  of  the  ear,  the  parts  about 
the  eye,  and  the  umbilicus.  In  short,  any  part  of  the  body  where  a 
break  in  the  overlying  structures  may  occur,  and  to  which  the  virus 
of  syphilis  can  be  carried,  may  become  the  seat  of  chancre.     Chancres 


856  SYPHILIS. 

occurring  upon  the  genitals  of  either  sex  are  spoken  of  as  genital  chan- 
cres, while  those  occurring  elsewhere  upon  the  body  are  known  as  extra- 
genital. 

All  chancres  have  at  least  three  determining  features  in  common. 
These  are — the  period  of  incubation  already  described,  a  peculiar  thick- 
ening and  hardening  in  and  about  the  lesion  known  as  induration,  and 
a  characteristic  enlargement  of  the  lymphatic  glands  in  the  near  neigh- 
borhood.    These  features  are  constant  and  diagnostic. 

Induration. — Induration,  in  its  degree  and  extent,  diifers  very  much 
in  diiferent  chancres  according  to  their  anatomical  location  and  the 
amount  of  external  irritation  to  which  they  are  subjected.  The  thick- 
ening may  involve  only  the  base  of  the  lesion,  seeming  to  the  touch 
like  a  bit  of  parchment  set  within  the  tissues,  or  it  may  produce  a  mass 
the  size  of  a  marble  and  varying  in  density  from  that  of  cartilage  to 
bone.  The  induration  frequently  can  be  detected  at  the  outset,  or,  if 
inappreciable  then,  will  usually  make  itself  apparent  within  a  few  days. 
It  continues  to  increase  for  a  period  varying  from  ten  to  fifteen  or 
more  days.  At  times  the  occurrence  of  induration  is  deferred  some- 
what longer,  but  it  never  fails  to  show  itself.  If  the  thickening  be 
slight,  it  may  disappear  entirely  before  the  chancre  heals,  but  if  extreme 
it  usually  disappears  slowly.  Some  trace  of  it  can  often  be  discovered 
at  the  time  of  the  first  macular  exanthem  unless  this  be  much  delayed. 
Occasionally  it  persists  for  longer  periods,  as  for  six  and  eight  months. 

Bubo. — The  accompanying  glandular  enlargement  is  known  as  syph- 
ilitic bubo.  When  the  chancre  is  situated  upon  the  penis,  the  bubo  ex- 
ists in  both  groins.  It  is  said  at  times  to  be  one-sided,  when  the  chancre 
is  not  situated  near  the  median  line.  This  statement,  however,  needs 
confirmation.  Enlargement  upon  one  side  only  is  of  doubtful  charac- 
ter. The  glands  are  but  slightly  or  not  at  all  painful,  and  freely 
movable  beneath  the  skin.  They  usually  form  in  a  series  decreasing 
in  size  from  the  one  nearest  the  chancre.  In  size  they  vary  from  that 
of  a  billiard  ball  to  that  of  a  hazelnut.  The  skin  is  not  inflamed  as  in 
chancroid,  and  they  rarely  suppurate.  Double  inguinal  adenopathy, 
with  a  characteristically  indurated  chancre  appearing  at  the  end  of  an 
incubative  period  of  not  less  than  three  weeks,  is  sufficient  to  establish 
a  diagnosis  of  syphilis.  Treatment  has  a  marked  influence  upon  the 
duration  and  character  of  the  bubo. 

Form. — Chancres  assume  a  variety  of  forms.  They  are  frequently 
developed  upon  the  site  of  pre-existing  lesions,  such  as  herpetic  vesi- 
cles, smokers'  patches,  fissures,  and  excoriations,  and  take  on  certain 
of  the  features  presented  by  such  lesions.  Anatomical  location,  pres- 
sure effects,  friction,  and  treatment  all  tend  to  modify  the  chancre  and 
in  various  ways  determine  the  form  that  it  shall  take.  No  one  lesion 
can  be  taken  as  the  type  of  all  chancres.  Each  must  be  studied  by 
itself.     Only  the  commonest  forms  can  here  be  described. 

Erosion. — This  is  the  simplest  type  and  the  one  most  frequently  met 
with.  It  appears  as  if  a  limited  area  of  the  epidermis  or  mucous  mem- 
brane had  been  rubbed  or  scraped  away.  This  form  is  frequently 
spoken  of  as  the  chancrous  erosion.  It  is  the  primary  form  of  the 
initial  lesion,  but  with  its  simplicity  it  is  the  form  that  presents  the 
greatest  difficulties  in  the  Avay  of  diagnosis.     At  the  outset  it  is  not 


SY  Ml '/'(>. ]fs.  857 

much  larii'iT  tluin  the  siiriacc  of  a  piuhcad,  is  roiiii(lc(l  oi-  dval  in  out- 
line, and  a])j)c'ars  as  il'  the  epithelium  had  been  removed  hy  friction 
with  the  (dotliino-  or  o|)posiii<i'  pai'ts  of  the  hody.  Tlie  eroded  surface  is 
on  a  level  with  the  surrouudiun-  intciiument  or  hut  little  dei)ressed  helow 
it.  Examination  of  its  base  usually  shows  a  sliu-lit  deg^ree  of  indura- 
tion, as  if  the  lesion  were  resting;  on  a  bit  of  mica  set  in  the  skin. 
This  may  be  wanting  if  the  chancre  is  seen  early,  but  it  makes  its 
appearance  within  a  short  time.  During  the  evolution  of  the  chancre 
the  induration  becomes  well  marked.  The  eroded  surface  remains 
diminutive  in  size,  or  enlarges  by  peripheral  extension  until  it  becomes 
iis  large  as  or  larger  than  a  ten-cent  piece.  The  lesion  is  dark  red  or 
grayish  in  color.  The  surface  has  a  glanced,  velvety  appearance,  and 
at  times  is  covered  with  a  closely  adherent  pellicle  looking  somewhat 
like  diphtheritic  membrane.  The  base  is  bathed  in  a  sticky  serous 
exudate.  This  exudate  can  be  made  to  flow^  freely  by  making  gentle 
pressure  at  the  sides  or  the  lesion  may  bleed  upon  manipulation. 

This  form  of  chancre  is  usually  single,  but  it  may  occur  in  numbers 
of  a  dozen  or  more.  The  minute  eroded  surfaces  in  such  instances  are 
grouped  together,  but  each  lesion  is  separate  and  distinct.  The  resem- 
blance of  such  chancres  to  the  lesions  remaining  after  the  rupture  of  a 
number  of  herpetic  vesicles  has  given  rise  to  their  designation  as  "  mul- 
tiple herpetiform  chancres."  Early  in  their  course  they  are  exceedingly 
hard  to  distinguish  from  progenital  herpes,  but  absence  of  itching  and 
burning  sensations  should  make  the  practitioner  wary  about  committing 
himself  to  a  positive  diagnosis.  Such  chancres  have  a  glazed  surface 
not  seen  in  herpetic  lesions.  Their  tendency  is  to  coalesce,  forming  a 
single  large  eroded  surface. 

When  single  the  chancrous  erosion  sometimes  assumes  a  cup-shaped 
depression  with  slightly  elevated  borders,  or  the  floor  may  be  lifted  by 
the  indurated  base  until  it  appears  like  an  excoriated  papule. 

This  form  of  chancre  is  found  frequently  in  the  male  on  the  under 
part  of  the  foreskin  or  in  the  sulcus  coronarius.  In  those  situations 
where  it  is  protected  from  friction  with  the  clothing  or  exposure  to  the 
air  it  finds  the  conditions  suited  to  its  best  expression. 

The  induration  may  increase  to  such  an  extent  as  to  give  the  chancre 
the  form  of  a  nodule  varying  in  size  from  a  pea  to  a  marble  and  as  hard 
as  ivory.  The  erosion,  often  no  larger  than  a  pinhead  and  retaining  its 
distinctive  features,  can  usually  be  found  upon  the  surface  of  this  en- 
larged and  hardened  mass,  or  the  chancre  may  heal  and  disappear  while 
the  nodule  continues  to  increase  in  size.  Xodular  lesions  of  this  kind 
are  most  frecpiently  met  with  in  the  furrow  back  of  the  corona  glandis. 
The  abundance  of  connective  tissue  in  this  locality  is  favorable  for  such 
development. 

The  Dry  Papule.  —  This  form  of  chancre  occurs  in  situations  not 
subject  to  heat  or  moisture.  The  skin  of  the  penis,  the  surface  of  the 
glans  in  men  who  have  been  circumcised,  the  pubic  regions,  and  the 
skin  of  the  body  in  general  furnish  favorable  sites  for  its  appearance. 
The  papule  begins  as  a  reddened,  indurated  point  not  much  larger 
than  a  pin-head,  and  increases  slowly  in  size  and  elevation  until  it  is 
several  lines  in  height.  The  lesion  is  firmly  indurated  throughout, 
and  the  tissues  at  the  base  are  more  or  less  involved.     The  summit  of 


858  SYPHILIS. 

the  papule  is  flat  or  convex,  and  is  usually  covered  by  a  dry,  somewhat 
adherent  grayish  scale.  The  papule  is  often  surrounded  by  a  reddened 
areola.  Its  hue  is  dusky  red  or  ham  color.  It  may  continue  as  a  papule 
throughout  its  entire  course  or  be  converted  into  a  pustule,  and  later 
degenerate  into  an  ulcer.  Frequently  after  resolution  a  deeply  pig- 
mented spot  remains. 

Pustule. — The  joustular  or  ecthymiform  chancre  develops  usually 
from  the  dry  papule.  This  type  never  originates  primarily  as  a  pus- 
tule, but  is  always  secondary  to  some  other  form,  and  is  due  to  infec- 
tion of  such  lesion  with  pus  cocci.  There  is  always  a  considerable 
degree  of  inflammation  in  and  about  the  chancre,  owing  to  the  nature 
of  its  pus-producing  elements.  The  roof  wall  soon  breaks  doAA^n,  and 
the  pustule  becomes  surmounted  by  a  friable,  yelloAvish  or  greenish 
yellow  crust.  Considerable  swelling  of  the  foreskin  is  apt  to  occur 
when  the  lesion  is  seated  upon  its  surface  or  upon  the  glans. 

Ulcer. — Chancres  occur  frequently  in  the  form  of  ulcers.  In  all 
cases  such  ulceration  is  caused  by  friction,  irritating  discharges,  un- 
cleanliness,  infection  Avith  pus  microbes,  or  improper  treatment,  A 
chancrous  erosion  is  often  converted  into  a  lesion  of  this  type  by  the 
early  and  severe  use  of  caustics.  The  ulcer  may  be  either  superficial  or 
deep.  When  superficial  the  ulcer  resembles  the  eroded  form  of  chancre 
in  its  early  stages  in  that  its  base  is  not  often  deeply  indurated.  The 
ulcer  is  shalloAv,  has  sloping  AA^alls,  a  raised  or  but  slightly  elevated 
border,  and  an  unhealthy  granular  pus-secreting  floor.  In  deep  ulcers 
the  ulceration  extends  profoundly  into  the  tissues,  and  the  induration 
seen  at  the  base  and  sides  of  the  chancre  exceeds  that  seen  in  any  other 
form.  This  form  of  chancre  is  knoAAai  as  the  "  Hunterian  chancre." 
The  Avails  are  never  perpendicular,  but  ahvays  slope  gradually  to  the 
floor  of  the  ulcer.  The  edges  are  raised,  thickened,  and  intensely 
hardened.  The  secretion  is  purulent,  and  may  be  scanty  or  profuse. 
At  times  the  lesion  may  be  hemorrhagic  and  blood  be  mixed  Avith  the 
pus.  The  base  of  the  penis  overlapped  by  the  pubic  hairs,  or  the  cruro- 
scrotal  angle,  is  a  faA^orite  site  for  its  de\^elopment.  SAvelling  and  oedema 
of  the  penis  are  frequent  accompaniments.  Resolution  is  attended  by 
loss  of  tissue  and  the  production  of  a  AA^ell  marked  cicatrix. 

Chancres,  as  a  rule,  undergo  complete  resolution,  leaving  no  trace 
of  their  existence  behind,  saA^e  perhaps  a  pigmented  spot.  When  per- 
sisting until  the  development  of  skin  eruptions  they  are  frequently 
converted  into  lesions  of  a  distinctly  different  type,  the  so-called  moist 
papule  or  mucous  patch. 

Mixed  Chancre. — This  term  is  applied  to  those  chancres  arising  from 
simultaneous  infection  Avith  the  virus  of  chancroid  and  of  syphilis. 
The  chancroidal  elements  are  the  first  to  develop.  There  is  no  incuba- 
tive period,  the  sore  appearing  shortly  after  exposure.  A  pustule 
appears  at  the  start.  It  is  markedly  inflammatory  in  its  nature,  and 
shortly  becomes  ulcerative.  No  induration  can  be  detected  at  its  base. 
If  the  sore  appears  upon  the  penis,  a  single  gland  in  one  groin  may 
enlarge.  Rarely  enlargement  occurs  in  both  inguinal  regions.  The 
gland  is  tender  to  the  touch,  and  soon  becomes  extremely  painful.  The 
skin  covering  it,  is  reddened  and  suppuration  may  occur. 

After  the  usual  period  of  syphilitic  incubation  has  gone  by  the  sore 


SYPHILIS   OF  THE  SKIS.  851) 

tukes  on  new  features.  The  base  heeoiues  hardened  and  tlie  eliaiiere 
assumes  tlu'  eharaeteristies  of  the  uh-erative  initial  lesion  of  syphilis. 
There  soon  follows  the  multiple  instead  of  single  glandidar  eularucment, 
and  systemie  syphilis  ensues. 

Syphilis  of  the  Skin. — Sypiiilis  displays  itself  upon  the  skin  of 
the  individual  sutierino-  with  the  disease  in  a  innnber  of  well  deiined 
and  eharaeteristic  ways.  It  is  usually  here  that  tiie  first  positive  ])roofs 
of  svstemie  invasion  are  made  manifest,  and  throughout  the  entire  course 
of  tlie  malady  the  skin  may  show,  in  some  portion  of  its  extent,  evidences 
of  the  disease.  The  lesions  presented  vary  much  in  their  nature,  cha- 
nicter,  form,  distribution,  extent,  and  gravity  of  deportment.  Those 
occurring-  early  in  the  course  of  the  disease  are  usually  benign  in  nature 
and  extensive  in  distribution,  while  those  occurring  at  late  periods  are 
apt  to  be  localized  and  destructive  in  their  tendencies.  The  ])rincipal 
lesions  exhil)ited  upon  the  skin  are  in  the  form  of  macules,  papules, 
pustules,  ulcers,  tubercles,  and  gummata,  and  they  are  called  the  syphilo- 
dermata.  Early  and  exact  recognition  of  these  skin  lesions  is  essential, 
because  of  the  important  help  they  furnish  in  establishing  a  diagnosis. 

Mdcidcs. — These  are  the  earliest  of  the  syphilitic  eruptions  to  make 
their  appearance.  They  begin  as  slightly  muddy  discolorations  of  the 
skin,  giving  to  the  surface  of  the  body  a  peculiarly  mottled  look.  Often 
this  condition  cannot  be  seen  with  light  reflected  directly  from  the  sur- 
face of  the  skin,  but  only  when  the  light  comes  to  the  eye  in  an  oblique 
direction.  The  eruption  may  come  out  slowly,  ten  or  more  days  being 
occupied  in  the  process,  or  it  may  develop  rapidly,  a  single  night  suffi- 
cing for  its  complete  evolution.  This  latter  is  more  apt  to  be  the  case 
if  the  patient  has  recently  indulged  in  a  Turkish  or  other  hot  bath,  by 
means  of  which  the  system  has  been  overheated  and  the  bloodvessels 
of  the  skin  thoroughly  relaxed. 

In  its  complete  expression  the  eruption  is  seen  to  consist  of  isolated 
macules,  roundish  or  irregular  in  outline,  from  the  surface  of  a  split 
pea  to  a  ten-cent  piece  in  size,  and  of  a  pinkish  or  brownish  hue.  The 
color  fades  at  first  upon  pressure,  but  later  becomes  more  or  less  per- 
sistent. The  eruption  usually  makes  its  appearance  first  upon  the  sur- 
face of  the  belly  or  of  the  chest,  but  it  may  occur  in  other  locations, 
as  the  dorso-lumbar  region  or  over  the  scapulae  and  shoulders.  The 
process  if  severe  may  extend  over  the  greater  part  of  the  body  surface. 
The  face  usually  escapes,  but  when  affected  the  process  is  seen  in  its  best 
development  at  the  base  of  the  hair  and  over  the  brow.  The  eruption 
occurs  almost  constantly  upon  the  palms  of  the  hands  and  the  soles  of 
the  feet.  Examination  of  these  regions  should  alwavs  be  made  in  anv 
case  of  suspected  syphilis.  The  spots  here  show  themselves  as  fliint  or 
well  pronounced  erythematous  patches,  circumscril)ed  or  ill  defined  in 
outline,  and  fading  upon  pressure.  They  may  persist  in  this  form 
throughout  their  entire  course,  or  later  develop  into  scaling  papules. 
The  dorsa  of  the  hands  and  feet  are  far  less  frequently  affected. 

The  macules  in  an  early  period  of  their  development  are  usually 
unmixed  with  other  forms  of  syphilitic  lesions,  but  they  may  be  readily 
transformed,  if  subjected  to  any  form  of  irritation,  into  maculo-papules, 
in  which  there  is  slight  elevation  of  the  surface,  and  these  be  converted 
later  intodistinctpapules.    Occasionally  they  arecommingled  with  pustules. 


860  SYPHILIS. 

There  is  little  or  no  sensation.  If  any  is  excited,  it  is  evinced  in 
the  form  of  a  slight  pruritus,  which  is  seldom  annoying.  The  patient 
may  not  be  aware  when  he  presents  himself  for  examination  that  his 
body  shows  any  traces  of  eruption.  It  should  therefore  be  the  rule 
whenever  practicable  to  examine  the  entire  body  surface.  This  should 
always  be  done  in  the  case  of  male  patients,  no  matter  at  what  stage  of 
the  disease  they  may  first  present  themselves.  AVhen  not  visible  the 
mottling  of  the  surface  can  be  made  to  appear  by  exposing  the  skin  for 
a  short  time  to  a  slightly  chilly  atmosphere. 

In  many  cases  the  eruption  is  preceded  by  subjective  symptoms, 
such  as  malaise,  inappetence,  headache,  and  temperature  varying  from 
slightly  above  normal  to  102°  or  103°  F. 

The  eruption  does  not  often  persist  for  any  great  length  of  time. 
Under  appropriate  and  energetic  treatment  it  can  be  made  to  disappear 
in  a  few  days.  Untreated  cases  may  continue  for  a  month  or  longer, 
but  usually  transformations  of  the  lesions  into  papules  takes  place  before 
the  expiration  of  this  period  is  reached,  and  the  type  of  the  disease  is 
changed  completely.  Recurrence  of  the  macular  syphiloderm  may  take 
place  at  any  time  during  the  first  year,  but  it  is  not  often  generalized. 
There  is  at  these  times  a  tendency  on  the  part  of  the  lesions  to  assume 
a  circinate  grouping. 

There  is  usually  some  accompanying  involvement  of  the  mucous 
surfaces.  Inspection  of  the  throat  shows  hypersemia  of  the  pharynx, 
of  the  pillars  of  tjtie  fauces,  and  of  the  soft  palate.  Tenderness  of  the 
gums  is  also  noticeable. 

Resolution  is  usually  complete,  no  relics  being  left  to  show  the 
existence  of  previous  trouble.  But  sometimes  where  the  process  has 
been  severe  more  or  less  pigmentation  may  follow.  This  disappears  in 
the  course  of  time. 

Papules. — Papules  are  among  the  commonest  and  most  characteristic 
of  syphilitic  eruptions.  They  may  appear  at  any  time  after  the  third 
month  of  the  disease.  Any  part  of  the  body  surface  may  be  aifected. 
Frequently  they  appear  in  crops,  and  recurrence  often  takes  place. 
They  are  discrete  or  in  groups.  Careful  examination  shows  the  groups 
formed  in  curved  lines,  circles  or  parts  of  circles,  and  S -shaped  figures. 
Such  grouping  is  pathognomonic.  It  is  best  seen  over  the  abdominal 
and  chest  regions  or  upon  the  surface  of  the  back.  The  papules  vary 
in  size  from  a  grape  seed  to  a  split  pea,  or  even  larger.  The  large  and 
the  small  varieties  may  be  commingled  in  the  same  subject  or  be  sepa- 
rate and  distinct,  a  given  individual  showing  but  one  form  throughout 
the  course  of  his  disease.  Rarely  these  small  papules  may  be  converted 
into  the  larger  varieties.  Occasionally  they  become  pustules.  They  are 
many  or  few,  conical  or  flat,  moist  or  dry,  and  vary  in  hue  from  a  light 
red  to  a  dark  ham  color.     Resolution  is  usually  complete. 

Papules  may  form  the  first  eruption  that  appears  upon  the  skin,  or 
they  may  be  developed  with  or  directly  follow  the  macular  exanthem. 
They  are  best  classified  as  dry  and  as  moist  papules. 

Dry  Papules. — Dry  jiapules  occur  in  two  forms,  known  as  the  miliary 
and  the  lenticular.  Miliary  papules  occur  less  frequently  than  do  the 
lenticular.  They  are  seen  oftenest  in  uncleanly  and  neglected  cases. 
For  this  reason  they  are  seen  more  frequently  in  pulilic  than  in  private 


SYPIIIIJS   OF   Till-:  SKIN.  8G1 

])nK'ti('(\  Women  cxliiWit  tlit'iu  oi'teiuT  than  men.  The  jxipiilos  arc 
about  the  size  of  a  piiihcad,  and  when  seen  in  tlieir  conipletest  expres- 
sion are  thickly  set  over  the  entire  body  suri'aee.  There  is  nsnallv  no 
subjective  sensation,  but  patients  sometimes  complain  of  sli<z,ht  itching 
or  burning.  The  papules  are  conical  in  form,  and  the  summit  may  be 
capi)ed  by  a  minut(>  scale  or  be  the  seat  of  a  tiny  vesicle.  Jnvolvement 
of  the  hair  follicK'  fre(juently  occurs,  and  the  papule  is  then  pierced  l>v 
the  hair  fihunent.  Limitation  of  the  miliary  |)apules  to  exposc^d  sur- 
faces, such  as  the  face  and  the  hands,  s(jmetimes  takes  place,  while  the 
parts  of  the  body  protected  by  the  clothing  are  the  seat  of  much  larger 
varieties.  In  cachectic  and  anaemic  patients  the  appearance  of  a  crop 
of  miliary  pajniles  is  often  the  precursor  of.  an  extensive  pustular 
syphiloderni  soon  to  follow. 

Lenticular  papules  are  the  most  frequently  met  with  of  any  of  the 
early  syi)liilodermata.  They  are  liable  to  occur  at  any  time  during  the 
first  two  years  after  infection,  and  may  appear  at  a  still  later  period. 
They  vary  in  size  from  a  large  pinhead  to  a  coffee  bean,  have  a  flat- 
tened or  rounded  surface,  are  seldom  much  elevated,  and  are  frequently 
surrounded  by  a  fringe  of  scales  known  as  the  corona  veneris.  The 
base  of  the  papule  is  usually  quite  firmly  indurated.  The  summit  is 
smooth  and  glistening  or  capped  with  a  thin  firmly  adherent  scale. 
Often  the  papules  are  so  slightly  elevated  as  to  be  distinguishable  from 
macular  lesions  only  by  the  sense  of  touch.  Such  lesions  are  known  as 
maculo-papules,  or  the  summit  may  be  converted  into  a  pustule  without 
the  base  undergoing  any  change,  the  lesion  then  being  called  a  papulo- 
pustule. 

In  syphilis  scaling  papules  are  frequently  met  with  that  are  difficult 
for  any  but  the  expert  to  distinguish  from  the  lesions  of  j)Soriasis.  The 
scales  here  lack  the  lustrous  appearance  presented  in  psoriasis  and  are 
not  so  freely  shed.  On  the  contrary,  they  are  frequently  so  firmly 
attached  to  the  surface  as  to  require  some  force  on  removal,  and  when 
the  scale  is  lifted  away  there  are  no  minute  bleeding  points  found 
beneath  as  in  the  psoriatic  lesion.  Other  lesions  can  usually  be  found 
in  the  near  neighborhood  or  elsewhere  upon  the  surface  of  the  body 
that  are  unmistakably  syphilitic. 

Papules  frequently  appear  in  the  palms  and  on  the  soles,  and  in  such 
localities  present  features  somewhat  different  from  any  shown  in  other 
parts.  This  is  owing  to  the  density  of  the  epidermal  coverings  in  the 
regions  named.  Instead  of  involving  the  epidermal  layers  thronghout, 
as  is  usually  the  case,  they  here  appear  to  be  buried  beneath  the  epi- 
dermis or  confined  at  least  to  its  lower  strata.  Later  they  make  their 
way  to  the  surface  and  become  true  scaling  paj^ules,  not  at  all  or  only 
slightly  elevated.  •  The  epidermis  covering  the  centre  of  the  lesion  is 
first  cast  off,  thus  giving  to  its  summit  a  pitlike  depression.  The  edge 
of  this  depression  is  surrounded,  by  a  fringe  of  torn  and  dirty  looking 
epithelium.  The  centres  of  the  palms  and  soles  are  the  parts  usually 
first  to  be  affected.  Later  the  papules  by  peripheral  extension  and 
coalescence  may  form  scaling  patches  covering  surfaces  as  large  as,  or 
larger  than,  a  silver  dollar,  or  they  may  remain  as  distinct  and  discrete 
papules,  wdiile  thickly  studding  the  surface.  Extension  to  the  digits 
may  take    place.      They  are  not    often    productive    of  any  sensation. 


862  SYPHILIS. 

Frequently  they  appear  with  the  first  exaiithem,  and  persist  during  a 
part  or  the  Avhole  of  the  course  of  the  disease,  or  they  may  appear  after 
all  other  symptoms  of  the  malady  have  vanished,  and  continue  for  a 
number  of  years  in  spite  of  vigorous  and  energetic  treatment.  The 
eruption  is  usually  symmetrical,  but  the  right  hand  is  the  one  most  apt 
to  be  severely  affected. 

Moist  Papules. — Papules  presenting  a  moist  and  secreting  surface 
are  found  upon  the  skin  in  situations  favoring  such  development. 
Warmth  and  moisture  are  necessary  conditions,  and  such  factors  are 
found  in  the  axillae,  between  the  nates,  in  the  perineal  region,  between 
the  scrotum  and  thigh,  within  the  lips  of  the  vulva,  and  underneath 
the  overhanging  breasts  of  fleshy  women.  Here  the  papules  begin  as 
in  the  dry  form,  but  are  quickly  converted  into  lesions  little  or  not  at 
all  elevated,  and  having  a  circumscribed  eroded  surface  secreting  a 
sticky,  mucilaginous  fluid.  Sometimes  they  are  covered  by  a  grayish 
pellicle  looking  much  like  diphtheritic  membrane.  The  lesions  when 
plentiful  and  fully  develoj^ed  give  forth  an  almost  unbearable  odor. 
This  form  of  moist  papule  differs  in  no  wise  from  mucous  patches  seen 
within  the  mouth  cavity.  Its  structure,  development,  and  complete 
evolution  are  the  same  as  the  mucous  patch,  and  it  is  frequently  called 
by  the  same  name. 

About  the  mucous  outlets  of  the  body  a  different  kind  of  moist 
papule  is  apt  to  form.  This  variety  is  characterized  by  hyperplasia  of 
the  cell  elements,  with  consequent  elevation  of  the  resulting  lesion. 
Papules  of  this  kind  are  known  as  condylomata  and  occur  in  either  a 
flat  or  pointed  form. 

Flat  condylomata  appear  as  eminences  varying  in  size  from  a  ten- 
cent  piece  to  a  silver  dollar,  and  having  a  whitish  or  grayish  white, 
macerated  surface  bathed  in  a  tenacious,  mucoid  fluid  or  covered  with 
an  adherent  grayish  pellicle.  The  secretion  is  extremely  offensive  in 
odor  and  in  the  highest  degree  infectious.  Often  the  irritating  effects 
of  the  secretion  beget  a  similar  lesion  upon  the  apposed  surface  when 
the  condyloma  is  between  the  buttocks,  so  that  two  lesions  of  like  nature 
are  brought  face  to  face.  This  form  of  condylomata  may  be  single  or 
multiple.  Frequently  the  lesions  form  a  complete  collarette  about  the 
anal  or  vulvar  openings.  They  are  often  the  seat  of  intense  itching 
and  burning  sensations,  and  productive  of  the  greatest  discomfort. 
Flat  condylomata  are  absolutely  diagnostic  of  syphilis. 

Pointed  condylomata,  or  venereal  warts,  seen  so  often  in  syphilitic 
subjects,  differ  from  the  preceding  form,  not  only  in  their  character  and 
appearance,  but  in  the  fact  that  they  are  not  strictly  syphilitic  lesions. 
They  are  produced  at  any  time  when  the  parts  are  subjected  to  undue 
and  long  continued  irritation,  such  as  happens  when  pathological  dis- 
charges like  those  of  gonorrhoea  and  leucorrhcea  flow  over  the  vulva, 
over  the  perineum,  and  over  the  anus,  or,  in  the  male,  are  imprisoned 
beneath  the  foreskin.  Secretions  from  certain  syphilitic  lesions,  such  as 
moist  papules  and  flat  condylomata,  give  rise  to  them  as  well.  Hence 
it  happens  that  they  are  found  accompanying  true  lesions  of  syphilis  as 
an  accident  only  of  the  process.  It  is  important,  therefore,  that  too 
much  significance  should  not  be  attached  to  this  form  of  condylomata  in 
determining  the  presence  or  absence  of  syphilis. 


sYpnrfjs  OF  THE  Sk'fx.  863 

One  or  inniiv  of  these  pointed  |>;ii)iiles  may  he  jireseiil.  They  are 
filitbrni  or  eonieal  in  shaj)t',  with  a  hroad  or  narrow  hase  and  a  tufted 
apex.  When  nudtiph'  they  frecpiently  form  mas.scs  as  hirge  as  a  jjood- 
sizod  hen's  egg-.  Inspeetion  t)f  sueh  mass  always  shows  it  to  be  made 
nj)  of  a  great  niunher  of  distinct  and  individnal  wartlike  strnetures. 
The  lesions  may  be  dry,  but  are  usnally  covered  with  moisture.  This 
mav  be  a  true  secretion  on  the  part  of  the  wart  or  be  sweat  arising  from 
the  warmth  of  the  part.  The  lesions  are  a[)t  to  bleed  readily  and  freely 
upon  the  slightest  irritation  or  surgical  interference.  The  sidcus  coro- 
narius  in  the  male  and  the  inner  surface  of  the  labia  majora  and  minora 
in  the  female  are  often  the  sites  of  their  occurrence. 

Absolute  cleanliness  and  the  use  of  disinfecting  solutions,  such  as 
l)oric  acid,  corrosive  sublimate,  and  permanganate  of  potassium,  are  the 
essentials  in  treatment.  If  persistent,  the  lesions  may  be  snipped  oif 
with  a  pair  of  scissors  or  removed  with  a  curette,  and  the  base  then  be 
touched  with  a  pencil  of  silver  nitrate  or  a  drop  of  carbolic  acid. 

Pustules. — Pustules  are  frequently  met  Avith  in  syphilis.  They  occur 
oftenest  in  the  ill  fed,  unclean,  debilitated  subjects  seen  in  public  prac- 
tice. Well  cared-for  patients  seldom  exhibit  them.  This  fact  strongly 
suggests  their  being  an  accident  rather  than  a  definite  symptom  of 
syphilis,  and  such  belief  is  gaining  ground  among  syphilographers. 
Pustules  are  usually  developed  from  papules.  They  seldom  appear  as 
elementary  lesions.  The  summit  of  the  papule  is  first  converted  into  a 
minute  vesicle.  As  this  enlarges  its  contents  become  turbid,  and  then 
pustular.  The  pustule  may  be  confined  to  the  apex  of  the  papule, 
occupying  only  that  space  first  showu  in  the  vesicle,  or  the  entire 
papule  may  become  involved  in  the  process.  Pustules  mav  appear 
on  any  part  of  the  body.  In  the  early  stages  of  the  disease  they  are 
apt  to  be  symmetrical  and  extensive  in  their  distribution.  Later  they 
appear  in  groups  having  a  circinate  arrangement. 

The  pustules  vary  in  size  from  a  pinhead  to  a  pea.  Early  in  the 
course  of  the  disease  they  are  small,  and  more  abundantly  developed 
than  when  occurring  at  later  periods.  When  first  appearing  they  are 
discrete,  but  later  may  become  confluent  and  give  rise  to  superficial  or 
deep  ulcers.  The  lesions  may  be  clustered  in  circinate  groups  or  be 
distributed  freely  without  definite  arrangement.  Frequently  they  in- 
volve the  hair  follicle,  especially  on  the  face  and  scUlp.  A  dull  ham- 
red  areola  is  often  distinguishable  at  the  base  of  the  pustule  or  of  the 
papule  on  which  the  pustule  rests.  When  ulceration  does  not  follow, 
the  pustules  disappear  and  exfoliation  of  the  epidermal  coverings  takes 
place.  If  the  pustules  have  been  large  and  deep,  well  marked  cicatrices 
are  left  as  relics  of  the  troulole.  Pigmentation  frequently  occurs,  the 
stain  having  a  dark  coppery  hue. 

Ulcers  arise  by  coalescence  of  a  number  of  pustules  or  by  enlarge- 
ment of  individual  lesions.  They  are  apt  to  occur  late  in  the  disease 
and  in  cachectic  and  anaemic  subjects.  Only  the  superficial  layers  of 
the  epidermis  may  be  involved  in  the  process,  or  the  ulcer  may  burrow 
deeply  into  the  skin  and  subcutaneous  tissue.  Superficial  ulcers  are 
usually  small,  not  often  increasing  much  beyond  a  ten-cent  piece  in  size. 
The  base  is  indurated  and  the  ulcer  is  covered  by  a  light,  friable, 
greenish  yellow  or  dirty  looking  crust. 


864  SYPHILIS.  ■ 

In  the  later  stages  of  syphilis,  or  early  when  the  disease  is  pursuing 
a  severe  course,  large  pustules  occurring  in  groups  of  half  a  dozen  or 
more  may  appear  at  different  sites  upon  the  body.  These  pustules  unite 
and  form  what  is  known  as  the  pustulo-ulcerative  syphiloderm.  This 
ulcer  is  deeply  seated,  frequently  painful,  and  secretes  pus  in  abundance. 
It  is  capped  by  a  large  dark  green  or  brownish  crust,  underneath  which 
a  well  of  blood  and  pus  can  always  be  discovered.  The  pus  dries 
readily,  and  the  resulting  crust  is  more  or  less  firmly  adherent  to  the 
edge  of  the  ulcer.  When  the  crust  is  removed  and  the  lesion  cleaned 
of  its  contents,  the  ulcer  shows  a  punched-out  appearance.  The  sides 
are  j)recipitous  and  the  base  is  uneven  and  granular.  Such  ulcers  leave 
a  deforming  cicatrix  unmistakable  to  the  eye  of  the  trained  observer. 

Bupia  is  a  term  employed  to  designate  ulcers  occurring  in  syphilis 
in  which  the  crusts  assume  a  conical  or  oyster-shell  shape.  The  crust 
is  made  up  of  a  number  of  layers,  the  one  at  the  bottom  covering  the 
greatest  extent,  and  each  succeeding  layer  becoming  smaller  as  the 
summit  is  approached.  The  crusts  may  reach  an  inch  or  more  in 
height  and  cover  an  area  as  large  as  a  silver  half  dollar.  They  are 
produced  by  successive  additions  to  the  crust  from  beneath,  while  the 
ulcer  enlarges  peripherally.  The  layer  at  the  top  represents  the  first 
one  formed.  The  ulcer  may  be  superficial  or  deep.  Rupia  occurs  only 
in  uncleanly,  uncared-for  subjects,  and  generally  indicates  a  severe  and 
persistent  type  of  the  disease. 

Tubercles. — Tubercles  are  of  frequent  occurrence  in  syphilis.  They 
may  appear  at  any  time  in  the  course  of  the  disease  after  the  expiration 
of  the  first  three  months,  but  are  seen  more  frequently  in  late  rather 
than  in  early  stages  of  the  malady.  They  occur  oftenest  in  those  cases 
in  which  early  treatment  has  been  improperly  conducted  or  entirely 
neglected. 

Tubercles  differ  but  little  in  their  characteristics  from  gummata. 
They  are  apt,  however,  to  occur  at  a  somewhat  earlier  stage  and  to  run 
a  milder  and  more  tractable  course.  They  also  appear  in  greater  number 
and  involve  the  skin  less  deeply.  But  in  the  clinical  features  that  they 
present  it  is  often  a  matter  of  considerable  difficulty  to  distinguish  them 
from  the  gummy  tumors  (Plate  XL). 

Tubercles  may  appear  upon  any  part  of  the  body  surface,  but  are 
found  most  frequently  upon  the  face  and  the  extremities.  The  tip  of 
the  chin,  the  alse  of  the  nose,  and  the  integument  covering  the  knee  and 
elbow  joints  are  favorite  sites  for  their  occurrence.  They  may  occur 
singly,  but  usually  develop  in  groups  of  half  a  dozen  or  more.  They 
appear  as  small  pea-  to  bean-sized  nodules,  set  well  within  the  tissues  of 
the  skin,  and  present  externally  a  globoid  surface.  They  are  firm  to 
the  touch,  and  in  the  earlier  course  of  their  development  are  usually 
painless.  In  color  they  vary  from  a  dark  red  to  a  coppery  hue.  Their 
color  varies  with  any  change  in  the  blood  supply  of  the  part,  such  as  is 
apt  to  ensue  after  violent  exertion.  There  is  then  a  decided  deepening 
of  the  previous  stain.  The  circular  form  of  grouping  distinctive  of  syphi- 
litic lesions  is  here  frequently  met  with.  Often  extension  of  the  process 
is  by  the  formation  of  new  rings  about  or  in  conjunction  with  similarly 
formed  groups.  In  this  way  figure-of-8  and  other  odd  looking  arrange- 
ments are  formed. 


PLATE    XI. 


Tubercular  Syphiloderin,  Resolutive  and  Serpiginous.     (Hyde. 
From  a  photograph  of  a  hospital  patient. 


SYPirilJS   OF   THK  SKIN.  805 

'riil)('rol(>s  (litt'cr  niuch  in  thf  ooiirst'  that  they  pursue  and  in  the 
manner  in  whk-h  resohition  takes  })hi('e.  Fre([uently  the  h-sion  under- 
goes degeneration,  .and  absorption  of  its  products  takes  phice  witliout 
destruction  of  the  overlying  integument.  This  happens  frequently  upon 
the  face.  In  such  cases  there  is  the  formation  of  a  true  scar  without 
breaking  down  and  removal  of  the  epidermal  layers.  The  scar  is  de- 
pressed and  oftentimes  pigmented.  The  pigment  usually  disai)])ears  in 
the  course  of  time.  Sometimes  resolution  occurs  in  this  manner  in  one 
part  of  the  group  while  the  lesions  in  another  part  are  still  in  full  pro- 
cess of  development. 

Degenei'ation  and  destruction  of  the  tubercle  by  ulceration  is  a  fre- 
quent method  of  its  removal.  Softening  of  the  summit  occurs,  the 
roof  wall  breaks  down,  and  the  degenerated  products  of  the  lesion  are 
discharged.  The  ulceration  goes  on  to  complete  removal  of  the  tuber- 
cle, and  may  extend  much  more  deeply  into  the  tissues.  In  this  latter 
case  the  deep  extension  of  the  ulcerative  process  is  undoubtedly  due  to 
gummatous  infiltration  of  the  tissues  about  and  below  the  tubercle 
proper.  After  destruction  of  the  tubercle  is  complete,  repair  ensues 
by  the  formation  of  a  cicatrix.  Frequently,  where  the  process  is 
unrecognized  and  unchecked,  the  lesions  continue  to  develop  in  circles 
or  parts  of  circles  about  the  sites  of  existing  tubercles,  each  new  crop 
gradually  enlarging  the  area  affected.  In  this  way  patches  may  be 
formed  covering  the  greater  extent  of  the  forearm,  the  thigh,  or  one  or 
both  buttocks.  At  the  border  of  the  area  is  the  line  of  advancing 
tubercles,  many  of  them  in  a  state  of  ulceration,  while  within,  the 
process  is  represented  only  by  the  lesion  relics  of  the  disease  in  the 
form  of  scar  tissue.  The  process  is  extremely  indolent,  and  in  many 
cases  may  continue  for  a  number  of  years. 

Gummata. — Gummata  usually  occur  in  the  skin  late  in  the  course  of 
the  disease.  In  malignant  cases  or  where  the  progress  of  the  malady  is 
rapid  and  destructive  they  may  appear  \vithin  the  first  six  months  after 
infection.  They  present  the  appearance  of  firm  nodules  deeply  set 
within  the  skin  or  subcutaneous  tissue.  At  first  they  are  freely  mov- 
able over  the  deeper  structures  and  within  the  skin  itself,  but  later  they 
become  attached  to  the  underlying  periosteum,  bones,  cartilage,  or 
muscles.  The  skin  becomes  reddened  and  inflamed,  finally  breaking 
down  and  permitting  the  discharge  of  the  gummy  mass.  Gummata 
vary  in  size  from  a  pea  to  an  orange.  They  are  spherical  or  globoid  in 
shape,  or  may  be  flattened  and  irregular  in  outline.  In  their  earlier 
stages  they  are  sensitive  in  a  slight  degree  only,  but  later  they  become 
extremely  tender  and  painful.  They  are  usually  single  or  but  few  in 
number.  Rarely  they  occur  in  great  numbers,  as  hundreds  in  one 
subject.  Any  part  of  the  body  surface  may  be  the  seat  of  gummata, 
but  they  are  seen  with  greatest  frequency  upon  the  lower  limbs  and  the 
integument  of  the  forehead  and  scalp.  The  effect  of  gravity  acting 
upon  the  blood  no  doubt  influences  their  frequent  development  upon 
the  limbs. 

The  tendency  of  gummata  wherever  occurring  is  toward  ulceration 
and  destruction  of  the  part.  This  may  occur  in  the  skin  with  startling 
rapidity,  a  few  days  only  sufficing  for  complete  softening  and  removal 
of  the  tissues  affected  ;  or  the  lesion  may  persist  for  weeks  and  months, 

Vol.  I. — 55 


866  SYPHILIS. 

with  no  evidence  of  change  occurring  in  its  substance  save  that  of 
gradual  enlargement.  Frequently  the  gumma  extends  deeply  into  the 
tissues,  involving  muscle,  bone,  and  cartilage  in  its  destructive  course. 
When  this  occurs  upon  the  face  frightful  deformities  are  likely  to  result. 
Thus  the  cartilages  and  bones  of  the  nose  may  be  attacked  and  entirely 
destroyed,  or  the  lobe  of  the  ear  be  in  part  or  wholly  removed.  The 
severitA^  of  the  process  can  only  be  likened  to  the  ravages  made  in  the 
same  region  by  malignant  disease.  The  importance  of  early  recognition 
of  the  condition  is  apparent. 

Ulcers  resulting  from  the  destruction  of  gummata  are  apt  to  be 
sluggish  and  indolent  in  their  deportment.  Their  size  is  determined 
by  the  lesion  from  which  they  arise.  They  are  circular,  oval,  or 
irregular  in  outline.  The  edges  may  be  thickened  or  undermined,  the 
sides  precipitous,  and  the  floor  uneven,  foul,  and  dirty  with  Ijrown  or 
greenish  colored  pus.  In  cachectic  and  poorly  nourished  patients  such 
ulcers  may  become  the  seat  of  gangrene.  "When  the  necrotic  mass  is 
entirely  eliminated  the  ulcerative  process  ends  and  repair  begins. 
Healthy  granulations  cover  the  floor  and  sides  of  the  ulcer,  the  thick- 
ened edge  is  smoothed  out,  and  the  process  is  completed  by  the  forma- 
tion of  a  cicatrix.  This  cicatrix  is  circular  in  outline,  smooth,  white  in 
the  centre  and  pigmented  at  the  border.  The  scar  is  deep  and  firm, 
usually  being  attached  to  the  parts  beneath.  Its  recognition  is  fre- 
quently ©f  great  value  in  establishing  a  diagnosis  of  preceding  syphilis. 

At  times  a  diffuse  gummatous  infiltration  of  the  skin  or  subcutaneous 
tissue  takes  place.  This  is  apt  to  occur  over  the  back  or  upon  the  lower 
extremities,  as  the  parts  of  the  leg  between  the  knee  and  ankle.  The 
skin  becomes  reddened,  swollen,  tumefied,  and  sodden.  Xodules  ai)pear 
at  various  points,  break  down  quickly,  and  discharge  their  typical 
gummy  exudate.  The  process  if  unrecognized  may  go  on  for  long 
periods  of  time,  resulting  in  great  thickening  of  the  integument  and  the 
production  of  abundant  scar  tissue,  or  the  entire  gummatous  area  may 
break  down,  forming  a  single  gigantic  ulcer.  Upon  the  abdomen  gum- 
matous infiltration  is  apt  to  result  in  a  serpiginous  ulcer.  Gummata  are, 
however,  rare  in  this  location.  In  the  genital  region  such  infiltration 
results  in  contraction  and  deformity  of  the  penile  organ  or  in  narrow- 
ing of  the  entrance  to  the  vagina. 

Affections  of  the  Hair  due  to  Syphilis. — The  hair  is  frequently 
affected  in  the  course  of  syphilis.  The  nutrition  of  the  filaments  may 
be  impaired  in  so  slight  a  degree  as  to  give  rise  only  to  a  certain  amount 
of  dryness  and  lack  of  lustre,  or  the  process  may  be  so  severe  as  to  bring 
about  an  extreme  and  deforming  alopecia.  These  syphilitic  alopecias 
are  important  from  a  diagnostic  standpoint  because  of  the  help  they 
furnish  in  arriving  at  exact  conclusions  regarding  the  existence  of  the 
disease.  They  appear  as  the  result  of  one  of  two  processes  :  either  the 
hair  falls  as  the  result  of  defective  nutrition,  with  no  structural  change 
occurring  in  the  part  from  which  it  arises,  or  there  is  a  preceding  organic 
change  in  such  part.  The  alopecia  in  the  first  form  may  be  said  to  be 
due  to  a  primary  process,  while  in  the  other  it  is  secondary. 

In  the  primars^  form  the  hair  may  come  out  slowly  or  very  abruptly. 
There  may  be  a  gradual  thinning  of  the  hair  of  the  scalp  and  of  other 
parts  of  the  body,  a  few  filaments  only  coming  away  each  day,  mitil  the 


SY  riff  US  OF  THE  NATLS.  867 

complote  loss  bceomcs  decidedly  apparent,  or  the  process  may  be  cha- 
racterized l)v  the  development  of  numerous  bald  patches  no  larj^er  in 
size  than  a  ten-cent  piece.  A\  hen  these  patches  occur  upon  the  scalp 
they  affect  the  back  and  sides  of"  the  head  more  than  other  parts.  In 
these  regions  the  bald  areas  are  set  so  thickly  as  to  alm<tst  occupy  the 
entire  surface.  They  give  to  the  hair  of  the  head  a  characteristic 
"ragged"  appearance  not  seen  in  any  other  form  of  baldness.  The 
patches  are  irregular  in  shape  ;  the  surface  is  scaly  and  often  set  with 
a  few  dead  stumps  of  hairs,  as  in  ringworm,  and  the  color  is  a  dead 
grayish  white.  The  eyebrows,  beard,  hairs  of  the  pubic  region  and  of 
the  axilhe  may  share  in  the  process.  Usually  the  hair  in  these  parts 
does  not  fall  independently  of  that  on  the  head.  The  loss  is  apt  to 
be  asymmetrical,  and,  when  this  occurs  iu  the  case  of  the  eyebrows  or 
beard,  results  in  peculiar  disfigurement.  The  eyelashes  are  not  often 
affected.  The  hairs  remaining  are  loosened  and  can  be  readily  removed 
from  their  pouches.  This  form  of  syphilitic  alopecia  is  by  far  the  most 
common  and  occurs  most  frequently  in  the  early  stages  of  the  disease, 
accompanying  or  shortly  following  the  appearance  of  the  exanthemata. 
AVliile  productive  of  much  mental  discomfort,  it  is  not  a  serious  mis- 
fortune, as  the  hair  is  always  replaced  under  simple  and  appropriate 
treatment. 

The  secondary  form  of  syphilitic  alopecia  results  from  previous 
changes  in  the  integument  due  to  the  presence  of  syphilodermata. 
Such  syphilodermata  may  be  in  the  form  of  macules,  papules,  pustules, 
tubercles,  ulcers,  or  gummatous  infiltration.  The  loss  of  hair  occurs  as 
the  result  of  partial  or  complete  destruction  of  the  hair  follicle.  The 
process  belongs  to  a  late  period  of  the  disease,  but  in  severe  forms  of 
syphilis  it  may  occur  early.  The  alopecia  is  permanent  if  the  hair  fol- 
licles be  entirely  destroyed.  If  destruction  is  not  complete,  there  may 
be  a  partial  and  stunted  growth.  The  scalp  is  the  part  usually  affected 
and  in  limited  areas  only. 

Syphilis  of  the  Nails. — Syphilis  may  attack  the  nails  at  any  time 
in  the  course  of  the  disease.  The  affection  may  begin  in  the  nail  itself, 
and  its  manifestations  throughout  be  confined  to  the  nail  substance,  or 
it  may  begin  in  the  soft  parts  and  later  extend  to  the  nail  tissue.  The 
first  form  is  called  syphilitic  onychia,  and  the  second  syphilitic  paronychia. 
Syphilitic  Onychia. — Changes  in  the  nail  substance  are  characterized 
by  loss  of  lustre,  formation  of  puncta,  striae,  brittleness,  and  deformity. 
These  changes  are  due  to  disturbances  in  nutrition,  and  are  common  in 
the  earlier  periods  of  the  disease.  Careful  examination  of  the  nails  shortly 
after  the  outbreak  of  constitutional  manifestations  will  usually  show  per- 
ceptible changes  in  their  structure  and  appearance.  The  nail  often  ap- 
pears dead,  and  along  its  border  a  pale  Avhite  line  shows  where  nutritional 
changes  are  taking  place.  With  the  atrophic  condition  there  may  be  an 
accompanying  hyjiertrophy  of  parts  of  the  nail,  leading  to  the  formation 
of  longitudinal  lines  and  ridges  much  elevated  above  the  surface  ;  or  the 
nail  may  be  greatly  thickened  throughout,  while  over  the  surface  cha- 
racteristic striffi  and  puncta,  due  to  the  accompanying  atrophic  condition, 
can  be  detected.  These  changes  may  lead  to  complete  or  partial  re- 
moval of  the  nail.  One  or  all  of  the  nails  may  suffer.  The  nails  of 
the  fingers  and  those  of  the  great  toes  are  most  frequently  attacked, 


868  SYPHILIS. 

Syphilitic  Paronychia. — This  form  begins  as  an  inflammatory  con- 
dition at  the  base  or  sides  of  the  nail.  It  may  be  superficial,  only  the 
epidermal  structures  being  involved,  or  it  may  extend  so  deeply  as  to 
involve  the  distal  phalanges  of  the  digits.  The  parts  are  greatly  thick- 
ened, and  at  times  there  is  the  production  of  a  mass  of  new  tissue  hav- 
ing a  decidedly  verrucous  appearance.  Fissures  and  excoriations  form 
and  the  part  may  become  exceedingly  tender.  The  nail  is  affected  as 
described  under  Syphilitic  Onychia.  It  is  usually  first  elevated  at  one 
side,  and  then  gradually  pushed  off".  The  process  may  occur  at  any  time 
during  the  first  two  years  after  infection.  The  nails  of  the  fingers  suffer 
more  frequently  than  do  those  of  the  toes,  owing  probably  to  their  ex- 
posed position  and  their  greater  liability  to  injury.  The  process  is  apt 
to  pursue  an  indolent  course,  but  the  final  results  of  energetic  treatment 
are  good,  and  in  the  end  the  integrity  of  the  nail  is  restored. 

Syphilis  of  the  Mouth  and  Tongue. — Syphilitic  affections  of  the 
mouth  and  tongue  are  of  frequent  occurrence.  The  nature  of  lesions 
appearing  in  the  mouth  and  tongue  demands  early  recognition  owing  to 
the  extremely  infectious  nature  of  the  secretions  they  furnish  and  the 
ready  means  by  which  the  virus  can  be  transmitted  from  these  parts  to 
sound  individuals.  Any  of  the  various  lesions  displayed  upon  the  skin 
during  the  entire  course  of  the  disease  may  appear  upon  the  mucous 
membranes  of  the  mouth  and  throat.  They  are  modified  somewhat  by 
varying  conditions  of  heat,  moisture,  and  friction  to  which  they  are  here 
subjected.  Frequently  they  pursue  an  obstinate  and  intractable  course, 
and  at  times  occasion  a  marked  degree  of  distress.  Often  the  mouth 
cavity  shows  the  only  evidence  that  the  individual  is  affected  with  or  is 
still  suffering  from  syphilis,  and  the  lesion  relics  in  the  form  of  cavities 
and  scars  remaining  after  the  disease  displays  no  fiu*ther  active  manifes- 
tations furnish  valuable  evidence  as  to  its  previous  existence. 

The  initial  sclerosis  is  found  upon  the  lips  or  Avithin  the  mouth  cavity 
with  greater  frequency  than  upon  any  other  portion  of  the  body,  except- 
ing the  genital  region.  Its  occurrence  here  is  not  in  the  innocent  only, 
but  is  frequently  the  result  of  vile  and  disgusting  practices.  Chancres 
appear  upon  the  lips  having  the  t}q3ical  features  elsewhere  described. 
They  are  usually  single,  but  may  be  double,  one  appearing  upon  either 
lip  in  direct  apposition  to  each  other.  The  lower  lip  and  the  median 
line  furnish  the  site  of  their  most  frequent  occurrence.  Fissures,  cold 
sores,  and  cigarette-burns  upon  the  border  of  the  lip  often  furnish  the 
solutions  of  continuity  through  which  the  poison  enters.  The  pre-exist- 
ence  of  such  lesions  modifies  in  a  measure  the  features  presented  by  the 
developing  chancre. 

Chancre  of  the  tongue  occurs  either  at  the  tip  or  upon  its  anterior 
half.  The  lesion  usually  appears  as  an  erosion  or  as  a  nodule  super- 
ficially seated  and  indolent  in  its  course.  Induration  is  marked  if  the 
tip  of  the  tongue  be  its  seat,  but  if  placed  upon  the  dorsum  or  sides  it 
may  be  slight  and  easily  overlooked.  The  submaxillary  and  subhyoid 
glands  enlarge  and  the  degree  of  induration  is  often  very  great.  It  is 
important  that  the  chancre  should  be  distinguished  from  tuberculosis 
and  cancer,  both  of  which  are  apt  to  occur  in  these  situations.  la 
tuberculosis  the  onset  of  the  malady  is  slow,  the  lesion  is  very  painful, 
and  the  accompanying  glandular  enlargement  is  slight.     Discovery  of 


SYPHILIS  OF   Till-:  Morn  I   AM)    TONGUE.  869 

tubercle  bacilli  in  the  lcsii)n  or  its  .secretions  definitely  determines  the 
diaonosis.  Cancer  is  more  difficult  to  distinguish.  It  begins  as  a 
nodule  and  its  acconipanving  adenopathy  is  great.  Its  development  is 
slow,  and  it  occurs  usually  in  individuals  well  past  middle  life,  while 
svphilis  is  apt  to  occur  before  that  ])eri()d  is  reached.  Cancer  is  seen  in 
tobacco  smokers,  the  site  of"  the  lesion  being  that  part  of  the  tongue 
coming  in  contiict  with  the  tip  of  the  cigar  or  pipe.  Cancer  of  the  lip 
occurs  most  frequently  near  the  angle  of  the  mouth,  while  chancre,  as 
has  been  noted,  appears  near  the  median  line.  A  short  delay,  with  or 
without  the  exhibition  of  mercurials,  will  involve  no  })eril  and  will 
enable  the  physician  to  reach  a  satisfactory  and  conclusive  diagnosis. 

The  tonsil  is  the  occasional  seat  of  chancre.  The  lesion  here  presents 
no  constant  and  characteristic  features  because  of  the  peculiar  formation 
of  the  tonsillar  tissue,  this  differing  in  each  individual.  There  is  usually 
much  distress  in  swallowing,  and  the  pain  may  often  be  continuous  and 
severe.  The  neighboring  ganglia  in  the  neck  become  very  much  en- 
larged and  densely  indurated.  Induration  of  the  tonsil  sometimes 
occurs,  but  is  not  constant.  Considerable  difficulty  is  sometimes  ex- 
perienced in  distinguishing  between  the  malady  and  a  chronic  tonsillitis. 
In  tonsillitis  there  is  usually  a  history  of  previous  attacks,  and  an  accom- 
panying coryza  wdth  a  greater  or  less  degree  of  temperature.  There  is 
but  slight  enlargement  of  the  glands  in  the  neck,  and  these  are  tender 
and  painful  to  the  touch. 

Chancres  may  appear  upon  the  gums,  cheeks,  or  soft  palate,  but  are 
exceedingly  rare  in  these  situations.  Chancres  of  the  lips  and  mouth 
cavity  are  liable  to  persist  until  the  development  of  constitutional 
syphilis,  and  then  to  be  converted  into  moist  papules  or  mucous 
patches  of  the  parts. 

Constitutional  syphilis  may  be  represented  in  the  mouth  by  macules, 
papules,  pustules,  tubercles,  ulcers,  and  gummata.  Hypersemia  of  the 
pharynx,  fauces,  and  soft  palate  occurs  with  or  shortly  after  the  appear- 
ance of  the  erythematous  syphiloderm.  The  hyperemia  is  bright  or 
dark  red  in  color,  usually  extensive,  and  diffuse  or  bordered  by  well 
defined  outlines.  It  may  also  appear  in  spots  varying  in  size  from  a 
pin-head  to  a  ten-cent  piece.  These  spots  may  be  few  in  number  or 
scattered  thickly  over  the  walls  of  the  pharynx,  cheeks,  and  roof  of  the 
mouth.  The  throat  is  dry,  and  is  the  seat  of  somewhat  painful  and 
uncomfortable  sensations.  Deglutition  is  accompanied  by  considerable 
distress.  The  hypersemic  condition  usually  subsides  quickly  under 
treatment.  Mucous  patches  or  ulcerative  lesions  of  severe  type  may 
follow.  The  delicate,  moist  epithelium  may  be  removed  by  macera- 
tion, with  the  production  of  raw-looking  ham-red  patches  varying  in 
size  from  a  pin-head  to  a  ten-cent  piece.  The  ulcers  are  oval  or  linear 
in  shape  and  have  a  punched-out  appearance,  with  a  grayish  pus-secret- 
ing floor. 

Papules  are  represented  in  the  mouth  by  the  mucous  patch.  That 
there  is  no  distinction  to  be  made  between  the  two  is  evidenced  by  the 
readiness  with  which  the  papule  occurring  on  the  skin  when  subjected 
to  heat  and  moisture  is  made  to  take  on  characteristics  that  render  it  in 
no  wise  distinguishable  from  the  mucous  patch  in  the  mouth.  These 
mucous  patches  may  be  the  result  of  transformation  of  a  chancre  occur- 


870  SYPHILIS. 

ring  iu  the  part,  as  has  been  noted,  or  they  may  develop  independently 
and  primarily.  They  then  begin  as  reddened,  circumscribed  macules  in 
the  mucous  membrane.  Elevation,  due  to  multiplication  of  the  cells  in 
the  substance  of  the  lesion,  soon  follows.  Removal  of  the  epithelial 
covering  by  maceration  and  friction  follows,  and  the  lesion  takes  on  a 
grayish  white  appearance,  as  if  the  part  had  been  touched  by  a  pencil 
of  silver  nitrate.  Mucous  patches  occur  singly  or  in  groups.  Often 
they  come  in  successive  crops.  Coalescence  may  ensue,  with  the  for- 
mation of  an  irregular  patch  varying  much  in  size.  Neglected  cases 
frequently  show  the  entire  roof  wall  of  the  mouth  or  the  inner  surface 
of  the  cheek  covered  bv  a  lesion  of  this  nature.  Patches  occurring^ 
tipon  the  cheek  or  tongue  are  apt  to  beget  like  lesions  upon  the  surfaces 
with  which  they  come  in  contact.  Favorite  sites  for  their  appearance 
are  just  wdthin  the  angles  of  the  mouth  and  underneath  the  tongue. 
When  occurring  upon  the  surface  of  the  tongue  they  frequently  have  a 
glistening,  shiny  look,  and  may  appear  depressed  instead  of  being 
elevated.  This  is  due  to  the  elevation  of  the  surrounding  papillae. 
The  shining  appearance  is  produced  by  the  removal  of  the  epithelium 
and  the  exposure  of  the  rete  layer  beneath.  Mucous  patches  are  often 
painful,  and  when  seated  upon  the  walls  of  the  pharynx  occasion  con- 
siderable distress  in  swallowing. 

Hypertrophy  of  the  patch  may  occur  as  the  result  of  its  infiltration 
with  small  round  cells.  AVhen  such  patch  is  situated  on  the  cheek 
near  the  labial  angle  it  often  becomes  deeply  fissured,  owing  to  the 
movement  of  the  j)arts  in  mastication,  and  it  then  becomes  exceed- 
ingly painful.  It  may  even  pass  beyond  the  angle  of  the  mouth  and 
extend  for  some  distance  upon  the  surface  of  the  cheek.  Hypertrophy 
of  mucous  patches  upon  the  surface  of  the  tongue  gives  rise  to  lesions 
having  very  much  the  appearance  of  venereal  warts.  This  form  has 
given  rise  to  its  designation  as  the  "  toad's-back  "  tongue.  Lesions  of 
this  class  belong  to  the  type  of  moist  papules  seen  so  frequently  in 
syphilis  about  the  anus  and  vulva. 

Ulcerative  lesions  resulting  from  the  papules  arc  not  rare,  and  are 
due  to  irritation  of  the  parts  and  their  infection  with  pus  cocci.  Such 
ulcers  are  apt  to  be  deep  and  destructive  in  their  course  and  to  be  pro- 
ductive of  considerable  pain. 

Syphilitic  lesions  occurring  in  the  mouth  are  often  the  result  of 
undue  irritation  of  the  parts.  The  use  of  tobacco,  either  by  smoking 
or  chewing,  the  ingestion  of  hot  or  very  cold  fluids,  indulgence  in  highly 
spiced  articles  of  food,  and  the  presence  of  decayed  or  roughened  teeth 
are  frequent  and  prolific  sources  of  mischief. 

Pustules  occur  in  the  mouth  but  rarely.  They  are  produced  by 
infection  of  papular  lesions  with  pus-producing  bacteria.  AVhen  pus- 
tules appear  in  the  mouth,  lesions  of  the  same  character  can  usually  be 
found  upon  the  integument. 

Fissures  may  be  formed,  as  described,  in  connection  Avith  moist- 
papules  or  independently.  The  commissures  of  the  lips  and  the  sur- 
face of  the  tongue  are  favorite  sites  for  their  appearance.  At  the 
angle  of  the  lips  the  condition  is  aggravated  by  the  motion  of  the 
parts,  and  extension  of  the  process  to  the  cutaneous  surface  may  take 
place  as  in  the  case  of  moist  papules.     Fissures  are  slow  in  healing  and 


SYPHILIS  OF  THE  DIGESTIVE  TRACT.  871 

may  U'live  dotonuiiii>,-  ciciiti'lt'C's.  lipon  the  .siirlac-c'  <»1"  tlio  tongue  they 
usually  present  themselves  as  loni^-  linear  eraeks  extendino-  (lee[)ly  into 
its  substance.  Often  they  appear  as  if  the  tissues  hacl  been  dei'tiy 
divided  by  a  sharj)  knife.  Their  walls  are  then  in  close  contact,  and 
their  separation  is  needed  to  reveal  the  extent  of  the  fissure.  Fissures 
usually  follow  mucous  patches  or  areas  of  small-celled  intiltration. 

Tubercles  occurring  upon  the  tongue  and  mucous  membrane  of  the 
mouth  resemble  enlarged  or  hyperplastic  moist  papules.  They  are 
rounded  or  tiattened  nodules  involving  the  tissues  somewhat  deeply,  and 
occurring  at  points  where  there  is  but  little  pressure,  as  on  the  under 
surface  of  the  tongue. 

Gummata  do  not  develop  in  the  mouth  until  a  late  stage  of  the  dis- 
ease has  been  reached.  They  may  occur  in  any  part,  but  most  fre- 
quently attack  the  tongue.  They  begin  in  either  the  deep  or  superficial 
tissues,  and  are  ai)t  to  run  a  much  more  rapid  course  than  when  occur- 
ring elsewhere  upon  the  body.  The  supei'ficial  variety  is  first  noted  as 
a  small,  round,  reddened  nodule  appearing  in  the  mucous  membrane. 
The  nodule  is  slightly  elevated  and  is  moderately  firm  to  the  touch. 
The  lesion  may  increase  in  size  slowly,  but  its  most  frequent  course  is 
to  enlarge  with  startling  rapidity.  The  centre  becomes  necrotic,  case- 
ous degeneration  follows,  and  the  roof  wall,  which  at  first  is  tense,  is 
broken  down  and  a  gaping  ulcer  results.  There  may  be  but  one  or 
there  may  be  several  of  these  lesions  scattered  over  the  tongue,  the 
hard  palate,  and  the  cheeks.  The  gummata  are  seldom  painful,  and 
often  are  not  discovered  until  softening  and  ulceration  have  occurred. 

Gummata  originating  in  the  deeper  structures,  such  as  the  muscular 
tissues  of  the  tongue  and  the  bones  of  the  hard  palate,  are  apt  to  be 
much  more  formidable  and  severe  in  the  course  they  pursue.  The  neo- 
plasm usually  occurs  singly.  Its  onset  is  insidious  and  without  pain. 
It  is  a  circumscribed,  indurated,  firm  tumor,  varying  in  size  from  a 
hazelnut  to  an  olive.  Degeneration  and  ulceration  occur  at  times  with 
great  rapidity.  Perforation  of  the  palate  may  take  place  within  a  week 
from  the  first  appearance  of  the  nodule.  If  not  promptly  checked,  the 
process  may  go  on  to  more  or  less  complete  destruction  of  the  roof  wall. 
Ulcers  in  which  a  marble  may  be  hidden  destroy  with  the  same  rapidity 
the  tissues  of  the  cheek  and  tongue.  The  ulcers  are  round,  oval,  linear, 
or  irregular  in  shape.  Their  edges  are  elevated  and  roughened  or  some- 
times undermined.  Even  wdth  the  most  marked  ulceration  the  pain  is 
not  often  severe.  The  prognosis  is  good.  Repair  of  the  soft  tissues 
occurs  with  the  production  of  cicatrices  that  are  markedly  deforming. 
Destruction  of  the  hard  palate  can  be  remedied  by  the  use  of  an  obtura- 
tor. Treatment  must  be  energetic  and  chiefly  by  the  use  of  the  iodides, 
pushed  in  increasing  drop  doses  of  the  saturated  solution  until  the  ulcer 
yields.  Locally,  antiseptic  w^ashes  and  stimulating  applications  of  car- 
bolic acid,  iodine,  or  silver  nitrate  are  of  decided  value.  Tonics  such  as 
iron,  strychnine,  and  quinine  are  usually  needed. 

Syphilis  of  the  Dig-estive  Tract. — Syphilis  seldom  attacks  the 
oesophagus.  Gummatous  infiltration  of  its  walls,  resulting  in  cicatricial 
stenosis  and  narrowing  of  the  lumen,  has  been  described.  Little  is 
known  definitely  regarding  syphilitic  affections  of  the  stomach.  Gum- 
mata have  been  discovered  in  post-mortem  examination  of  syphilitic 


872  SYPHILIS. 

subjects  in  whom  no  appreciable  gastric  symj)toms  were  present  during 
life.  Gummatous  infiltration  of  limited  or  extended  areas  of  the  mucous 
and  submucous  tissues  may  result  in  considerable  fibrous  thickening  of 
the  walls  of  the  organ.  In  the  intestinal  tract  the  rectum  suffers  with 
greatest  frequency  and  needs  separate  description.  Elsewhere  the  walls 
of  the  intestine  may  become  the  seat  of  gummata.  These  are  super- 
ficial and  seldom  give  rise  to  serious  symptoms. 

Syphilis  of  the  Heart  and  Bloodvessels. — Syphilis  appears  to  find 
in  the  vascular  system  conditions  favoring  its  first  expression.  In  the 
chancre,  before  marked  invasion  of  the  body  by  the  syphilitic  virus  has 
taken  place,  constant  and  characteristic  changes  are  noted  in  the  vessels 
entering  and  leaving  the  part,  and  throughout  the  course  of  the  disease 
the  bloodvessels  are  apt  to  suffer  in  a  marked  degree.  This  is  doubt- 
less due  to  the  abundant  development  of  connective  tissue  entering  into 
the  formation  of  the  arteries  and  veins. 

The  Heart. — The  heart  suffers  less  frequently  than  do  the  vessels, 
but  when  affected  the  intensity  of  the  trouble  is  greater  and  more 
serious  mischief  is  apt  to  result.  Not  infrequently  a  fatal  termination 
ensues.  Manifestations  of  syphilis  in  the  heart  usually  appear  late  in 
the  disease.  When  attacked  the  heart  may  become  the  seat  of  gum- 
mata or  a  specific  fibrous  myocarditis  may  develop. 

Gummata  may  occur  in  any  part  of  the  heart,  but  appear  most  fre- 
quently in  the  endocardium,  along  the  edges  of  the  valves,  and  in  the  in- 
terventricular septum.  The  neoplasms  vary  in  size  from  a  pinhead  to  a 
hazelnut,  and  appear  as  circumscribed,  spherical,  non-vascular,  yellow- 
ish or  whitish  bodies  set  somewhat  deeply  in  the  tissues  aifected.  They 
show  on  section  a  necrotic,  cheesy  centre  surrounded  by  a  connective 
tissue  capsule.  From  this  capsule  strands  of  fibrous  tissu.  can  be  seen 
radiating  into  the  surrounding  parts.  No  trace  of  musci  lar  elements 
remains  at  the  site  of  the  nodule.  They  apj)ear  to  have  undergone  fatty 
degeneration  with  complete  absorption.  Small  gummata  have  been 
found  in  the  chordse  tendinese.  When  this  occurs,  shortening,  thicken- 
ing, and  weakening  of  these  structures  take  place.  Death  produced 
by  their  rupture  has  been  known  to  follow.  In  stillborn  infants  affected 
with  hereditary  syphilis  the  heart  has  been  found  thickly  studded  with 
minute  gummata. 

Fibrous  myocarditis  of  the  heart  due  to  syphilis  occurs  as  the  result 
of  an  arterio-sclerosis  or  obliterating  endarteritis  of  the  coronary  arteries.' 
The  part  of  the  heart  supplied  with  blood  by  the  branches  of  the  par- 
ticular artery  aifected  becomes  impoverished,  undergoes  degeneration, 
and  its  structures  are  replaced  by  fibrous  tissue.  Any  part  of  the  heart 
may  be  affected.  Frequent  sites  of  its  occurrence  are  the  papillary 
muscles  and  the  septum.  These  parts  are  thickened,  become  dense 
and  firm,  and  are  found  on  section  to  be  composed  almost  entirely  of 
fibrous  connective  tissue  with  only  a  meagre  vascular  supply.  Occa- 
sionally spindle  cells  are  found  mingled  with  the  fibrous  elements. 
Gummata  frequently  exist  in  intimate  association  with  this  form  of 
affection.  The  endocardium  in  some  cases  undergoes  a  like  fibrous 
change.  It  is  then  greatly  thickened,  becomes  gray  or  grayish-white 
in  color,  and  takes  on  somewhat  the  consistency  of  cartilage.  The 
rigidity  produced  often  interferes  greatly  with  the  action  of  the  heart. 


syrirrrrs  of  the  iiemit  axi>  bloodvessels.  873 

Aitcitri/siii  of  the  lu'art  walls  Ixdiiidiiit;-  the  vciitiMclts  may  occur. 
This  liappons  as  the  result  of  sof'toiiinj::  and  excavation  in  a  ^uninia 
o|)eniui»-  into  the  ventricular  cavity,  or  it  is  due  to  the  dilatation  of  an 
area  of  tibrous  myocarditis.  The  walls  of  such  aneurysms  are  com- 
posed of  dense  til)rous  tissue,  and  their  cavities  arc  fre(juently  Idled 
-with  thrombi. 

The  symjitoms  produced  by  syphilitic  disease  of  the  heart  arc  not 
distinctive.  The  history  of  each  case  as  re<>;ards  skin  lesions  and  other 
characteristic  symptoms  must  usually  be  relied  U])on  to  estaljlish  the 
diag-nosis.  By  some  it  is  thought  that  the  dyspncea  occurrinii-  in  dis- 
eases of  the  heart  is  apt,  when  the  trouble  is  due  to  sy])hilis,  to  come 
on  more  frequently  at  night  when  the  patient  is  resting  quietly  in  bed. 
This  fact,  however,  is  not  well  established,  and  to(j  much  reliance  should 
not  be  placed  upon  its  diagnostic  importance.  Many  persons  suffering 
with  syphilis  with  marked  involvement  of  the  heart  go  through  life 
without  manifesting  any  signs  of  trouble  in  the  organ,  the  condition 
•only  being  disclosed  at  the  autopsy.  With  obliterating  endarteritis  of 
the  coronary  arteries  and  its  resulting  heart  lesions  death  may  ensue 
j:?uddenly  and  without  marked  prodromal  symptoms. 

The  Bloodvessels. — Syphilis  affects  the  bloodvessels  both  early  and 
late  in  the  course  of  the  disease.  The  greater  part  of  its  energy  is 
expended  upon  the  arteries,  while  the  veins  very  largely  escape.  Little 
is  known  regarding  the  effects  of  the  disease  on  the  capillaries.  Fatty 
degeneration  and  gummatous  changes  in  their  walls  have  been  ob- 
served. 

The  most  frequent  lesions  met  with  in  the  walls  of  the  arteries  are 
gummata,  aneurysm,  arterio-sclerosis,  and  obliterating  endarteritis. 

Obliterath  g  Endarteritis.  —  This  is  by  far  the  most  frequent  and 
serious  trouble  occurring  in  the  arteries  that  is  due  to  syphilis.  The 
smaller  arteries  are  principally  affected.  There  is  partial  or  complete 
closure  of  the  lumen  of  the  vessel  due  to  proliferation  of  the  endothe- 
lial elements  in  the  intmia.  The  specific  virus  of  the  disease  or  the 
product  of  such  virus  circulating  in  the  blood  excites  the  ]3rolife ration 
by  means  of  its  irritative  action.  Thickening  of  the  intima  takes 
place,  layer  after  layer  of  the  endothelial  cells  forming  one  within  the 
other  until  the  vessel  is  nearly  or  entirely  closed.  The  adventitia  is 
attacked,  and  gradually  all  the  coats  of  the  vessel  become  affected.  A 
true  inflammation  may  be  excited,  with  subsequent  production  of  gran- 
ulation tissue.  This  latter  is  converted  into  fibrous  connective  tissue 
having  a  marked  tendency  to  contract.  If  the  lumen  of  the  vessel  is 
still  partly  patent,  the  contractility  of  this  newly  formed  tissue  is  usually 
sufficient  to  close  it.  The  nutrient  vessels  are  made  to  share  in  the 
process  and  are  completely  obliterated.  The  process  is  usually  confined 
to  limited  and  localized  areas.  The  arteries  at  the  base  of  the  brain 
and  the  coronary  arteries  suffer  most  frequently.  Arteries  in  any  part 
of  the  body,  however,  may  be  affected. 

Gummata. — Gummatous  changes  occur  in  the  larger  arteries.  They 
are  localized  or  diffuse.  The  adventitia  suffers  more  often  in  the  cir- 
cumscribed form  than  do  the  other  coats.  The  lumen  of  the  vessel  is 
partly  closed  by  pressure  of  the  mass  inward.  The  narrowing  is  still 
further  accomplished  by  thickening  of  the  intima.     Thrombi  frequently 


874  SYPHILIS. 

form  at  the  narrowed  point.  The  gumma  undergoes  its  peculiar  changes, 
softens,  discharges  its  contents  into  tlie  circulating  blood,  and  then  be- 
comes the  seat  of  an  aneurysm.  In  the  diffuse  form  the  gummatous 
infiltration  occurs  between  certain  of  the  vessel's  coats,  such  as  the 
intima  and  adventitia.  The  entire  circumference  of  the  vessel  wall 
may  be  involved  or  only  a  part  be  affected,  while  the  process  may 
extend  along  the  artery  for  some  distance.  Fatty  or  cheesy  degenera- 
tion of  the  gummy  infiltrate  takes  place,  and  later  calcification,  leading 
to  the  production  of  atheroma.  The  carotids  and  arteries  of  the  brain 
appear  to  suffer  most  frequently.  The  weakened  walls  of  vessels 
affected  in  the  brain  are  liable  to  rupture  suddenly  when  subjected 
to  strain  and  give  rise  to  apoplectic  seizures. 

Arteriosclerosis. — Syphilis  is  one  of  the  many  causes  capable  of  pro- 
ducing arterio-sclerosis  of  the  bloodvessels.  This  condition  when  due 
to  syphilis  is  seen  most  frequently  in  robust  individuals  between  thirty 
and  fifty  years  of  age  who  have  suffered  from  the  disease  in  early  life. 
The  affection  is  apt  to  be  generalized.  The  lumen  of  the  vessels  is 
enlarged,  instead  of  being  narrowed  as  in  endarteritis.  The  intima  is 
thickened  and  often  becomes  the  site  of  atheromatous  change.  The 
walls  throughout  are  hardened  and  inelastic.  To  the  touch  they  feel 
like  whipcords  placed  beneath  the  skin.  The  condition  is  in  no  wise 
distinguishable  from  the  same  disease  when  it  is  caused  by  alcoholic  or 
lead  poisoning  or  gout,  nor  does  it  appear  more  amenable  to  treatment. 
Iodide  of  potassium  in  full  doses  is  indicated  and  may  be  tried  in  in- 
terrupted courses,  pushing  it  each  time  to  the  patient's  limit  of  toler- 
ance.    A  well  regulated,  quiet  life  must  be  insisted  upon. 

Syphilis  of  the  Genito -urinary  Organs. — In  men  the  penis  is  fre- 
quently the  seat  of  the  initial  sclerosis.  This  has  been  described  (page 
854).  CEdema  and  diffuse  swelling  of  the  organ  are  complications 
liable  to  occur  in  connection  with  chancre,  especially  if  the  lesions  be 
large  and  subject  in  any  manner  to  irritation.  Phimosis  and  paraphi- 
mosis are  produced  as  complications.  The  organ  then  is  swollen,  hot, 
and  tender.  The  lymphatics  become  inflamed  and  painful,  and  seem 
to  the  touch  like  whipcords  running  along  the  dorsum  of  the  penis  and 
encircling  its  root.  These  conditions,  while  productive  of  some  dis- 
comfort and  much  alarm  on  the  part  of  the  patient,  seldom  occasion 
serious  mischief.  Rest,  elevation  of  the  organ,  frequent  immersion  in 
warm  boric  acid  solution,  and  the  administration  of  a  laxative  inter- 
nally usually  suffice  for  their  removal. 

The  glans  penis,  owing  to  interference  with  the  return  circulation 
by  the  chancre,  sometimes  assumes  a  bluish  color,  suggestive  of  gan- 
grene. This  is  apt  to  occur  with  large,  deeply  indurated  chancres  situ- 
ated in  the  sulcus  coronarius.  The  discoloration  vanishes  with  resolu- 
tion of  the  chancre.  Balanitis  and  posthitis  may  result  from  irritating 
discharges  from  the  primary  sore. 

Consecutive  lesions  occur  in  the  varying  forms  seen  elsewhere  upon 
the  surface  of  the  body.  Scaling  papules  may  be  found  at  times  upon 
the  glans  penis  when  no  other  lesions  indicative  of  syphilis  can  be  dis- 
covered. A  slight  catarrhal  discharge  from  the  urethra  is  sometimes 
noted  as  occurring  in  early  syphilis.  This  is  probably  due  to  the  pres- 
ence of  mucous  patches  within  the  walls  of  the  passage.     Gummata 


sirJiiLis  uF  THE  (!KMT(j-rnisAnY  onaAMs.  875 

aj)pcai'ini;  as  Hnn,  splu'rical  nodules  occur  within  the  corpora  caver- 
nosa. 'riu'V  (Icvi'lop  slowly  and  without  pain,  the  patient  first  notin*:- 
that  the  penis  is  "crooked"  when  erect,  and  later  discovering-  a 
"Iuni[)"  deep  within  the  tissues  o{"  the  or^an.  The  tendency  of"  such 
neoplasms  is  toward  deiicneration,  with  al)S()rption  of  the  j)roducts  and 
^the  suhsequent  development  of  circiunscrihed  areas  of  fibrous  connec- 
\tive  tissue.  Permanent  deformity  of  the  organ  then  results,  (jiummata 
arc  not  apt  to  occur  in  the  corj)Us  s|)on<>iosum.  When  doin<»;  so  they 
give  rise  to  exceediuiily  rebellious  strictures  of  the  urethra. 

A  pecidiar  condition  resembling  a  circular  band  j)lace(l  alxjut  the 
penis  results  occasionally  from  a  fibnms  development  taking  place 
within  the  cavernous  bodies.  This  band  may  encircle  the  penis  com- 
pletely or  only  in  ]Kirt,  and  usually  interferes  greatly  with  perfect  erec- 
tion of  the  organ. 

Syphilitic  affections  of  the  testicles  and  their  appendages  are  common, 
but,  owing  to  the  slight  distress  occasioned,  are  often  overlooked.  It 
should  be  the  invariable  rule  of  the  ])ractitioner  to  examine  these  organs 
at  the  time  of  the  patient's  first  presentation  when  the  body  is  searched 
for  specific  lesions,  and  throughout  the  course  of  the  disease  the  testicles 
should  be  ^vatched  with  care.  Trouble  occurring  here  may  show  it- 
self early  or  late.  The  epididymis  usually  betrays  some  slight  degree 
of  irritation  at  the  time  of  the  first  eruption.  It  becomes  somewhat 
swollen  and  is  painful  to  the  touch.  Later  in  the  course  of  the  dis- 
ease a  circumscribed  area  may  become  the  seat  of  inflammation.  This  is 
a  true  specific  epididymitis,  and  is  to  be  distinguished  from  that  due  to 
gonorrhoea  by  its  slow,  insidious,  painless  onset,  and  by  the  fact  that 
the  globus  major  instead  of  the  globus  minor  is  the  part  most  often 
affected.  One  or  both  organs  may  be  attacked.  Circumscribed  gum- 
mata  or  diffuse  areas  of  gummatous  infiltration  occur  late  in  the  disease. 
They  are  painless  and  slow  in  growth.  The  gummatous  infiltration 
may  involve  the  entire  epididymis  or  be  confined  to  a  portion  of  the 
organ  only.  The  discovery  of  a  lump  in  his  testicle  is  often  the  first 
indication  given  the  patient  of  existing  trouble.  Extension  of  the  pro- 
cess to  the  testicle  proper  and  to  the  cord  often  takes  place.  When  dis- 
covered early  treatment  is  usually  successful  in  removing  the  deposit 
and  saving  the  organ.  If  neglected,  irreparable  damage  maybe  done 
and  a  useless  organ  may  result. 

Trouble  in  the  testicle  usually  begins  late  in  the  disease,  and  is  due 
to  the  formation  of  gummata.  These  may  appear  first  in  the  substance 
of  the  testicle,  or  they  may  begin  in  the  tunica  vaginalis  investing  the 
organ,  and  from  this  extend  to  the  deeper  structures.  In  the  tunic  they 
can  be  felt  as  small,  round,  firm,  freely  movable  nodules.  If  deep  in 
the  testicle,  they  cannot  be  detected  by  touch  until  they  have  enlarged 
to  a  considerable  extent.  There  is  no  pain.  They  may  be  single  or 
multiple.  The  testicle  may  be  invaded  throughout  its  entire  substance 
by  the  gummatous  deposit  or  the  process  be  limited  to  a  portion  only  of 
the  organ.  The  gummata  enlarge  slowly.  Their  substance  is  dense, 
often  as  hard  as  ivory.  The  testicle  increases  in  size,  sometimes  becom- 
ing as  large  as  a  child's  head.  Its  weight  drags  u])on  the  cord,  ])rodu- 
cing  uncomfortable  sensations  in  the  groin  and  abdomen.  Aside  from 
this  there  is  no  pain.     Pressure,  unless  excessive,  elicits  little  or  no 


876  SYPHILIS. 

response.  The  surface  is  smooth.  In  this  it  differs  from  tuberculosis, 
in  which  the  organ  is  uneven  and  rough.  Occasionally  there  is  effusion 
of  fluid  into  the  tunica  vaginalis  with  the  formation  of  hydrocele.  One 
or  both  testicles  may  be  aif'ected.  The  course  of  the  malady  is  exceed- 
ingly slow,  years  often  being  occupied  in  the  process.  The  trouble 
ends  in  absorption  of  the  gummy  exudate  and  the  development  of 
fibrous  tissue,  leaving  a  shrunken,  withered  organ,  or  softening  of  the 
gumma  may  result  in  complete  destruction  of  the  testicle.  This,  how- 
ever, is  unusual.  Fungous  growths  sometimes  arise.  During  the  prog- 
ress of  the  affection  there  is  oftentimes  no  marked  change  in  the  sexual 
appetite. 

Syphilitic  orchitis  responds  readily  to  specific  treatment  begun  early 
in  the  attack  and  pushed  with  sufficient  vigor.  The  iodides  are  indicated 
in  full  doses.  Locally,  inunctions  of  the  oleate  of  mercury  in  5  per 
cent,  strength  are  of  value.  The  tendency  of  the  disease  is  to  destroy 
the  seminiferous  tubules,  and  when  such  destruction  has  taken  place 
repair  cannot  ensue. 

In  women  chancres  occur  as  frequently  upon  the  genitals  as  they  do 
in  men,  but,  owing  to  their  being  hidden  from  sight,  are  not  as  readily 
recognized.  The  os  uteri  and  vulvar  portal  are  favorite  sites.  Chancres 
are  seldom  seen  upon  the  vaginal  walls.  They  may  occur  in  the  urethra. 
The  early  lesions  of  systemic  syphilis  may  develop  upon  the  vulva  and 
within  the  vaginal  canal,  most  frequently  as  condylomata  or  mucous 
patches.  Condylomata  present  the  features  described  elsewhere  (page 
862).  Mucous  patches  occurring  upon  the  vaginal  walls  differ  but  little 
from  those  ajDpearing  in  the  mouth  cavity.  These  patches  give  rise  to 
but  little  distress  unless  irritated  by  leucorrhoeal  discharges.  In  such 
cases  the  lesions  are  greatly  aggravated  and  frequently  very  painful. 
Mucous  patches  of  the  vagina  and  os  uteri,  whether  occurring  early  or 
late  in  the  course  of  the  disease,  are  undoubtedly  the  most  fruitful  source 
of  infection. 

The  posterior  wall  of  the  vagina  may  be  involved  in  the  syphilitic 
affections  occurring  in  the  rectum.  The  remainder  of  the  tract  is  not 
often  the  site  of  gummata.  Little  is  known  regarding  early  syphilitic 
affections  of  the  uterus  and  ovaries.  In  both,  gummata  may  develop  in 
later  stages.  In  the  ovary  the  changes  taking  place  resemble  those 
occurring  in  the  testicle.  The  gummatous  deposit  may  be  diffuse  or  cir- 
cumscribed and  lead  to  wasting  and  shrinkage  of  the  organ. 

The  bladder  is  rarely  attacked  by  syphilis.  It  is  believed  to  be 
affected  slightly  in  the  early  stages  of  the  disease,  but  little  is  known 
regarding  the  condition.  At  the  most,  it  is  probal^ly  but  a  transient 
hypersemia.  Gummata,  papillomata,  and  hypertrophic  growths  due  to 
syphilis  occur  in  later  stages.  Fistulous  tracts  may  be  formed  by  ex- 
tension of  ulcers  occurring  in  neighboring  organs. 

The  kidney  may  be  affected  at  any  time  in  the  course  of  the  disease 
after  the  development  of  systemic  syphilis.  Early  manifestations  of 
trouble  differ  very  much  from  those  occurring  at  later  periods.  They 
are  sudden  in  their  onset,  not  often  being  announced  by  any  prodromal 
symptoms.  Oedema  occurring  in  and  beneath  the  lower  eyelids  is  usu- 
ally the  first  evidence  furnished  showing  that  the  kidney  is  affected. 
This  is  more  noticeable  in  the  morning  after  the  patient  rises  from  rest 


SYPiiiTjs  OF  THE  ai'.Mro-rinsMiY  run; ass.  Sll 

than  latiT  in  the  conrsc  of  the  day.  Tlit'  (I'dcinatous  condition  later 
appears  in  the  extremities  and  in  other  parts  of  tlie  body. 

Examination  of  tiie  urine  sliows  albumin  in  small  or  larg;e  quantities, 
jjranular  easts,  blood,  j)us,  and  kidney  epithelium.  The  amount  ])asscd 
in  twi'utv-i'our  hours  is  somewhat  lessened  or  even  <ireatly  decreased. 
The  si)eeitie  uravitv  is  hiuh  and  the  color  dark.  The  urine  is  turbid 
when  first  passed.  Calls  to  urinate  are  frecpient,  though  the  amount 
passotl  each  time  is  small. 

Other  symi)toms  referable  to  the  condition  of  the  kidneys  are  evi- 
denced in  headache,  vomitino;,  malaise,  inappetence,  digestive  disturb- 
ances, and  disordered  vision. 

Post-mortem  examination  of  tlu'  kidney  at  this  time  shows  well 
marked  organic  changes  in  the  renal  substance.  The  organ  is  much 
enlarged,  and  appears  gray  or  grayish  white  on  section.  The  cortical 
portion  is  thickened,  the  epithelium  in  the  convoluted  tubules  swollen, 
and  the  tubes  in  places  filled  Avith  broken-down  tissue  and  catarrhal 
products.     The  organ  is  in  the  condition  known  as  large  white  kidney. 

Earlv  svphilitic  aflPections  of  the  kidney  usually  respond  promptly 
to  proper  mercurial  treatment.  At  times,  however,  the  administration 
of  mercury  may  aggravate  and  intensify  the  process.  In  such  cases 
resort  must  be  had  to  the  iodides,  the  iodide  of  potassium  having  the 
preference.  It  is  well  always  to  examine  the  urine  at  frequent  intervals 
in  a  patient  under  treatment  for  sy])hilis,  in  order  to  anticipate  trouble 
occurring  in  the  kidney.  It  is  particularly  desirable  to  do  this  after  an 
albuminous  attack,  as  recurrences  are  frequent.  Rest  and  a  milk  diet 
will  help  in  restoring  the  kidneys  to  a  sound  condition. 

Late  changes  in  the  kidneys  are  more  severe  and  disastrous  in  their  re- 
sults than  are  the  earlier  lesions.  The  process  here  is  usually  complex  in 
character  and  referable  to  several  distinct  and  separate  conditions.  Prin- 
cipal among  these  are  the  formation  of  gummata,  amyloid  degeneration, 
and  inflammation  of  the  interstitial  connective  tissue.  These  processes 
operate  in  conjunction  in  various  degrees,  though  rarely  one  may  exist 
singly.  Usually  both  kidneys  are  affected.  The  symptoms  depend 
upon  which  one  of  the  above  conditions  is  most  fully  developed.  If 
interstitial  inflammation  be  the  chief  lesion,  the  urine  will  be  increased 
greatly  in  quantity,  its  specific  gravity  will  be  low,  and  the  quantity  of 
albumin  will  be  small.  If  amyloid  degeneration  exists  alone  or  exceeds 
the  other  complications  in  its  gravity,  the  urine  will  be  but  slightly  in- 
creased in  quantity,  albumin  will  be  abundant,  hyaline  and  waxy  casts 
plentiful,  and  free  fiit  globules  with  degenerated  cells  will  be  present  in 
the  flocculent  precipitate.  Purely  gummatous  changes,  unless  so  exten- 
sive as  to  interfere  greatly  with  the  function  of  the  kidney,  are  said  not 
to  be  productive  of  definite  symptoms.  Gummata  are  often  found  post- 
mortem in  the  kidneys  in  subjects  in  whom  during  life  no  definite  renal 
symptoms  Avere  exhibited. 

In  chronic  interstitial  nephritis  due  to  syphilis  the  process  is  usually 
localized.  The  areas  of  implication  are  contracted,  giving  to  the  sur- 
fiice  of  the  organ  when  seen  in  post-mortem  examination  an  irregular, 
uneven  appearance.  Gummata  are  often  found  in  or  near  the  affected 
areas.  They  may  be  few  in  number  or  numerous,  and  vary  in  size  from 
a  pinhead  to  that  of  a  hazelnut. 


878  SYPHILIS. 

Early  treatment  offers  the  only  hope  of  success.  If  the  process  has 
become  extensive  and  well  established,  repair  of  the  mischief  done  can- 
not be  accomplished.  If  the  process  can  be  checked,  the  work  of  the 
kidney  must  be  done  by  the  parts  that  may  remain  unaffected.  In 
treatment  the  iodides  are  indicated  and  must  be  g'iven  in  large  doses. 
If  successful  in  checking  the  albuminuria,  they  still  must  be  continued 
for  long  periods  of  time.  Often  mixed  treatment  is  of  value  when 
active  manifestations  of  the  trouble  have  ceased.  Especial  care  of  the 
skin  is  needed  when  the  kidneys  have  been  broken  down  in  part  by 
disease,  as  a  portion  of  their  eliminative  work  must  now  be  done  by 
this  organ. 

Syphilis  of  the  Lung-. — Acquired  syphilis  does  not  often  attack 
the  lungs.  When  it  does  the  malady  is  always  in  a  late  stage.  In  the 
inherited  form  lung  syphilis  is  more  frequent.  The  changes  found  in 
post-mortem  examination  are  due  to  a  chronic  interstitial  inflamma- 
tion or  to  a  gummatous  deposit,  either  circumscribed  or  diffuse.  The 
two  forms  may  be  distinct  or  associated.  Neither  one  nor  the  other 
gives  rise  to  symptoms  during  life  by  means  of  Avhich  the  troul)le  can 
be  definitely  diagnosticated  as  due  to  syphilis. 

Cjrummaia. — Gummata  occur  in  the  lungs  as  tumors  varying  in  size 
from  a  pea  to  a  hen's  egg.  They  may  appear  singly  or  be  distributed 
profusely  throughout  the  lung  tissue.  The  root  of  the  lung  is  a  favor- 
ite site  for  their  development.  The  tumors  are  grayish  or  yellowish 
white  in  color.  In  their  earlier  stages  they  are  firm,  indurated,  cir- 
cumscribed nodules  surrounded  by  a  dense  connective  tissue  envelope 
and  well  sujDplied  with  small  vessels.  These  vessels  later  disappear, 
and  the  tumors  take  on  the  retrograde  changes  described  elsewhere  as 
typical  of  gummata.  If  softening  takes  place  rapidly,  rupture  and  dis- 
charge into  one  of  the  bronchi  occur.  A  cavity  is  then  formed  in  the 
lung  tissue  not  differing  in  character  from  that  produced  in  tubercu- 
losis. The  walls  of  small  cavities  unite,  with  the  event aal  formation 
of  a  cicatricial  nodule.  Large  cavities  remain  patent.  The  gummata, 
instead  of  undergoing  destruction  by  ulcerative,  caseous,  or  hyaline 
degeneration,  may  become  the  sites  of  deposition  of  lime  salts,  with 
the  formation  of  calcareous  nodules.  Xo  change  in  the  tissues  about 
the  gumma  may  occur,  or  a  true  diffuse  broncho-pneumonia  may  be 
developed.  Diffuse  gummatous  infiltration  is  rare,  and  usually  fol- 
lows the  course  of  the  larger  vessels,  as  previously  described  uj)on 
p.  873. 

Diffuse  Chronic  Interstitial  Sclerosis. — Virchow  first  described  this 
condition  and  attributed  it  to  syphilis.  The  process  consists  of  the 
steady  and  progressive  development  of  fibrous  connective  tissue  within 
the  lungs.  The  sclerosis  commences  at  the  root  of  the  lung  or  in  the 
pleura,  and  advances  along  the  bloodvessels  and  the  bronchi,  invading 
large  areas  of  the  lung  tissue.  The  parenchyma  of  the  organ  is  at- 
tacked, and  the  air  vesicles  are  narrowed  in  size  and  at  times  com- 
pletely obliterated.  The  newly  formed  tissue  is  sclerotic.  The  areas 
affected  become  dense  and  hard  and  do  not  furnish  a  vesicular  mur- 
mur upon  auscultation.  The  surface  of  the  organ  is  uneven,  owing 
to  contraction  taking  place  in  the  deeper  parts.  A  large  portion  of 
one  lobe,  and  sometimes  of  two,  is  affected.     The  process  is  usually 


SYI'IIILIS    OF    Tin:   LIVFJl.  879 

<'(»iiHn('(l   to   the    base  ul"  (lie    liiiiii',   I'arcly   aijproacliiiii!;  the   apex.      In 
this  re,-j)eet   it  differs  marketUy  iVoin  tiihereidusis. 

In  stilll)()rn  infants  the  lungs  are  tVecjuently  ufleeted  with  what  has 
been  ileserihetl  as  irhiiv  j)ii('iiin()iii(i.  The  lung  is  dense  and  hard,  the 
alveolar  walls  are  thiekened  and  inliltrated,  and  the  air  eells  are  ehoked 
with  epithelial  debris. 

TIk'  synipt(»nis  oeeurriiig  in  syphilis  of  the  lung  are  not  distinctive. 
The  affection  comes  on  slowly  and  without  fever  or  pain.  The  respira- 
tory act  grows  feeble.  There  may  be  dulness  over  limited  areas  at  the 
base  of  the  lung.  Cough  is  usually  mild  and  accompanied  by  slight 
expectoration.  At  times,  however,  it  may  be  severe.  Bleeding  from 
the  lungs  sometimes  takes  place.  Asthmatic  attacks  occur.  And  final- 
ly, as  the  disease  becomes  thoroughly  established,  it  exhibits  many 
of  the  signs  and  svmptoms  displayed  in  tuberculosis  and  mav  end 
flitally. 

Evidences  of  syphilis  in  other  organs  of  the  body  and  a  definite  his- 
tory of  a  previous  attack  are  essential  elements  in  diagnosis.  Gradual 
development  without  fever,  pain,  or  distress  in  the  lungs  points  to 
syphilis.  The  early  involvement  of  the  base  instead  of  the  apex  of 
the  lung  helps  to  distinguish  it  from  tuberculosis.  The  discovery  of 
tubercle  bacilli  definitely  determines  the  existence  of  the  latter  disease. 
Marked  dyspncea  occurring  at  night  is  believed  to  be  a  typical  feature 
of  the  syjihilitic  affection. 

Syphilis  of  the  Liver. — Syphilis  manifests  itself  in  the  liver  either 
in  the  production  of  gumraata  or  in  the  development  of  fibrous  connec- 
tive tissue.  Early  in  the  course  of  the  disease  icterus  is  apt  to  occur. 
This  is  due  only  to  functional  disturbances  occurring  in  the  liver.  The 
process  is  seldom  sevcn-e  and  always  transient.  Gummata  are  usually  a 
late  development.  They  occur  in  small  or  large  numbers  and  in  any 
part  of  the  organ.  In  their  earlier  stages  they  are  small,  firm  nodules 
composed  largely  of  connective  tissue.  Spindle  and  small  round  cells 
are  scattered  throughout  their  substance.  The  connective  tissue  sends 
radiate  processes  into  the  surrounding  parenchyma.  When  the  lesion  is 
situated  near  the  capsule  the  surface  of  the  organ  is  apt  to  show  a  de- 
pression due  to  contraction  occurring  in  the  connective  tissue  elements 
of  the  underlying  gumma.  Gummata  here  undergo  various  forms  of 
degeneration.  Softening  and  ulceration  occur,  but  are  infrequent. 
Caseous  degeneration  with  absorption  of  the  product  and  the  develop- 
ment of  fibrous  connective  tissue  are  more  usual.  Calcification  may 
occur.  Contraction  of  the  areas  affected  often  takes  place  in  such  way 
as  to  produce  appearances  resembling  new  lobes.  At  first  the  liver  is 
enlarged,  oftentimes  so  as  to  be  noticeable  on  palpation  and  percussion. 
Later,  owing  to  contraction  of  the  resolving  gummata,  it  becomes  much 
reduced  in  size.  The  gummatous  development  is  apt  to  be  particularly 
free  in  the  neighborhood  of  the  suspensory  ligament. 

Development  of  fibroid  tissue  occurs  in  the  liver  without  accom- 
panying gummatous  change.  In  such  case  the  fibroid  tissue  ajipears  to 
arise  in  the  capsule  of  the  organ  and  to  penetrate  the  liver  in  broad  or 
narrow  bands.  The  septa  thus  formed  are  again  intersected  by  like 
bands  arising  in  the  larger  bundles.  In  this  way  the  organ  is  divided 
into  a  number  of  separate  and  distinct  lobules.     The  process  is  chronic 


880  SYPHILIS. 

and  rebellious  to  treatment.  Atrophy  of  the  portions  affected  usually 
results. 

Syphilis  of  the  Anus  and  Rectum. — Syphilitic  affections  of  the 
anus  and  rectum  are  liable  to  occur  at  any  time  in  the  course  of  the 
disease.  Chancres  are  frequently  found  here,  infection  in  women  being 
due  to  misplacement  of  the  penile  organ,  and  in  men  occurring  as  the 
result  of  disgusting  practices.  If  the  chancre  occur  within  the  sphincter 
ani,  it  is  rarely  discovered.  On  the  anal  border  or  upon  the  perianal 
surfaces  it  presents  itself  as  a  firm  flat  or  spherical  lesion,  somewhat 
resembling  a  small  hemorrhoid.  It  may  also  appear  as  an  eroded  sur- 
face or  as  an  anal  fissure.  The  lesion  is  usually  painless,  but  may  be 
the  seat  of  considerable  distress  when  straining  at  stool. 

The  early  consecutive  lesions  occurring  about  the  anus  are  either  in 
the  form  of  macules  or  papules.  They  appear  usually  in  conjunction 
with  the  first  macular  exanthem.  Syphilitic  lesions  occurring  in  this 
region  are  often  intensely  pruritic.  Papules  about  the  anus,  in  conse- 
quence of  the  heat  and  moisture  incident  to  the  part,  are  liable  to  be 
converted  into  mucous  patches  and  condylomata.  The  secretion  fur- 
nished by  such  lesions  is  extremely  contagious  in  character,  and  it 
possesses  a  most  offensive  odor. 

Late  affections  of  syphilis  occurring  in  the  rectum  are  more  com- 
monly met  with  in  women  than  in  men.  They  consist  of  gummatous 
infiltration  of  the  parts  and  the  free  development  of  fibrous  connective 
tissue. 

Gummata  may  form  at  any  point  within  the  rectum.  They  may  be 
single  or  multiple  and  localized  or  extensive  in  distribution.  Diffuse 
gummatous  infiltration  may  envelop  the  entire  surface  of  the  gut  in  a 
broad  band  or  extend  along  one  of  its  sides  for  a  considerable  distance. 
When  small,  gummata  are  apt  to  be  numerous.  Their  point  of  origin 
is  in  the  mucous  or  submucous  tissues.  In  their  earlier  development 
they  feel  to  the  tip  of  the  finger  like  smooth,  round,  firm  nodules  set 
somewhat  deeply  within  the  rectal  tissues.  Later  they  become  elevated, 
less  firm,  and  often  develop  into  papilliform  bodies.  Ulceration  occa- 
sionally happens. 

Gummata  of  the  rectum  are  not  often  painful.  The  first  symptoms 
of  trouble  are  usually  a  prolonged  and  constant  or  intermittent  diarrhoea. 
This  is  followed  by  obstinate  constipation,  with  uneasy  and  painful  sen- 
sations occurring  in  the  rectum  Avhen  at  stool.  When  the  gummy  infil- 
tration encircles  the  gut,  stricture  is  almost  sure  to  result.  This  is 
accomplished  by  absorption  of  the  gummatous  material  and  the  pro- 
duction of  fibrous  connective  tissue.  A  chronic  proctitis  usually  accom- 
panies such  stricture,  and  the  discharges  from  the  bowel  are  liquid  in 
character.  Steady  and  progressive  contraction  of  such  strictures  is  apt 
to  continue  until  the  lumen  of  the  bowel  is  so  greatly  narrowed  as  to 
interfere  in  a  dangerous  degree  with  the  discharge  of  the  intestinal  con- 
tents. Examination  with  the  finger-tip  shows  the  lumen  narrowed  in 
various  degrees,  a  roughened,  corrugated,  dense  mass  of  contractile  tis- 
sue encircling  the  gut,  a  pouch-like  expansion  above  it,  and  tongue-like 
projections  olf  rectal  tissue  beneath.  Strictures  arising  in  this  manner 
have  been  called  by  the  French  ano-rectal  syphilomas. 

Taylor  has  described  a  form  of  stricture  occurring  in  the  rectum, 


SYPIULfS  OF  TlIK  BONES.  881 

due  to  syphilis,  cliMractt'rized  by  the  tonuatioii  of  dense  fibrous  tissue 
without  [)re(H'din<;-  iiiHauinuitorv  conditions  or  exudative  ])ro(bi('ts  takinji 
place  in  the  i)arts.  It  occurs  in  yoiuii>;  and  old  syphilitic  w(nnen  long' 
after  syniptonis  of  the  disease  have  ceased. 

Syphilis  of  the  Bones. — Syj)hilis  is  liable  to  affect  the  bones  or 
their  })eriosteal  coverinj2;s  at  any  period  early  or  late  in  the  course  of 
the  disease.  As  a  rule,  the  attack  is  late,  several  years  elapsing  between 
the  appearance  of  the  chancre  and  the  time  when  definite  lesions  of  the 
bones  first  show  themselves. 

The  earliest  effects  of  syphilis  manifested  in  the  osseous  system  are 
what  are  known  as  osteocopic  pains.  These  pains  occur  at  or  about 
the  time  of  the  first  exanthem  or  even  before  it.  They  are  not  always 
present :  in  some  cases  they  are  light  and  transient,  while  in  others  tliey 
are  extremely  severe  and  produce  the  most  intense  suffering.  The 
pains  are  grinding,  boring,  or  splitting  in  character,  and  are  usually 
referred  to  the  joints  with  deep  extension  into  the  bones  forming  such 
parts.  The  knee,  elbow,  and  shoulder  joints  are  most  frequently 
affected.  The  pains  are  not  stationary,  but  shift  from  one  part  to 
another  with  considerable  rapidity.  They  are  worse  at  night,  often 
occurrinp-  at  a  oiven  hour  and  making  rest  for  the  remainder  of  the 
night  impossible.  During  the  day  complete  freedom  from  pain  is  often 
experienced.  Patients,  if  they  be  aware  that  mercury  is  being  given 
them,  often  attribute  these  pains  to  its  use.  This  idea  is  entirely 
erroneous,  and  there  is  no  indication  for  cessation  of  the  drug  if  the 
pains  come  on  after  its  use  has  begun.  Its  dosage  should  rather  be 
increased  than  diminished  if  ptyalism  be  not  imminent. 

Nodose  swellings  may  occur  upon  the  tibia,  scapula,  sterniuii,  and 
bones  of  the  skull  shortly  after  the  appearance  of  the  first  exanthem. 
The  lesions  are  tender  and  at  times  extremely  painful  to  the  touch. 
Usually  they  disappear  within  a  few  weeks.  Such  nodes  must  not  be 
confounded  with  those  occurrino^  later  in  the  disease,  in  which  there  is 
gummatous  deposit  in  the  part.  The  earlier  lesions  are  circumscribed 
areas  of  hypersemia  with  slight  exudation  into  the  periosteum,  but  no 
new  cell  formation. 

Late  lesions  of  bone  occurring  in  syphilis  have  been  classed  by 
Lancereaux  as  follows : 

(«)  Inflammatory  osteo-periostitis  ; 
(6)  Gummata ; 
((•)  Dry  caries. 

Such  lesions  may  occur  at  any  time  after  the  sixth  month  and  as  late 
as  the  twentieth  year.  Any  bone  in  the  body  may  suffer,  Tlie  tibia, 
ulna,  sternum,  scapula,  clavicle,  and  the  bones  of  the  cranium,  of  the 
nose,  and  of  the  face,  suffer  most  frequently.  One  bone  only  may  be 
affected  at  a  given  time  or  a  number  may  suffer  simultaneously  or  in 
succession. 

Inflammatorii  Osfeo-periostltis. — The  lesions  occurring  in  this  form 
of  bone  syphilis  are  true  nodes.  Any  of  the  bones  may  be  affected, 
the  superficial  ones,  such  as  the  tibia  and  bones  of  the  skull,  most  fre- 
quently. The  periosteum  and  superficial  layers  of  tlie  bone  are  the 
parts  attacked.  The  j)rocess  begins  in  the  connective  tissue  of  the 
part  and  consists   of  inflammatory  swelling,  with  the  production  of 

Vol.  I.— 56 


882  SYPHILIS. 

numerous  embryonic  cells.  The  bloodvessels  of  the  Haversian  canals 
are  involved  in  the  process,  and  the  canals  are  enlarged  and  filled 
with  a  plastic  exudate  resembling  bone-marrow.  There  is  consider- 
able determination  of  blood  to  the  part.  Thickening  of  the  tissues 
occurs  with  the  formation  of  a  distinct  tumor  involving  the  periosteum 
and  the  parts  of  the  bone  immediately  beneath.  In  size  the  tumor 
varies  from  a  pea  to  a  walnut,  and  is  soft  and  doughy  to  the  touch. 
The  overlying  skin  is  freely  movable  and  is  not  reddened  in  the  earlier 
stages  of  the  lesion.  The  swelling  is  exceedingly  tender  upon  pressure, 
and  is  usually  the  seat  of  a  dull,  continuous,  grinding  sensation,  very 
liable  to  be  intensified  at  night  when  subjected  to  the  warmth  of  the 
bed.  If  the  node  occur  upon  the  inner  table  of  the  skull,  it  is  apt  to 
produce  continuous  and  severe  headache  or  nervous  symptoms  of  con- 
siderable gravity. 

The  nodes,  unless  subjected  to  appropriate  treatment,  enlarge  rapidly, 
the  skin  becomes  red  and  adherent,  the  tumor  softens,  breaks  down,  and 
finally  discharges  upon  the  surface,  with  the  production  of  a  deep  carious 
ulcer.  Dead  bone  comes  away  at  frequent  intervals.  The  ulcer  runs  a 
sluggish,  indolent  course,  after  which  the  cavity  closes  with  the  forma- 
tion of  a  depressed  cicatrix  surrounded  by  a  hard  bony  ridge.  At 
times  the  nodes  do  not  undergo  ulceration,  but  are  converted  into  new 
bone  extremely  dense  and  hard  in  its  organization.  These  growths 
are  persistent  and  are  known  as  exostoses.  Such  exostoses  may  be 
found  in  the  periosteum,  and  they  are  freely  movable  upon  the  bone 
beneath.     Later  they  may  become  attached  to  it. 

Grummata. — Gummata  are  found  in  and  underneath  the  periosteum, 
within  the  bone  substance,  and  in  the  medullary  canal.  The  long  bones, 
bones  of  the  skull  and  face,  the  ribs,  and  the  bones  of  the  fingers  and 
toes,  are  most  frequently  affected.  Gummata  occurring  early  in  the  course 
of  the  disease  are  far  more  apt  to  be  numerous  than  when  developing 
late.  They  form  rapidly  and  are  extremely  painful,  the  pain  being 
nocturnal  in  character.  When  involving  the  periosteum,  gummata  can 
be  felt  as  moderately  firm  tumors  varying  in  size  from  a  pea  to  a  walnut. 
The  neoplasms  may  soften,  break  down,  and  discharge  outward  with 
the  production  of  typical  degenerate  syphilitic  ulcers,  or  they  may  un- 
dergo resolution  and  absorption  without  the  production  of  such  lesions. 
In  the  long  bones  gummata  are  found  most  frequently  w^ithin  the 
medullary  canal.  The  bone  enlarges  either  locally  or  throughout  the 
greater  part  of  its  extent.  The  Haversian  canals  entering  the  cavity 
become  distended  with  the  degenerated,  cheesy  products  of  the  gum- 
matous lesion.  The  pain  is  intense,  continuing  with  unabated  fury  both 
day  and  night.  The  process  ends  by  absorption  of  the  gummy  material 
or  the  production  of  carious  bone.     Calcification  may  take  place. 

In  the  flat  bones  of  the  skull  the  process  is  somewhat  different, 
owing  to  their  peculiar  anatomical  structure.  The  diploe  is  the  part 
that  is  here  most  frequently  attacked.  The  gummy  deposit  may  be  so 
extensive  as  to  separate  the  tables,  one  or  both  of  which  may  become 
carious.  iS^ecrosis  of  the  inner  table  gives  rise  to  serious  brain  symp- 
toms. In  the  outer  table  sequestra  are  frequently  formed  and  removed 
by  ulceration.  Destruction  of  scalp  tissue  occurs  and  a  deforming  cica- 
trix results. 


SYPHILIS   OF   THE  SERVOUS  SYSTE^r.  883 

Dry  Caries. — This  atfoction  is  declarod  by  Vircliow  t<}  be  fluo  to 
syphilis  alone,  and  is  fbnnd  most  l"r('(|iicntly  attackiiii;  the  frontal  and 
parietal  bones.  The  proeess  begins  as  a  <i:uniinat<»us  deposit  about  one 
of  the  vertieal  vaseular  ehannels  in  either  table  of  the  bone  affected. 
Destruction  of  tlie  bony  tissue  about  the  canal  takes  place.  The  gum- 
my substance  disapi)ears  by  absorption  and  a  depression  in  the  skull 
results.  If  both  tallies  be  involved  at  diametrically  opposite  points, 
perforation  of  the  cranium  may  follow.  The  skin  is  not  involved, 
there  is  no  suppuration,  and  no  sequestrum  is  ever  formed. 

Syphilis  of  the  Joints. — Pains  in  and  about  the  joints  are  frequent 
and  early  in  syphilis.  These  are  not  referable  to  any  organic  change  in 
the  part,  but  are  due  to  the  toxins  of  syphilis  circulating  in  the  blood. 
Later  in  the  disease  a  true  synovitis  may  develop.  This  inflammation 
is  characterized  by  slight  pain,  impairment  of  motion,  and  eifusion  of 
fluid  into  the  joint  capsule.  The  joint  enlarges  slowly.  There  is  thick- 
ening of  the  fibrous  parts  due  to  hyperplasia  of  their  elements.  The 
synovial  membrane  may  become  the  seat  of  circumscribed  gummata  or 
of  difluse  gummatous  infiltration.  The  joint  becomes  tumid,  hot,  and 
tender  to  the  touch.  Pain  is  severe,  and  is  worse  at  night.  If  un- 
checked, the  thickening  becomes  permanent  and  there  is  more  or  less 
loss  of  motion.  Complete  ankylosis  does  not  often  take  place,  and 
ulceration  with  the  formation  of  sinuses  is  unusual.  The  knee  joint  is 
the  part  most  frequently  affected.  The  diagnosis  depends  upon  the 
patient's  history  or  the  discovery  of  evidences  of  syphilis  elsewhere 
in  the  body.  Treatment  is  by  internal  administration  of  the  iodides 
and  mercury,  with  rest  of  the  parts  affected  and  light  mercurial  inunc- 
tion of  the  joints.     Dry  heat  to  the  part  is  frequently  grateful. 

Syphilis  of  the  Nervous  System. — The  nervous  system  may  be 
affected  by  s^qihilis  at  any  time  in  the  course  of  the  disease  after  the  de- 
velopment of  constitutional  symptoms.  Serious  lesions,  however,  are 
not  apt  to  occur  early.  More  often  they  are  delayed  until  an  extremely 
late  period,  as  the  end  of  the  first  or  second  decade.  ^len  are  more 
apt  to  suffer  than  women,  owing  to  the  greater  care,  overwork,  and 
worry  that  they  experience.  Usually  the  victims  of  nervous  s^'philis 
are  individuals  not  yet  past  middle  life.  The  belief  is  current  that 
nervous  affections  are  prone  to  develop  in  cases  exhibiting  but  few  if 
any  of  the  earlier  manifestations  of  the  disease.  This  statement,  how- 
ever, lacks  confirmation.  It  will  probably  be  found  that  owing  to  the 
mildness  of  the  early  symptoms  proper  treatment  was  neglected  or 
delayed,  and  the  disease  thereby  allowed  to  establish  itself  thoroughly 
in  the  svstem. 

At  the  time  of  the  first  eruption  many  patients  complain  of  severe 
headache.  This  is  due  not  to  the  development  of  organic  lesions  in  the 
brain,  but  to  the  circulation  in  the  blood  of  toxins  produced  by  the 
syphilitic  virus.  These  headaches  are  comparable  in  their  nature  and 
origin  to  the  o.steocopic  and  muscular  pains  experienced  at  the  same 
time.  They  are  often  severe  and  productive  of  great  distress.  Under 
appropriate  treatment  they  usually  disapj^ear  in  a  relatively  short  period 
of  time.  If  no  mercurials  have  l)een  administered  previously,  a  tenth 
of  a  grain  of  calomel  may  be  given  every  hour  until  relief  is  obtained 
or  until  signs  of  ptyalism  begin  to  appear.     This  is  the  readiest  and 


884  SYPHILIS. 

quickest  way  of  relieving  the  sufferer.  If  for  any  reason  mercury 
cannot  be  used,  resort  must  be  had  to  the  iodides,  either  of  potassium 
or  sodium.  These  must  be  given  in  increasing  doses  until  freedom  from 
distress  is  secured. 

Nervous  affections  due  to  organic  and  structural  change  can  be  re- 
ferred to  lesions  occurring  in  the  bones  enclosing  the  nervous  organs, 
the  meningeal  coverings,  the  nervous  tissue  itself,  or  the  bloodvessels 
ramifying  in  it. 

Gummata,  nodes,  exostoses,  carious  and  necrotic  centres  developing 
upon  the  inner  surface  of  the  vault  or  vertebral  canal,  or  in  the  bones 
enclosing  these  cavities,  are  a  fruitful  source  of  nervous  trouble  in  the 
pressure  effects  they  are  apt  to  produce.  Symptoms  arising  directly  from 
such  lesions  are  declared  in  mental  and  visual  disturbances,  intense  and 
prolonged  headaches,  hemiplegia,  convulsive  attacks,  interference  with 
locomotion,  and  changes  in  the  reflexes.  Inflammation  of  the  brain  and 
cord  may  result  from  direct  extension  of  the  disease  occurring  in  these 
parts. 

The  meninges  of  the  brain  and  cord  are  subject  to  gummatous  infil- 
tration, either  in  localized  deposits  or  throughout  extensive  areas.  Dif- 
fuse or  circumscribed  inflammatory  patches  arise  in  which  the  height- 
ened vascularization  results  in  marked  thickening  of  the  membranes. 
The  dura  mater,  owing  to  the  free  development  of  connective  tissue  en- 
tering into  its  composition,  is  most  frequently  attacked.  The  gumma- 
tous formation  may  begin  in  its  substance  or  be  the  result  of  extension 
from  neighboring  bony  tissue.  The  meninges  of  the  brain  are  more  apt 
to  suffer  than  are  those  of  the  cord.  The  process  gives  rise  to  intense 
headaches,  delirium,  muscular  inco-ordination,  aphasia,  and  hemiplegia. 
Headache  beginning  as  a  slight  dull  pain,  and  increasing  in  intensity 
with  nocturnal  exacerbations  in  which  the  suffering  becomes  frightful, 
is  characteristic  of  meningeal  involvement.  Extension  of  the  process 
may  result  in  the  development  of  a  meningo-encephalitis  affecting  large 
portions  of  one  or  both  hemispheres. 

Syphilis  of  the  Brain  and  Nerves. — Gummata  occurring  in  the 
brain  are  found  more  frequently  in  the  cortex  than  in  the  deej)er  por- 
tions, and  in  the  cerebrum  oftener  than  in  other  parts.  The  neoplasms 
exist  as  single  or  multiple  tumors  varying  in  size  from  a  poppy  seed  to 
an  olive.  They  often  occur  in  very  great  numbers,  and  are  nearly 
always  found  accompanying  similar  lesions  in  the  meninges.  In  their 
earlier  stages,  when  seen  in  post-mortem  examination,  the  lesions  appear 
as  small  circumscribed  translucent  bodies  imbedded  in  the  substance  of 
the  brain  tissue.  As  the  gummata  enlarge  they  undergo  the  caseous 
degeneration  seen  in  like  lesions  elsewhere.  They  are  usually  sur- 
rounded by  an  inflammatory  area  in  which  increased  development  of 
neuroglia  occurs.  Resolution  is  usually  accomplished  by  absorption 
of  the  product,  or  the  neoplasm  may  undergo  calcareous  or  cystic 
degeneration.  Gummata  are  found  but  rarely  in  the  deeper  struc- 
tures, such  as  the  ventricles,  optic  thalamus,  internal  capsule,  and 
corpus  striatum.  Syphilitic  affections  of  these  parts  are  more  apt  to 
be  expressed  in  some  form  of  arterial  disease.  The  middle  cerebral 
artery  or  some  one  of  its  branches  suffers  the  most  frequently,  either  in 
the  form  of  a  specific  endarteritis  or  periarteritis.     Occlusion  of  the 


SYrillLlS   OF  THE  CORD.  885 

bloodvessels  by  thrombi  may  take  place,  or  the  vessel  may  rii]>ture  and 
liem()rrhag:e  into  the  surrouiidinn'  tissnes  result.  The  size  of  the  lesion 
is  here  in  no  wise  projjortioned  to  the  gravity  of"  the  symptoms  re- 
sulting', occlusion  of  the  smallest  artery  in  the  internal  capsule  giving 
rise  to  the  most  serious  and  disastrous  consequences.  Aneurysmal 
dilatations  or  pouches  of  the  arterial  walls  may  be  })roduced  by  the 
disease.  Paralysis  coming  on  as  the  result  of  thrombosis  is  slow  in 
its  onset,  while  that  caused  l)y  rupture  of  an  aneurysm  is  sudden. 
When  slow  in  its  approach,  numbness  is  first  noted  in  the  foot,  hand,  or 
cheek,  or  it  may  be  that  some  slight  difficulty  in  speech  is  first  expe- 
rienced. These  symptoms  increase  slowly  in  intensity  and  extent  until 
a  part  or  the  whole  of  one  side  is  paralyzed.  Several  days  may  be  occu- 
pied in  the  process.  Or,  when  rapid,  the  patient,  without  premonition 
of  coming  trouble,  suddenly  finds  himself  unable  to  speak  or  to  use  hand 
or  foot.  Consciousness  is  not  completely  lost.  This  feature  is  almost 
typical  of  syphilis.  The  senses  are  deadened  and  mental  activity  is 
decidedly  in  abeyance,  but  the  patient  can  still  be  aroused  sufficiently 
to  show  by  signs  that  he  is  conscious  of  his  surroundings.  Convulsions 
are  not  often  present.  The  reflexes  of  the  affected  side  are  exaggerated. 
Recovery  may  be  rapid,  slow,  or  delayed  indefinitely.  Atrophy  of  the 
parts  paralyzed  is  unusual,  but  contractures  may  occur. 

No  grouping  of  symptoms  referable  to  syphilis  of  the  brain  is  pos- 
sible. The  best  established  feature  of  such  symptoms  is  their  varia- 
bility. Headache  is  always  present.  It  usually  begins  insidiously, 
increases  gradually,  is  nocturnal  in  character,  and  is  usually  described 
as  grinding,  boring,  or  hammering  in  nature.  Gummata  of  the  brain, 
if  large,  may  give  rise  to  all  the  symptoms  produced  by  the  different 
forms  of  brain  tumor.  In  these  symptoms  may  be  included  convul- 
sions, vomiting,  and  optic  neuritis.  Occasionally  syphilitic  disease  of 
the  brain  may  be  manifested  in  emotional  or  psychical  disturbances, 
such  as  mental  hebetude,  hysteria,  hypochondriasis,  stupor,  somnolence, 
dementia,  or  mania. 

Syphilis  of  the  Cord. — The  cord  is  not  as  frequently  attacked  as  is 
the  brain.  The  trouble  may  begin  in  the  bones,  in  the  coverings  of 
the  cord,  or  in  the  cord  itself.  Gummata  and  a  diffuse  proliferation  of 
the  connective  tissue  elements  are  the  forms  of  syphilitic  affi?ction  most 
likely  to  occur.  Symptoms  arising  from  such  involvement  are  mani- 
fested in  exaggeration  of  the  reflexes,  loss  of  control  of  the  sphincters, 
spastic  paralysis  of  the  lower  limbs,  anaesthesia  or  partesthesia,  lanci- 
nating pains  in  the  back  and  down  the  thigh,  and   contractures. 

The  relation  of  syphilis  to  tabes  dorsalis  appears  to  be  definitely 
settled.  Erb,  in  a  series  of  369  cases  of  the  latter  disease,  established 
the  fact  that  89  per  cent,  of  the  patients  had  previously  suffered  with 
syphilis.  Such  a  preponderance  cannot  be  regarded  in  any  light  but 
that  of  cause  and  effect. 

The  Peripheral  Nerves. — Specific  involvement  of  the  peripheral  nerves 
may  occur,  and  is  characterized  by  mild  or  severe  neuralgias,  by  vague, 
indefinite  sensations,  by  burning  ])ains  in  the  toes  or  fingers,  and  by 
para?sthesia  of  limited  or  extended  areas  of  the  skin.  The  sensations 
produced  are  sometimes  distressing  in  the  extreme,  and  are  a])t  to 
increase  as  the  disease  progresses.     The  symptoms  are  often  rebellious 


886  SYPHILIS. 

to  treatment,  requiring  the  largest  doses  of  the  iodide  to  subdue 
them. 

Syphilis  of  the  Eye. — All  of  the  tissues  of  the  eye,  the  soft  parts 
about  it,  and  the  bones  forming  the  orbit  may  be  the  seat  of  syphilitic 
affections.  Owing  to  the  delicacy  and  sensitiveness  of  the  structures 
involved  such  afFections  are  apt  to  be  grave. 

The  Orbital  Bones. — Gummata  may  form  in  the  periosteum  or  in  the 
orbital  bones,  and  by  their  pressure  effects  give  rise  to  severe  pain  in 
the  eye,  disturbances  in  vision,  or  displacement  of  the  globe.  Nodes 
are  not  rare.  The  bones  may  be  affected  by  periostitis,  osteitis,  carious 
degeneration,  and  necrosis.  The  inflammation  excited  by  such  processes 
may  extend  to  the  eyeball  and  give  rise  to  a  deep  seated  or  superficial 
cellulitis.  Abscess  may  follow  with  discharge  through  fistulous  tracts 
in  the  eyelids.  Such  sinuses  are  frequently  rebellious  to  treatment,  and 
may  require  surgical  interference  before  they  can  be  closed.  Pain  is 
often  intense,  and  constitutional  disturbances  due  to  depression  are  some- 
times great.     The  adjacent  cerebral  structures  may  become  involved. 

In  gummata  of  the  orbit  treatment  should  be  prompt  and  energetic. 
Reliance  must  be  placed  upon  the  iodides,  and  they  must  be  given 
often  in  the  largest  doses.  Their  administration  should  be  accompanied 
by  mercurial  inunctions  of  the  feet  each  night.  Supportive  measures 
are  needed.  The  bitter  tonics,  iron,  quinine,  strychnine,  cod-liver  oil, 
and  the  malt  extracts  are  often  necessary  to  improve  the  general  condi- 
tion. Locally,  fomentations  of  boric  acid  solution,  as  hot  as  they  can  be 
borne,  are  often  grateful,  or,  if  they  are  not  productive  of  comfort,  cold 
may  be  tried.  Operative  measures  to  remove  dead  bone  or  evacuate 
abscesses  are  sometimes  necessary. 

The  Lachrymal  Apparatus. — The  lachrymal  gland  and  ducts  may  be 
the  seat  of  a  chronic  catarrhal  process.  This  is  usually  associated  with 
some  thickening  of  the  Schneiderian  membrane  or  disease  of  the  nasal 
passages.  Stricture  of  the  lachrymo-nasal  duct  is  apt  to  follow.  Atten- 
tion to  the  patient's  history  with  reference  to  a  luetic  taint  or  unmis- 
takable symptoms  of  syphilis  in  other  parts  are  needed  in  establishing 
the  diagnosis.  Treatment  is  by  antisyphilitic  measures,  and  in  case  of 
stricture  by  clivulsion  of  the  duct  with  large-sized  probes. 

The  Eyelids. — The  initial  sclerosis  may  occur  either  upon  the  inner 
or  outer  surface  of  the  eyelid.  The  lesion  is  here  characterized  by  the 
same  signs  as  when  appearing  elsewhere.  Usually  considerable  oedema 
of  the  parts  ensues.  Enlargement  of  the  pre-auricular,  parotid,  and 
submaxillary  glands  on  the  side  affected  constitutes  the  bubo.  Chan- 
cres occurring  on  the  mucous  surface  of  the  eyelid  may  interfere  seri- 
ously with  sight. 

The  early  consecutive  lesions  may  appear  on  both  surfaces  of  the 
lids,  but  are  not  frequent.  Upon  the  mucous  surface  they  are  produced 
only  after  the  part  has  been  irritated  in  some  manner.  Mucous  patches 
appearing  upon  the  conjunctiva  usually  follow  a  mild  course  and  respond 
readily  to  treatment.  Local  measures  consist  in  protecting  the  eye  w^ith 
a  shade  and  stimulating  the  lesions  slightly  by  the  application  each  day 
of  a  mild  solution  of  silver  nitrate.  One  to  three  grains  of  the  salt  to 
a  fluidounce  of  distilled  water  is  sufficient. 

Gummata  may  appear  upon  the  eyelid,  usually  late  in  the  course  of 


SVl'IIILIS   OF   THE  FAi:.  887 

the  tlisoasc.  Tlicir  site  of  pn-fiTciu't'  is  aloii^-  tlu'  free  Ixji'dcr.  \n  size 
they  vary  from  a  pinhcad  to  a  pea.  Care  iiiiist  he  cxtTciscd  in  distiii- 
guishin<»'  thciii  iVoin  cystic  or  tihroid  tumors,  which  they  arc  a|)t  to 
resemble.  (Jiimmata  usually  involve  all  of  the  tissues  of  the  lid,  while 
either  of  the  forms  of  tumor  noted  are  frequently  confined  to  a  single 
layer,  as  to  the  integument  or  conjunctiva. 

The  ( hiijunctird. — Injection  and  inflammation  of  the  ocular  con- 
junctiva are  common  in  syphilis  and  are  usually  accompanied  by  an 
iritis  of  the  same  eye.  Two  cases  of  chancre  oi'  the  part  have  been 
reported.  Consecutive  lesions  may  occur  in  connection  with  the  first 
skin  erujjtion.  The  lesions  appear  as  circumscribed  macular  spots  or 
small  ])aj)ular  elevations,  coppery  in  hue  and  without  injection.  They 
are  seldom  numerous.  Gummata  are  rare.  They  are  found  oftenest  in 
the  pal[)cbral  conjunctiva,  but  may  develop  in  the  ocular  portion  at  the 
border  of  the  cornea.  The  neoplasms  vary  in  size  from  a  i)iuhead  to  a 
pea,  and  are  usually  spherical  in  shape.  The  inner  surface  is  often 
reddened,  while  the  outer  is  whitened  or  yellowish.  They  are  liable  to 
terminate  in  ulceration.  If  numerous,  the  nodules  may  interfere  with 
the  nutrition  of  the  cornea  in  sufficient  degree,  by  pressure  upon  the 
lymphatics,  to  bring  about  destruction  of  the  part  and  complete  loss 
of  vision. 

IVie  Cornea. — The  cornea  is  far  more  frequently  affected  in  inherited 
than  in  acquired  syphilis.  A  diffuse  interstitial  keratitis  sometimes 
appears,  giving  to  the  part  a  cloudy,  muddy  appearance.  The  process 
begins  at  the  centre  and  spreads  gradually  to  the  border  of  the  cornea, 
or  it  may  follow  the  reverse  direction,  beginning  at  the  periphery  and 
advancing  toward  the  centre.  The  affection  is  always  chronic,  lasting 
often  for  years.  A  true  punctate  keratitis  may  arise.  In  this  form  the 
lesions  are  pinhead  sized,  grayish  looking  deposits.  They  are  never 
vascularized  and  never  ulcerate.     Gummata  have  been  observed. 

The  Sclerotic. — Syphilitic  affections  develop  here  in  the  form  of  epi- 
scleritis, parenchymatous  scleritis,  or  gummatous  deposit. 

Episcleritis  occurs  as  a  superficial  congestion  of  the  sclerotic.  It  is 
never  extensive,  though  several  patches  may  be  discovered  at  once  upon 
the  visible  portion  of  the  membrane.  The  conjunctiva  is  usually  injected 
at  the  same  time,  and  in  a  measure  obscures  recognition  of  the  process 
in  the  sclerotic.  There  is  but  little  distress  accompanying  the  condition. 
Parenchymatous  scleritis  is  deeper  and  far  more  severe.  Exudation  is 
marked.  The  conjunctiva  is  swollen  and  elevated.  An  iritis  usually 
accompanies  it.  The  pain  may  be  light  or  severe.  The  process  is 
always  chronic.  Atrophy  and  thinning  of  the  tissues  may  follow,  but 
ulceration  never  takes  place.  Gummata  developing  in  the  sclerotic 
appear  first  as  small  reddened,  interstitial  deposits.  If  unchecked  in 
their  course,  they  enlarge,  extend  into  other  coats  of  the  eye,  and  may 
go  on  to  complete  destruction  and  removal  by  ulceration  of  the  eyeball. 

The  Iris. — Inflammation  of  the  iris  due  to  syphilis  is  an  exceedingly 
common  affection.  It  appears  early  in  the  course  of  the  disease,  usually 
shortly  after  the  subsidence  of  the  exanthemata,  but  it  is  by  no  means 
rare  at  later  periods.  One  eye  only  may  be  involved  or  both  may  suffer 
in  succession  or  simultaneously.     liecurrences  may  happen. 

The  patient  first  notices  uneasy  sensations  or  decided  pain  in  the  eye  ; 


888  SYPHILIS. 

light  is  distressing  to  the  organ ;  there  is  inability  to  see  clearly,  and 
epiphora  results.  Inspection  shows  the  pupil  small  and  sluggish  in  its 
reaction  to  light,  and  of  a  dull  hazy  color ;  the  iris  is  discolored  and 
slightly  swollen  ;  the  conjunctiva  is  lightly  or  deeply  injected ;  the  lids 
are  cedematous,  and  there  is  more  or  less  lachrymation.  As  the  result 
of  posterior  synechia  the  iris  may  become  attached  to  the  crystalline  lens. 

Serous  iritis  may  give  rise  to  exudation  into  the  anterior  chamber  of 
the  eye.  The  aqueous  humor  then  becomes  muddy  and  semigelatinous 
in  consistency.  The  iris  and  lens  are  pushed  back  by  the  exudate,  and 
sight  is  seriously  interfered  with.  Nodular  lesions  may  occur  in  the 
iris  or  on  its  surface,  due  to  organization  of  the  plastic  material  fur- 
nished by  the  inflammatory  process.  The  membrane  may  be  thickly 
covered  with  these  bodies,  and  by  their  means  become  firmly  attached 
to  the  capsule  of  the  crystalline  body.  In  such  cases  the  iris  exhibits 
the  convexity  of  the  lens. 

The  prognosis  is  good  if  treatment  be  begun  before  adhesions  have 
formed.  Rest,  exclusion  of  light  by  means  of  a  shade  or  colored 
glasses,  and  freedom  from  worry  are  essential  measures  in  treatment. 
Antisyphilitic  medication  must  be  continued,  but  it  is  not  often  of 
value  to  push  it  much  beyond  the  average  dose.  Local  measures  are 
of  the  greatest  importance.  Complete  mydriasis  must  be  produced  and 
continued  until  the  process  is  at  an  end.  Two  to  five  drops  of  the  fol- 
loAving  solution  should  be  instilled  into  the  eye  three  times  each  day 
until  the  pupil  is  widely  dilated : 

^.  Atropinse  sulphatis,  gr.  j  ; 

Aquse  destillatse,  3iv. — M. 

Sig.  Two  to  five  drops  in  the  eye  three  times  a  day. 

Pain  may  be  lessened  by  the  addition  of  an  eighth  of  a  grain  of 
morphia  to  the  above  solution  or  by  the  use  of  warm  fomentations. 

The  Ciliary  Body. — Syphilitic  cyclitis  or  inflammation  of  the  ciliary 
body  is  a  somewhat  rare  but  exceedingly  grave  affection.  Owing  to  the 
anatomical  location  of  the  structure,  the  signs  displayed  in  its  affections 
cannot  be  observed  by  the  naked  eye  nor  by  the  aid  of  the  ophthalmo- 
scope, and  reliance  must  be  placed  upon  the  subjective  symptoms  alone 
in  determining  the  diagnosis.  The  affection  may  be  serous,  plastic,  or 
gummatous.  Its  development  and  course  are  marked  by  severe  pain, 
visual  disturbances,  ciliary  injection,  more  or  less  diminution  of  tension, 
and  serous  exudation  into  the  vitreous  humor,  obscuring  or  completely 
destroying  vision.  Usually  the  iris  and  choroid  are  implicated  in  the 
process,  and  the  affection  is  then  designated  an  irido-choroiditis.  When 
the  iris  is  not  involved  it  is  often  retracted  toward  the  part  of  the 
ciliary  body  affected.  Such  retraction  frequently  results  in  considerable 
deepening  of  the  anterior  chamber.  Particles  are  visible  floating  in 
the  vitreous  humor.  Minute  deposits  on  the  membrane  of  Descemet 
can  be  detected.  The  aqueous  humor  may  become  dark  and  turbid. 
Glaucoma  is  a  frequent  result  of  posterior  synechia. 

Gummata  may  extend  into  the  ciliary  body  from  the  iris  or  develop 
in  it  primarily.  Atrophy  of  the  body  usually  results  after  gummatous 
infiltration. 


SYPHILIS  OF  THE  IJAIi.  889 

The  Choroid. — Choroiditis  is  next  in  i"r('(|U('ncy  to  iritis  as  a  syphilitic 
affection  oi"  tiic  eye,  and  is  often  associated  with  it.  Two  forms  have 
been  noted,  ditVcrinji,-  in  the  htcation  of  the  trouhh-  ratiier  than  in  the  j)ceu- 
liarity  or  severity  of  the  syni[)tonis  numifestech  The  iirst  form  is  confined 
to  the  anterior  portion  of  the  choroid  and  is  always  acconij)anicd  by  an 
iritis.  The  second  affects  the  ])()sterior  portion  of  tlie  membrane  only. 
In  eitiier  ease  there  is  exndation  into  the  [)(»sterior  chamber  with  resnlt- 
inir  clondiness  of  the  vitreons  humor.  FK)ccnli  floatin<>;  free  in  tiic 
humor  in  the  anterior  part  of  the  chand)er  are  visible.  Reticulated 
bauds,  ajipcaring  like  cobwebs,  may  be  formed  by  the  plastic  exudate. 
Small  yellow  specks  can  be  seen  with  the  o})hthalmoscope  upon  the 
fundus  or  upon  the  wall  of  the  posterior  chamber.  Atro})hy  of  the 
cell  elements  at  the  place  where  these  bodies  are  situated  is  apt  to 
follow.  The  retina  is  frequently  affected  in  conjunction  with  the 
choroid.  The  optic  nerve  usually  shows  a  hypenemic  condition.  True 
gunimata  are  not  known  to  appear  in  the  choroid.  Choroiditis  occurs 
late  in  the  course  of  the  disease  and  usually  in  patients  past  middle 
life. 

The  Refhia. — Syphilitic  retinitis  occurring  without  previous  impli- 
cation of  the  choroid  is  rare.  One  or  both  eyes  may  be  affected. 
Subjective  sensations  consist  of  slight  pain,  dimness  of  vision,  photo- 
phobia, flashes  of  light,  slight  lachrymation,  and  night-blindness.  The 
retina  appears  as  if  obscured  by  a  veil,  the  retinal  vessels  are  hypersemic, 
the  fundus  is  indistinct,  and  the  disk  engorged.  Loss  of  vision  is  slight 
or  marked  in  degree.  The  affection  may  be  confined  to  the  fundus  and 
the  parts  in  the  near  neighborhood,  or  the  peripheral  portion  of  the 
retina  may  alone  be  affected.  Syphilitic  retinitis  may  be  acute,  sub- 
acute, or  chronic.  Vision  is  usually  spared,  though  it  may  be  greatly 
diminished.  A  peculiarity  of  syphilitic  retinitis  is  that  it  is  apt  to 
occur  wdien  there  are  no  other  symptoms  of  the  disease  manifested  else- 
where in  the  body.  Reliance  must  be  placed  upon  the  history  in  such 
cases.  Early  recognition  is  essential  to  its  successful  treatment.  Mixed 
treatment  is  indicated,  either  by  combination  of  the  iodide  and  the  mer- 
curial in  solution,  or,  better,  by  the  administration  of  the  iodide  inter- 
nally and  the  use  of  the  mercury  by  inunction. 

The  ojitic  nerve  may  be  affected  either  within  the  orbit  or  within  the 
cerebral  tissue.  The  inflammation  develops  usually  in  connection  with 
retinitis.  The  symptoms  presented  are  those  of  choked  disk.  There  is 
engorgement  of  the  vessels  ;  the  nerve  is  greatly  swollen  and  infiltrated  ; 
its  color  is  red  or  reddish  gray,  and  its  retinal  border  is  wdiolly  obliter- 
ated. Usually  but  one  nerve  is  affected.  Partial  loss  of  sight  often 
results.     Only  rarely  does  complete  blindness  follow. 

Syphilis  of  the  Ear. — The  ear  is  not  often  the  seat  of  syphilitic 
invasion,  but  when  attacked,  especially  in  its  deeper  structures,  it  is  apt 
to  suffer  severely.  Chancres  due  to  kissing  or  biting  are  met  with  occa- 
sionally upon  the  external  ear,  and  one  case  of  chancre  in  the  meatus 
has  been  noted.  In  the  early  stages  of  the  disease  the  integument  of 
the  auricle  may  display  any  of  the  consecutive  lesions  incident  to  that 
period.  At  a  later  stage  the  substance  of  the  lobe  may  become  the  seat 
of  gummata.  Such  deposits  may  occur  within  the  lobule  or  upon  either 
surface  of  the  cartilage,  and  the  affection  is  apt  to  pursue  a  rapid  and  de- 


890  SYPHILIS. 

structive  course.     Eemoval  of  a  large  part  of  the  lobe  may  be  effected. 
Superficial  ulcerations  result  from  gummatous  nodules  in  the  skin. 

Early  consecutive  lesions  occur  within  the  canal.  They  may  be 
moist  or  dry  and  at  times  give  rise  to  a  tormenting  pruritus.  A  dry 
form  of  seborrhoea  developing  in  the  part  is  sometimes  seen  in  early 
syphilis.  The  accumulations  of  sebaceous  material  may  be  sufficient  to 
effectually  plug  the  passage.  Intractable  ulcers  may  appear  within  the 
walls  of  the  canal.  The  ulcers  are  usually  painful  and  productive  of 
free  discharge.  Exostoses  occur  at  the  meatus,  but  some  doubt  exists 
as  to  their  being  due  to  syphilis.  The  bony  growths  are  not  distin- 
guishable from  similar  lesions  occurring  in  individuals  free  from  the 
disease.  Condylomata  are  by  far  the  most  frequent  form  of  syphilitic 
lesion  found  in  the  meatus.  The  affection  occurs  with  greatest  fre- 
quency in  the  early  stages  of  the  disease,  and  severe  ulceration  is  apt 
to  follow.  The  lesions  begin  as  dry  papules  the  size  of  a  millet  seed 
and  enlarge  to  that  of  a  pea.  The  papule  becomes  moist,  the  ej)ithe- 
lium  is  macerated  and  removed,  and  a  typical  secreting  vegetation 
remains.  Considerable  pain  attends  the  development  of  the  lesions. 
Annular  contraction  of  the  meatus  due  to  cellular  infiltration  in  the 
true  skin  may  result  in  partial  deafness. 

Macules  and  papules  may  develop  on  the  membrana  tympani.  If 
ulceration  of  the  lesions  takes  place,  perforation  of  the  membrane  is 
apt  to  result.  Small  gummata  have  been  described  as  occurring  in  this 
structure.  Affections  of  the  tympanum  are  not  well  understood.  Its 
intimate  relationship  with  the  naso-pharynx  by  means  of  the  Eusta- 
chian tube  makes  it  liable  to  participate  in  the  troubles  arising  in  that 
region.  This  usually  happens  in  the  form  of  a  diffuse  catarrhal  inflam- 
mation of  the  lining  membrane  of  the  cavity,  with  closure  of  the  tube 
and  the  production  of  partial  or  complete  deafness.  This  form  of  serous 
inflammation  is  frequently  seen  in  children  suffering  with  hereditary 
syphilis.  A  true  suppurative  inflammation  due  to  syphilis  may  arise. 
It  is  distinguishable  in  no  wise  from  suppuration  of  the  middle  ear  due 
to  other  causes,  save  that  local  treatment  has  little  or  no  effect  upon  it, 
while  it  responds  readily  to  antisyphilitic  measures.  A  small-celled  in- 
filtration of  the  parts  may  occur  as  an  independent  affection  or  follow- 
ing one  of  the  above  described  forms  of  inflammation.  It  gives  rise  to 
considerable  thickening  of  the  walls,  and  may  produce  ankylosis  of  the 
ossicles.  Symptoms  of  trouble  taking  place  within  the  middle  ear  are 
declared  in  diminution  or  complete  loss  of  hearing,  earache,  suppura- 
tion, and  discharge. 

Little  is  known  regarding  syphilitic  affections  of  the  labyrinth. 
Thickening  of  the  lining  membrane  owing  to  a  hyperplastic  inflam- 
mation of  the  parts  may  occur.  Gummata  have  also  been  found.  A 
sensation  of  ringing  in  the  ears,  vertigo,  and  deafness  are  the  chief 
symptoms. 

Pathological  Anatomy. 

The  pathological  anatomy  of  syphilitic  lesions  is,  with  very  few 
exceptions,  not  distinctive.  Microscopical  study  of  the  lesions  shows, 
in  the  same  manner  as  does  the  clinical  study  of  the  disease,  the  imita- 
tive faculty  of  syphilis.     The  structural  features  of  syphilitic  neoplasms 


PATIfOLOaiCAL  AXATOMY.  891 

in  all  essential  respects  are  like  tlujse  seen  in  a  nniltitnde  of  lesions  (luo 
to  other  niorUid  [)roeesses.  Yet  here,  as  in  their  <;rossi'i'  f'eatnres,  those 
ehan>ies  present  some  eharaeteristie  a])pearanees  that  reveal  to  the  eye 
of  the  trained  [)athologist  their  true  natnre.  The  ini|)rint  of  -yj)hilis 
is  npon  them. 

The  most  eharaeteristie  lesion  of  syphilis  is  the  jjjnmmy  tumor.  It 
is  not  eoniined  to  any  sta*ie  of  the  disease,  bnt  occurs  either  early  or 
late  in  its  conrse.  ^lieroseopical  examination  of  such  a  tumor  in  the 
earlier  period  of  its  development  reveals  a  circumscribed  or  diffuse  mass 
of  embryonic  cells  enveloped  in  a  gelatinous  basement  substance  and 
surrounded  by  a  hypememic  area.  Epithelioid  and  giant  cells  sometimes 
ap])ear.  The  cells  are  of  a  low  order  of  organization  and  exceedingly 
fragile.  Within  the  hyperaMiiic  zone  first  formed  a  free  development 
of  connective  tissue  takes  ])lace,  forming  an  apparent  envelope  for  the 
embryonic  mass  within.  From  this  envelope  connective  tissue  pro- 
cesses invade  the  tumor  substance  and  radiate  into  the  surrounding 
tissues.  Infiltration  of  the  newly  formed  connective  tissue  with  sphe- 
roidal and  epithelictid  cells  takes  place.  Xew  formed  bloodvessels 
ramify  freely  in  the  mass,  and  there  is  a  considerably  increased  flow 
of  blood  to  the  part.  Enlargement  of  the  neoplasm  may  be  rapid  or 
slow  and  by  peripheral  extension.  It  will  be  seen  from  the  description 
thus  far  given  that  the  lesion  is  not  essentially  a  tumor  in  which  there 
is  a  new  growth  occurring,  but  a  neoplasm  arising  from  a  hyperplastic 
inflammation  and  belonging  distinctively  to  the  granulation  type. 

A  gumma  may  disappear  at  any  stage  of  its  early  development  by 
resolution,  absorption  of  its  products  taking  place,  or  it  may  and  does 
most  frequently  undergo  cheesy  degeneration.  When  this  happens  one 
or  more  necrotic  points  first  appear  within  the  substance  of  the  nodule. 
These  enlarge,  become  fused,  and  in  time  occupy  the  greater  part  of  the 
tumor.  The  mass  now  appears  as  if  composed  of  finely  grated  cheese 
pressed  closely  into  a  compact  body.  A  wall  of  granulation  tissue  forms 
about  the  cheesy  mass.  This  product  of  coagulation  necrosis  may  be 
removed  by  absorption,  or  ulceration  with  destruction  and  sloughing 
of  the  nodule  may  follow.    A  cicatrix  then  results. 

A  second  feature  of  syphilitic  inflammation  that  is  more  or  less 
typical  in  its  nature  is  the  frequency  with  which  the  process  invades 
the  vascular  structures.  The  arteries  show  the  specific  inflammation  in 
its  completest  development.  As  the  result  of  the  process  infiltration  of 
the  walls  of  the  vessel  with  small  round  or  polyhedral  cells  takes  place, 
producing  an  appearance  that  has  been  likened  to  the  arrangement  of 
the  coat-sleeve  about  the  arm.  This  infiltration  occurs  chiefly  within 
the  perivascular  lymph  spaces  and  between  the  coats  of  the  artery. 
Considerable  thickening  and  rigidity  of  the  walls  results.  The  pro- 
cess may  be  localized  or  extended  throughout  considerable  areas.  The 
product  may  be  absorbed,  but  more  often  results  in  the  formation  of 
fibrous  connective  tissue,  with  the  production  of  a  limited  arterio- 
sclerosis. The  vessels  in  the  near  neighborhood  of  the  chancre  are 
affected  early. 

The  initial  sclerosis  in  view  of  its  mcII  defined  clinical  aspects  ought 
to  present  definite  structural  features.  This,  however,  is  not  the  case. 
Its  minute  anatomy  is  not  definitely  characteristic.     The  changes  por- 


892  SYPHILIS. 

trayed  are  those  liable  to  occur  in  any  low  grade  of  inflammation. 
There  is  an  abundant  development  of  small  round  cells  within  a  more 
or  less  dense  connective  tissue  stroma.  The  parts  are  freely  invaded  by 
leucocytes.  Giant  and  epithelioid  cells  sometimes  occur.  Proliferation 
of  connective  tissue  elements  takes  place.  The  small  bloodvessels  en- 
tering the  part  display  the  above  described  coat-sleeve  infiltration  of 
their  tunics.  This  latter  feature  is  continued  along  the  vessels  to 
parts  at  some  distance  from  the  initial  lesion.  The  newly  formed  con- 
nective tissue  shows  a  tendency  to  persist  unchanged  for  some  length  of 
time,  but  is  finally  absorbed.  The  induration  of  the  chancre  is  caused 
by  dense  infiltration  of  the  connective  tissue  spaces  with  cells  and  by 
oedema  of  the  corium  and  epidermal  layers  at  the  borders  of  the  lesion. 
It  is  also  probable  that  the  syphilitic  poison  exerts  a  specific  influence 
upon  the  lymph  of  the  part  affected,  and  that  this  action  of  the  virus  is 
partly  responsible  for  the  induration  that  takes  place.  The  cells  de- 
veloping in  the  part  vary  but  little  in  size  at  first,  but  later  many  of  them 
become  much  enlarged  and  oftentimes  multinuclear. 

The  earlier  lesions  of  the  skin,  such  as  macules  and  papules,  present 
no  structural  features  that  distinguish  them  from  like  lesions  produced 
by  low  grades  of  inflammation  not  syphilitic.  There  is  congestion  of 
the  corium  with  exudation  into  its  parts,  and  a  resulting  hyperplasia  of 
the  epidermis.  Pustular  lesions  present  a  torn  condition  of  the  epider- 
mal structures,  with  partial  or  complete  destruction  of  the  corium  and  a 
mingling  of  the  products  of  necrosis  with  blood  and  leucocytes.  They 
are  in  no  wise  distinguishable  from  the  pustules  occurring  in  other  dis- 
eases. Lesions  of  the  mucous  membranes  have  the  same  features  as 
those  presented  in  like  lesions  appearing  upon  the  surface  of  the  skin. 
In  the  lymph  glands  infiltration  of  the  vascular  channels  with  sphe- 
roidal and  epithelioid  cells  appears  to  be  the  chief  pathological  process. 

The  free  production  of  new  connective  tissue  is  a  characteristic  feature 
of  the  syphilitic  process.  This  occurs  in  connection  with  the  develop- 
ment of  many  of  the  different  lesions  or  as ,  the  result  of  their  disinte- 
gration and  resolution.  This  tendency  is  particularly  well  defined  in 
the  nervous  system,  and  especially  late  in  the  course  of  the  disease.  It 
is  undoubtedly  the  element  that  makes  syphilis  an  etiological  factor  in 
the  production  of  tabes  dorsalis. 

Diagnosis. 

Early  recognition  of  the  chancre  is  chief  in  its  importance  in  the 
diagnosis  of  syphilis.  Such  recognition  depends  upon  several  factors, 
no  one  of  which  can  be  omitted  with  safety.  First  and  of  greatest  im- 
portance is  the  history  with  reference  to  the  time  of  suspected  infection. 
Sores  appearing  within  ten  days  after  exposure  to  a  possible  source  of 
infection  are  probably  not  syphilitic  in  nature.  Those  occurring  later 
than  ten  days,  and  especially  at  about  the  end  of  the  third  week,  are  to 
be  regarded  with  suspicion.  Peference  must  be  had,  in  determining  the 
length  of  time  that  has  elapsed  between  contamination  and  the  appear- 
ance of  the  sore,  to  records  not  only  of  the  last,  but  of  previous  indul- 
gences in  sexual  intercourse.  A  sore  may  be  found  upon  the  genital 
organs  shortly  after  coitus  that  in  reality  had  its   origin  some  weeks 


Dr.\(;x()Sfs.  ,si»;i 

previously  in  a  similar  exposure.  The  production  and  examination  i)i' 
the  person  suspected  tt)  be  the  sourei'  ol"  the  troul)le  is  alwavs  a  desir- 
able, but  often  an  unpleasant  and  imj)ossibk',  means  ol'  verilyin^-  the 
dia_<!:nosis. 

The  physical  characteristics  of  tlie  legion  I'lii'iiisli  another  ^^roup  of 
synij)toms  uselul  in  establish ini;-  a  dia<;iiosis.  Oftentimes  these  features 
are  the  only  evidences  obtainable  u[)on  which  to  base  conclusions.  The 
initial  lesion  of  syphilis  is  usually  single,  in  contradistinction  to  the 
lesion  of  chancroid,  which  is  almost  invariably  multiple.  The  inflam- 
mation exhibited  in  chancre  is  not  so  intense  nor  acute  as  in  chancroid. 
The  chancre  is  nearly  always  indurated,  the  chancroidal  lesion  is  never  so. 
It  must  be  remembered,  however,  that  in  early  stages  of  chancre  the 
induration  may  be  so  slight  as  not  to  be  perceptible,  and  that  in  some 
regions,  as  in  the  vagina,  it  may  never  appear.  It  should  also  not  be 
forgotten  that  the  use  of  caustics  upon  a  simple  lesion  may  produce  a 
condition  simulating  very  much  the  indurating  oedema  of  chancre. 
Inquiry  with  reference  to  the  previous  use  of  such  applications  is 
essential.  It  is  an  unwise  procedure  for  the  practitioner  to  he  posi- 
tive in  his  statements  concerning  any  sore  upon  the  genital  organs  in 
respect  to  which  he  must  base  his  conclusions  alone  upon  the  physical 
signs  presented  by  the  lesion.  The  better  practice  by  far  is  to  wait  for 
more  definite  symptoms.  These  are  soon  manifested  in  case  of  chancre 
by  enlargement  and  induration  of  the  neighboring  lymph  glands.  AVhen 
the  sore  is  seated  upon  the  penis  the  glands  in  both  groins  are  enlarged. 
Rarely  but  one  inguinal  region  shows  this  symptom.  This,  however, 
need  not  be  confused  with  the  enlargement  shown  in  chancroid.  In 
chancroidal  bubo  inflammatory  phenomena  speedily  appear ;  the  gland 
becomes  painful  and  boggy  to  the  touch,  the  skin  reddens  and  suppura- 
tion occurs  ;  while  the  bubo  of  chancre  remains  firm  and  movable  un- 
derneath the  skin,  is  not  painful,  and,  unless  complicated  by  chancroid, 
never  suppurates. 

In  the  case  of  men  presenting  genital  lesions  there  should  be  free 
exposure  of  the  body  surface.  Before  examination  of  the  sore  is  made 
it  should  be  the  rule  to  pass  the  finger-tips  firmly  over  both  inguinal 
regions.  If  any  enlargement  of  the  glands  has  taken  place,  it  can  be 
readily  noted.  If  the  investigation  of  the  groins  be  made  thus  early,  it 
will  not  be  neglected,  as  is  apt  to  be  the  case  when  the  fingers  have 
become  soiled  in  handling  the  chancre.  To  search  the  inguinal  region 
first  is  a  valuable  procedure  in  every  form  of  venereal  disease.  Often- 
times in  doing  so  a  hint  of  trouble  is  obtained  that  otherwise  might  not 
be  suspected.  This  is  frequently  the  case  in  blennorrhoea  accompanied 
by  chancre  of  the  urethra.  After  examination  for  bubo  has  been  made 
scrutiny  of  the  sore  should  follow.  The  lesion  should  be  freely  exposed 
and  cleansed  of  all  secretions.  If  more  than  one  sore  is  present,  each 
should  receive  the  same  careful  survey.  The  physician  need  not  hesitate 
to  handle  the  initial  sclerosis  between  the  thumb  and  fore  finger  if  the 
skin  covering  these  parts  be  intact  and  sound  and  the  hands  be  washed 
immediately  afterward. 

Next  in  order  is  inspection  of  the  body  surface.  This  should  be 
done  in  a  clear,  strong  light,  and  the  search  for  signs  of  the  disease 
should  be  thorough  and  complete.     Syphilodermata  usually  appear  first 


894  SYPHILIS. 

over  the  anterior  surface  of  the  chest  and  abdomen,  but  they  may  arise 
elsewhere  before  developing  in  these  regions.  In  examining  the  body 
note  should  be  made  of  scars  and  relics  of  former  trouble.  Of  especial 
value  are  cicatrices  in  the  groins  as  furnishing  evidences  of  previous 
venereal  disease. 

In  the  case  of  women  greater  delicacy  must  be  exercised  in  mak- 
ing such  an  examination.  Women  are  apt  to  inspect  the  surface  of 
their  bodies  with  greater  care  and  frequency  than  are  men,  and  their 
statements  with  reference  to  any  eruption  can  be  given  fuller  belief. 
Confirmation,  however,  should  always  be  sought,  and  this  can  usually 
be  accomplished  by  exposure  of  a  portion  of  the  body  only  at  a  time. 
Usually,  women  will  submit  the  part  affected  to  the  physician's  in- 
spection without  marked  objection. 

In  general,  it  should  be  remembered,  in  distinguishing  early  syphilo- 
dermata  from  other  eruptions,  that  the  syphilitic  lesions  are  usually  sym- 
metrical in  development,  extensive  in  distribution,  not  apt  to  be  the  seat 
of  subjective  sensations,  and  are  usually  accompanied  by  mucous  patches 
in  the  mouth  and  throat,  by  loss  of  hair,  and  by  other  symptoms  of 
syphilis. 

The  erythematous  syphiloderm  is  to  be  distinguished  from  the  rashes 
appearing  in  the  eruptive  fevers  by  its  deeper  color,  by  its  indolent 
character,  by  the  involvement  of  the  palms  and  soles,  and  by  the 
absence  of  catarrhal  discharge.  If  fever  is  present,  it  seldom  rises  as 
high  in  syphilis  as  in  the  exanthemata,  and  is  apt  to  persist  for  a  longer 
time.  In  syphilis  relics  of  the  initial  lesion  can  usually  be  found  or  a 
history  of  the  chancre's  recent  existence  elicited.  Osteocopic  pains,  sore 
throat,  mucous  patches  in  the  mouth,  and  alopecia  are  usually  present. 
Erythematous  eczema  is  usually  less  extensive  in  its  involvement  of  the 
skin,  and  is  productive  of  intense  itching,  while  the  lesions  of  syphilis 
give  rise  to  no  discomfort.  In  eczema  the  color  is  a  brighter  red  and 
moisture  of  the  surface  appears  sooner  or  later.  In  tinea  versicolor 
the  patches  are  tawny  in  color,  and  are  found  most  frequently  on  the 
surface  of  the  chest.  The  microscope  shows  the  characteristic  fungus. 
Drug  eruptions  are  accompanied  by  a  marked  degree  of  discomfort,  and 
appear  in  unusual  sites  and  forms.  A  history  of  some  ingested  medica- 
ment can  usually  be  obtained. 

Papular  syphilodermata  are  easily  distinguished  from  papules  occur- 
ring in  other  diseases  by  their  peculiar  forms  and  distinctive  groupings. 
Papules  in  eczema  are  frequently  surmounted  by  a  minute  vesicle  or 
covered  by  a  blood-crust  indicative  of  the  scratching  by  which  relief  is 
sought  from  the  tormenting  pruritus.  On  the  hands  and  feet  syphilis 
confines  its  attacks  to  the  palmar  and  plantar  regions,  while  eczema 
involves  both  anterior  and  posterior  surfaces.  Ringworm  can  be  dis- 
tinguished by  the  aid  of  the  microscope,  the  tricophyton  being  readily 
discoverable.  In  psoriasis  the  glistening,  pearly  white  scales  surmount- 
ing the  lesions  and  the  chronic  sluggish  action  of  the  process  are  distin- 
guishing features. 

The  pustular  syphiloderm  must  not  be  confused  with  the  lesions  of 
acne,  smallpox,  or  the  eruptions  produced  by  the  ingestion  of  potassium 
iodide  or  potassium  bromide.  In  acne  the  evident  involvement  and 
limitation  of  the  process  to  the  sebaceous  glands  at  once  determines 


TRKATMEST  OF  SYPHILIS.  895 

the  nature  of  the  disorder.  Comedones  also  arc  always  found  niin<2;led 
with  the  pnstidcs.  The  fever  antl  severe  eonstitutional  syiM|)toiiis  of 
smallpox  exchidc  syphilis.  Kno\vled»>-e  that  the  hroiiiinc  and  iodine 
compounds  have  been  ingested  is  usually  suitieient  to  establish  a  dis- 
tinction in  the  case  of  bromic  or  iodic  acne.  The  pustules  of  syphilis 
show  a  well  defined  areola,  while  ulcerative  lesions  are  nearly  always 
present. 

The  tliatiiiosis  of  late  manifestations  of  the  disease  must  dej)end 
uj)on  the  history,  upon  the  typical  grouping-,  upon  the  usually  sluggish 
action,  and  upon  the  destructive  course  of  the  lesions. 

Treatment  of  Syphilis. 

The  proper  treatment  of  syphilis  takes  into  consideration  the  im- 
provement of  the  patient's  general  health  by  hygienic  measures,  as 
Avell  as  the  medicinal  attack  to  be  made  upon  the  disease.  Neither  can 
be  neglected  with  safety,  and  only  as  they  are  made  to  supplement  and 
assist  each  other  can  the  best  results  of  treatment  be  hoped  for.  Atten- 
tion must  be  directed  early  to  the  patient's  habits  and  methods  of  life, 
and  if  these  be  found  faulty  or  vicious  they  must  be  corrected.  Pre- 
vious periods  of  ill  health  should  be  made  the  subject  of  inquiry,  and 
provision  be  made  for  their  recurrence  or  resulting  sequels.  If  the 
patient  be  surrounded  by  unhygienic  conditions  or  engaged  in  business 
calculated  to  produce  ill  health,  a  change  of  location  or  of  employment 
should  be  urgently  recommended.  Hopefulness  and  cheerfulness  on 
the  part  of  the  person  aifected  must  be  secured  if  possible.  Despond- 
ency, often  seen  in  patients  of  this  class,  frequently  nullijSes  the  physi- 
cian's eiforts.  Upon  the  untiring  watchfulness  with  which  the  practi- 
tioner guards  these  factors  depends  in  a  large  part  the  favorable  or 
unfavorable  outcome  of  the  therapeutical  measures  he  institutes. 

Hygienic  Measures. — Everything  looking  toward  the  maintenance  of 
the  patient's  health  on  the  highest  plane  possible  is  of  utmost  value  in 
the  treatment  of  syphilis.  As  in  the  treatment  of  disease  in  general, 
so  in  syphilis  it  may  be  affirmed  with  truth  that  the  patient  presenting 
and  maintaining  a  sound  body  is  in  the  best  condition  to  resist  the 
encroachments  of  the  malady.  To  the  end  of  securing  such  a  con- 
dition proper  nutrition  of  the  body  is  chief  in  importance.  Any 
conditions  or  disturbances  interfering  with  digestion  or  assimilation 
must  be  removed  as  early  as  possible.  The  diet  should  be  ordered  in 
such  manner  that  there  will  be  no  return  of  the  trouble,  while  ample 
nourishment  is  secured.  In  arranging  the  diet  reference  must  be 
had  to  peculiarities  of  the  patient's  case,  such  as  extreme  plethora  or 
aneemia.  In  general  it  may  be  said  that  a  person  suifering  with  syphilis 
needs  a  generous  diet  of  nutritious  and  easily  digestible  articles  of  food 
which  have  been  well  and  simply  cooked.  Meals  should  be  had  at 
regular  intervals,  and  should  be  eaten  slowly  and  with  care  in  thoroughly 
masticating  the  food.  Very  hot  or  very  cold  drinks  or  dishes,  as  well 
as  highly  seasoned  foods  or  an  undue  amount  of  sweets,  should  be  inter- 
dicted. Fresh  fruit,  fresh  vegetables,  and  fresh  meats  if  well  cooked 
may  be  permitted  in  abundance.  Tea  and  coffee,  if  drunk  sparingly 
and  after  the  meal,  do  no  harm.     Lemonade  mav  be  taken  if  agreeable. 


896  SYPHILIS. 

It  is  well  always  to  prohibit  the  use  of  alcoholic  beverages,  not 
because  the  moderate  use  of  the  milder  stimulants  is  harmful,  but  to 
avoid  danger  of  their  abuse  on  the  part  of  the  patient.  A  majority  of 
individuals  suffering  with  syphilis  are  persons  who  have  indulged  their 
appetites  with  reference  to  alcohol  freely,  and  limitation  of  its  use  is  to 
them  of  decided  advantage.  When  permitted,  drinking  should  be 
allowed  only  with  the  meals,  and  then  in  small  quantities  of  the  lighter 
wines  or  liquors,  such  as  claret  or  Rhine  wine,  and  beer,  ale,  or  porter. 
Drinking  at  a  bar  should  never  be  tolerated.  In  weak  and  cachectic 
subjects  alcoholic  stimulants  are  frequently  indicated,  and  the  practi- 
tioner need  not  then  hesitate  to  use  them. 

A  moderate  amount  of  daily  exercise  in  the  open  air  is  essential. 
The  regulation  of  this  must  be  determined  by  the  patient's  habits  and 
occupation.  For  persons  engaged  in  sedentary  pursuits  at  least  one 
hour  should  be  devoted  each  day,  when  the  weather  will  permit,  to 
walking,  rowing,  or  riding.  Outdoor  sports  that  do  not  call  for  too 
great  exertion,  such  as  tennis  and  golf,  are  of  decided  value  both  in  the 
exercise  they  furnish  and  the  diverting  influence  they  exert  upon  the 
mind.  Fatigue  of  both  body  and  mind  should  be  strictly  guarded 
against. 

Proper  bathing  of  the  body  needs  careful  attention.  Hot  baths,  not- 
withstanding their  vaunted  specific  proj^erties  at  certain  springs  and 
resorts  for  the  cure  of  the  disease,  are  in  the  early  stages  of  the  malady 
productive  of  a  great  deal  of  harm.  The  popular  Turkish  and  Russian 
baths,  as  well  as  hot  tub  baths,  should  be  strictly  prohibited.  In  their 
place  sponging  of  the  entire  surface  each  day  with  cool  or,  in  the  case 
of  weak  and  anaemic  patients  with  tepid,  water  should  be  ordered.  If  a 
small  quantity  of  salt  be  added,  as  a  handful  to  two  or  three  gallons  of 
water,  the  result  will  be  found  decidedly  exhilarating  and  refreshing. 
Friction  of  the  surface  after  the  bath  with  a  flesh  brush  or  coarse  toM^el 
should  not  be  omitted.  The  bath  is  best  taken  in  the  morning  imme- 
diately after  rising.  If  such  a  course  be  pursued,  many  of  the  severer 
syphilodermata  will  never  make  their  appearance.  Bathing  of  the  body 
in  the  case  of  women  should  be  stopped  at  the  time  of  the  monthly 
period. 

Tobacco  in  all  forms  is  decidedly  injurious,  and  frequently  produces 
lesions  that  give  rise  to  great  discomfort.  When  its  use  is  persisted  in, 
it  is  apt  to  excite  severe  ulcers,  mucous  patches,  and  fissures  of  the  lips 
and  parts  within  the  mouth  cavity.  Tobacco  also  exerts  a  vicious  influ- 
ence upon  the  system,  interfering  in  a  decided  manner  Avith  the  best 
results  to  be  obtained  from  therapeutical  measures.  Its  use,  either  by 
chewing  or  smoking,  should  be  abandoned  promptly  and  completely  at 
the  outset  of  the  disease. 

Especial  attention  should  be  given  to  the  care  of  the  mouth  and  to 
the  protection  of  the  throat.  Thorough  cleaning  of  the  teeth  by  means 
of  the  toothbrush  and  tepid  water  should  be  attended  to  after  each  meal. 
The  brush  used  should  be  sufficiently  firm  to  remove  all  particles  of 
food  clinging  to  the  teeth,  but  not  harsh  enough  to  wound  the  sensitive 
mucous  membrane  covering  the  gums.  Other  sources  of  irritation, 
such  as  holding  a  pipe  or  cigar  between  the  teeth,  chewing  a  toothpick, 
gum,  or  other  substance,  should  be  prohibited.     Decayed  teeth  should 


TJti-:A'nn:xT  of  syi-iulis.  897 

be  oxtnu'tod  or  have  their  oavitics  filh'd  ;  sharj)  iirojcctioiis  must  Ijc 
romuh'd  oil'  ami  atHMimiihitions  of  so-caUccl  tartar  he  thoroiiulily  sc'ra[)t'(l 
away  by  a  t'ai)abU»  ck'iitist  early  in  the  courrie  of  the  disease.  The  tliroat 
must  be  kept  warm  by  the  use  of  ample  coverings  in  cold  weather,  and 
the  wearing'  of  a  beard  by  men  should  be  encouraged,  both  for  the  pro- 
tection it  alViii'ds  and  to  guard  against  the  ill  effects  produced  Ijy  close 
shaving. 

The  scalp  needs  proper  attention  as  well,  in  order  that  loss  of  hair 
may  be  avcrtetl.  Indiscriminate  washing  of  the  head  with  each  ablu- 
tion of  the  face  is  harmful.  In  its  stead  thorough  cleansing  of  the  part 
with  warm  water  and  a  good  toilet  soap,  such  as  the  Kieger  or  Sarg 
fluid  soap,  should  be  secured  once  in  ten  days  or  two  weeks.  After 
each  washing  the  hair  should  be  well  dried,  and  a  few  drops  of  oil  of 
olives  or  sweet  almonds  should  be  thoroughly  applied.  Polishing  of  the 
scalp  with  a  moderately  stilf  brush  should  be  practised  each  morning. 
In  men  clipping  of  the  hair  is  not  needed  if  the  individual  does  not 
prefer  to  wear  it  in  that  manner.  Singeing  is  decidedly  harmful  and 
should  never  be  permitted.  The  crown  of  the  hat  should  be  perforated 
to  permit  as  free  ventilation  of  the  scalp  as  possible.  In  women  the 
hair  may  be  worn  in  any  form  suited  to  the  individual,  provided  that 
there  be  no  tension  exerted  upon  the  filaments.  The  use  of  the  curling 
iron  should  be  prohibited. 

Treatment  of  the  Chancre. — The  belief  that  syphilis  can  be  aborted 
by  excision  of  the  initial  lesion  is  entertained  now  by  only  a  limited 
number  of  syphilographers.  Admitting  that  the  poison  is  confined  at 
an  early  stage  to  the  chancre,  its  accompanying  glandular  enlargements 
and  the  intervening  lymphatics,  removal  of  all  the  foci  established  there- 
in, even  with  great  loss  of  tissue  and  severe  mutilation,  can  hardly  hope 
to  be  effected.  Excision  of  the  chancre  can  only  be  justified  when  its 
exposure  on  the  fiice  or  other  external  part  by  betrayal  of  the  patient's 
condition  seriouslv  interferes  with  social  or  business  engagements.  Its 
removal  then  must  not  be  with  any  hope  of  staying  the  subsequent 
course  of  the  disease. 

That  course  of  treatment  is  best  for  the  chancre  which  seeks  to 
remove  all  sources  of  irritation  from  the  lesion  and  to  keep  it  in  a 
thoroughly  aseptic  condition.  The  simpler  such  treatment  the  better 
are  the  results  obtained.  The  chancre  should  be  thoroughly  cleansed  at 
frequent  intervals  with  soap  and  warm  water,  after  which  the  sore 
should  be  dried  and  bathed  with  a  saturated  solution  of  boric  acid  as 
hot  as  can  be  comfortably  borne  by  the  patient.  This  should  be  done 
at  least  twice  a  day  at  times  best  suited  to  the  patient's  convenience. 
After  bathing  with  the  boric  acid  soluti(^n  the  part  should  be  dried  and 
dusted  freely  with  some  unirritating  antiseptic  poM'dcr,  such  as  boric 
acid  in  combination  with  talc  or  starch  in  the  proportion  of  one  to  four, 
aristol,  iodol,  europhen,  calomel,  or  iodoform  if  its  odor  be  not  offensive 
to  the  patient.  Other  solutions  of  value  when  boric  acid  is  not  at  hand 
are  permanganate  of  potassium  in  the  strength  of  one  grain  to  the  fluid- 
ounce  of  water,  bichloride  solution  1  :  20,000,  or  a  ^  to  1  per  cent,  solu- 
tion of  carbolic  acid.  These  should  always  be  used  warm.  Chancres 
of  the  penis  or  finger  may  be  conveniently  immersed  in  such  solutions 
contained  in  a  cup  or  tumbler  and  allowed  to  remain  for  ten  or  more 

Vol.  I. — 57 


898  SYPHILIS. 

minutes  at  a  time.  If  the  lesion  be  productive  of  much  pain,  as  hap- 
pens sometimes  in  the  case  of  mixed  chancre,  such  immersion  may  be 
continued  for  hours  with  great  advantage  and  comfort  to  the  patient. 
Chancres  of  the  finger  may  be  protected  by  a  light  bandage  neatly 
applied,  but  in  general  no  dressing  is  needed  for  the  lesion  in  other 
parts.  A  bandage  should  never  be  wrapped  about  the  penis.  Here  a 
square  of  muslin  or  unbleached  sheeting  may  be  fastened  in  the  form 
of  an  apron  to  the  under  side  of  the  shirt,  and  the  parts  then  be  gath- 
ered loosely  about  the  penis.  In  this  way  the  underclothing  need  not 
become  soiled  with  the  secretions  from  the  chancre.  All  dressings  used 
about  the  lesion  or  becoming  soiled  in  any  way  with  its  virus  should  be 
destroyed  by  burning.  Chancres  of  the  tongue,  tonsil,  and  mouth  cavity 
should  be  painted  lightly  once  each  day  with  a  solution  of  silver  nitrate 
in  the  strength  of  ten  grains  of  the  salt  to  an  ounce  of  distilled  water. 
If  chancre  of  the  lip  or  external  part  shows  signs  of  suppuration,  it 
should  be  touched  with  an  applicator,  made  of  a  toothpick  and  a  bit 
of  cotton,  dipped  in  the  following  solution  : 

^.  Hydrargyri  chloridi  corrosivi,  gr.  j  ; 

Tincturse  benzoini,  .^j. — M. 

Sig.  External  use. 

This  solution  is  decidedly  stimulating  and  should  not  be  too  freely  used. 

Chancres  of  the  os  uteri  and  vaginal  cavity  are  best  treated  by  the 
use  of  boric  acid  douches  as  hot  as  can  be  borne.  The  permanganate 
of  potassium  and  bichloride  solutions  can  be  used  here  as  well.  The 
douching  should  be  practised  at  least  once  in  the  day.  Frequent  appli- 
cations of  the  nitrate  solution,  used  as  in  the  case  of  mouth  lesions,  help 
to  promote  healing  and  resolution  of  the  sore.  Tampons  are  not  often 
needed. 

OEdema  of  the  penis  calls  for  its  prolonged  immersion  in  a  hot  borated 
lotion,  and  subsequent  elevation  of  the  organ  along  the  groin.  This  can 
be  accomplished  easily  by  putting  a  broad  band  of  muslin  firmly  about 
the  abdomen  and  then  passing  another  between  the  limbs  and  fastening 
it  before  and  behind  with  safety  pins.  To  those  who  can  secure  it 
a  jock-strap  furnishes  a  support  that  can  be  more  easily  and  quickly 
applied.  If  the  lymphatics  become  swollen  and  tender,  the  application 
of  the  following  ointment  after  sponging  the  parts  affected  with  hot 
water  will  usually  give  prompt  relief: 

1^.  Tincturse  belladonnse,  TTLx  ; 

Extract!  opii  (aqueous),  gr.  ij  ; 

Vaselini,  Iss. — M. 
Sig.  External  use. 

Care  should  be  exercised  in  the  use  of  the  above  ointment,  as  the 
mydriatic  effect  of  the  belladonna  may  be  readily  produced. 

Systemic  Treatment  of  Syphilis. — When  to  begin  the  systemic  treat- 
ment of  syphilis  is  a  question  concerning  which  a  great  diversity  of 
opinion  exists  among  syphilographers.  This,  however,  is  not  the  place 
to  give  in  detail  the  different  views  entertained  nor  to  promote  by  a  pro- 


TRKATMF.M    nf  SYI'IIIIJS.  899 

loniif'd  discussion  :uiv  one  |):irticiil;ir  course  ol"  jtroccdiirc.  Success  does 
not  do[)end  so  much  uj)on  tlii'  time  that  :intisy])hilitic  measures  are  hc^i'ini 
as  upon  their  intolliiicnt  direction  after  once  ht-ing-  instituted.  It  is 
believed  that  what  is  said  in  the  loUowini:-  patfcs  will  a|)|)ly  as  well  to 
treatment  first  employed  alter  the  erM])tion  of  tlie  syphih)(lermata  as 
when  the  course  is  ordered  at  an  earlier  sta*>-e. 

Treatment  should  he  <'()mmenc(Ml  as  soon  as  a  ))ositive  (hauiiosis  of 
syphilis  can  be  made,  and  it  shouhl  not  under  any  circmnstances  be 
instituted  before  such  time  is  reached.  If  the  ])ractiti()ner  is  in  doubt, 
he  siiould  wait.  If  he  is  to  guide  his  patient  through  the  disease  to  its 
successful  termination,  his  own  mind  must  not  be  clouded  by  a  doubt 
as  to  the  nature  of  the  malady  he  is  combating.  It  will  be  an  act  of 
wisdom  on  his  part  to  err  on  the  side  of  too  great  caution,  rather 
than  to  begin  mercurial  medication  upon  insufficient  grounds.  Treat- 
ment once  begun  is  apt  to  modify  the  nature  of  the  symptoms  mani- 
fested and  to  prevent  a  typical  expression  of  the  disease,  so  that  if  the 
practitioner  be  not  sure  of  his  position  at  the  start,  he  has  no  means  of 
verifvino'  his  diagnosis  later.  The  result  will  alwavs  be  a  weak  and 
ineifeetual  course  of  medication  at  a  time  when  energetic  treatment  is 
productive  of  the  greatest  benefit. 

The  question  thus  turns  on  the  diagnosis  of  syphilis.  Most  practi- 
tioners prefer  to  wait  until  the  disease  manifests  itself  in  unmistakable 
constitutional  symptoms,  such  as  a  generalized  exanthem,  glandular  en- 
largeiuent,  and  sore  throat.  If  treatment  be  begun  promptly  at  such 
time  and  pushed  vigorously,  the  great  majority  of  patients  will  respond 
readily  and  will  make  complete  and  good  recoveries.  But  it  is  not 
always  necessary  to  wait  for  all  of  the  above  described  symptoms  in 
order  to  make  a  diagnosis,  and  in  so  doing  valuable  time  is  often  lost. 
As  has  been  said  elsewhere,  a  sore  appearing  at  the  end  of  a  ^^■ell  defined 
incubative  period,  presenting  the  characteristic  slugijishness  and  indu- 
ration of  chancre,  and  accompanied  by  typical  enlargement  in  both 
groins,  is  sufficient  to  establish  a  diagnosis  of  syphilis  and  to  warrant 
the  commencement  of  systemic  treatment.  Experience  justifies  the 
assertion  that  measures  thus  early  begun,  if  properly  directed,  result 
in  the  production  of  a  milder  and  far  more  tractal)le  form  of  the  disease 
than  is  otherwise  the  case. 

Mercury. — There  is  no  drug  comparable  with  mercury  in  the  treat- 
ment of  syphilis.  Centuries  of  use  have  attested  the  efficiency  of  its 
action  in  checking  and  curing  the  disease.  The  employment  of  the 
drug,  hoAvever,  needs  skilful  direction.  To  the  abuse,  and  not  to  the 
[)roper  administration,  of  mercury  can  be  traced  all  of  the  ill  results 
with  which  it  has  been  so  often  charged,  while  the  charlatan  has  not 
hesitated  to  attribute  to  the  action  of  the  drug  many  specific  expressions 
of  the  disease. 

There  are  two  methods  of  employing  mercury — one  by  the  way  of 
the  stomach,  the  other  by  the  skin.  The  first  is  knoAvn  as  the  internal 
method  of  administration,  the  second  as  the  external.  Both  are  valuable 
means,  and  both  ai^e  equally  effective  in  the  results  they  produce.  Their 
individual  or  combined  employment  throughout  the  course  of  the  disease 
must  be  determined  by  the  necessities  and  emergencies  arising  in  the 
case. 


900  SYPHILIS. 

In  the  internal  administration  of  mercury  the  protiodide,  biniodide, 
bichloride,  blue  pill,  gray  powder,  and  mild  chloride  are  the  prepara- 
tions of  the  metal  commonly  employed.  Of  these,  the  protiodide  is  by 
far  the  most  reliable  and  effective  in  the  results  it  produces.  There  are 
few  patients  who  cannot  tolerate  its  action,  even  in  very  large  doses, 
and  its  use  can  be  continued  for  longer  periods  of  time  without  appar- 
ent diminution  in  the  good  to  be  obtained  from  it.  In  the  early  stages 
of  syphilis  it  is  often  necessary  to  increase  the  dose  very  largely  to  meet 
various  conditions  of  the  disease  that  may  arise.  Under  such  circum- 
stances it  is' well  to  give  the  drug  in  pill  form  uncombined  with  other 
medicinal  agents,  as  follows : 

^.  Hyclrargyri  iodidi  viridi,  gr.  xij  ; 

Confectionis  rosse,  q.  s. 

Misce  et  fiant  pilulse  No.  Ix. 
Sig.  One  pill  after  each  meal. 

Or  use  may  be  made  of  the  Garnier  and  Lamoureux  pill.  This  pill 
contains  one  centigram  of  the  protiodide,  and,  owing  to  the  manner  of 
its  preparation,  can  often  be  tolerated  by  the  stomach  when  the  drug  in 
its  pure  state  would  prove  irritating.  In  beginning  medication  one  of 
the  above  pills  should  be  given  after  each  meal.  If  urgency  in  the 
treatment  of  the  disease  is  demanded,  as  when  a  well  developed 
exanthem  accompanied  by  mucous  patches  and  sore  throat  is  first 
presented,  the  number  of  pills  taken  may  be  gradually  increased  until 
subsidence  of  the  symptoms  becomes  manifest  or  constitutional  effects 
of  the  drug  begin  to  appear.  In  sucih  increase  it  is  well  to  order  the 
patient  to  take  one  pill  after  each  meal  for  the  first  three  days.  Then 
an  additional  pill  is  to  be  taken  after  the  noon  meal  for  the  next  three 
days,  making  four  pills  taken  during  each  day.  During  the  succeeding 
three  days  two  pills  are  taken  after  the  morning  and  evening  meals,  and 
but  one  at  noon.  In  this  way  the  number  can  be  pushed  gradually  up- 
ward until  as  many  as  twenty  or  more  pills  may  be  taken  during  each 
day  without  the  production  of  toxic  symptoms.  These  large  doses, 
however,  are  rarely  needed  and  seldom  reached.  In  general,  it  will 
be  found  that  from  six  to  nine  pills  a  day  are  sufficient  to  bring  the 
disease  under  subjection  or  to  produce  gastric  disturbances  necessitating 
the  stoppage  of  further  increase.  During  this  time  the  patient  should 
be  under  strict  observation  by  his  physician.  Daily  inspection  of  the 
individual  should  be  had,  and  as  soon  as  evidences  of  toxic  action  on 
the  part  of  the  drug  are  manifested  the  increase  should  be  stopped  and 
the  number  of  pills  being  taken  reduced  one  half.  Toxic  effects  are 
first  shown  in  the  protiodide  by  increased  peristaltic  action  in  the  intes- 
tinal tract.  No  attention  need  be  paid  to  the  symptoms  if  the  number 
of  loose  stools  does  not  exceed  two  or  three  in  the  day,  but  when  they 
become  more  numerous  and  are  accompanied  by  severe  griping  pains, 
it  is  time  to  stop  pushing  the  drug.  Sometimes  the  first  effects  of  the 
protiodide  appear  in  the  usual  evidences  of  hydrargyrism,  such  as  soft- 
ening of  the  gums  with  the  formation  of  a  red  line  at  their  border,  fetor 
of  the  breath,  and  a  metallic  taste  in  the  mouth. 

If  improvement  in  the  specific  symptoms  has  not  been  noted  before 


'rj!i:ATM]:.\T  of  svrjiiLis.  '  ooi 

tlio  l)t'i]^iimino:  of  toxic  oflt'cts,  tlic  protiodidc  slidiild  not  he  coiitimicd 
loiigor  in  the  hope  that  it  may  ])rove  iK'Hclicial,  l)iit  it  iiiiist  he  discon- 
tinued and  some  other  ju'eparation  he  siihslitnted. 

Jt  is  usually  of  decided  advantai;e  to  comhine  a  liuht  course  ol"  mer- 
curial inunction  with  the  intei'ual  administration  ol"  the  jirotiodide.  A 
scruple  of  the  oilicinal  blue  ointment  should  be  thoroui^hly  rubbed  into 
the  sole  of  one  foot  each  night  before  the  patient  retires  to  rest.  The 
foot  should  be  bathed  first  in  warm  water,  and  afterward  be  thoroughly 
dried  before  applying  the  ointment.  A  light  sock  may  be  drawn  on  to 
protect  the  sheets  from  being  soiled.  On  the  following  night  the  <»ther 
foot  may  be  treated  in  like  manner.  Between  ten  and  twenty  oi'  these 
rubbings  may  be  given  as  seems  best  to  the  physician.  Such  inunctions 
should  be  discontinued  promptly  if  constitutional  effects  of  the  drug 
intervene. 

Iron  in  some  form  is  indicated  if  the  patient  be  in  any  wise  anaemic 
or  cachectic.  It  is  well  always  to  begin  its  administration  in  small 
doses  at  the  time  that  mercurial  treatment  is  instituted,  in  order  to 
prevent  the  appearance  of  the  above-named  conditions  and  to  check  in 
a  measure  the  peristaltic  action  produced  by  the  protiodide.  The  follow- 
ing will  be  found  valuable  : 

I^.  Ferri  et  quininae  citratis,  oj~iy  j 

Syrupi  limonis,  f  Sij  ; 

Aquse  destillattie,  q.  s.  ad  fovj. — M. 

Sig.  A  teasjjoonful  in  water  before  two  meals. 

Attention  should  be  directed  early  to  the  enlarged  glands  both  of 
the  bubo  and  those  appearing  later  in  different  parts  of  the  body.  It 
should  be  remembered  that  these  glands  are  foci  for  distribution  of  the 
virus  and  the  products  of  syphilis,  and  that  a  direct  attack  on  the  seat 
of  the  disease  can  here  be  made.  The  integument  over  each  gland 
should  be  sponged  at  night  with  warm  w^ater,  and  after  drying,  the 
following  ointment  should  be  gently  and  lightly  rubbed  in : 

I^.  Unguenti  hydrargyri,  3ij  ; 

Lanolini,  5ss. — M. 

Sig.  External  use. 

If  the  ointment  be  warmed  slightly  before  applying  it  to  the  skin,  better 
penetration  w^ill  be  secured.  Care  should  be  exercised  not  to  produce  a 
dermatitis  by  its  too  frequent  application. 

With  subsidence  of  the  symptoms  decrease  in  the  amount  of  the 
protiodide  taken  should  be  ordered,  until  a  dose  is  reached  that  will 
hold  the  disease  well  under  control  and  suppress  all  symptoms  of  it. 
This  dose  should  be  continued  steadily,  with  such  increase  or  decrease 
in  quantity  as  varying  conditions  of  the  disease  may  seem  to  indicate, 
for  a  period  varying  from  one  and  a  half  to  two  years.  The  iron  and 
the  protiodide  may  conveniently  be  combined  as  follows  : 

^.  Hydrargyri  iodidi  viridi,  gr.  xvj  ; 

Ferri  et  quinine  citratis,  9iv. 

Misce  et  fiant  capsulie  Xo.  Ixxx. 
Sig.  One  after  each  meal. 


902  SYPHILIS. 

Or, 

^.  Hydrargyri  iodidi  viridi,  gr.  xvj  ; 

Massse  ferri  carbonatis,  9iv. 

Misce  et  fiant  capsulse  Xo.  Ixxx. 
Sig.  One  after  each  meal. 

The  above  prescriptions  can  often  be  used  interchangeably  with  con- 
siderable value,  the  different  forms  of  the  iron  apparently  agreeing  well 
with  the  stomach.  If  at  any  time  symptoms  of  the  disease  make  their 
appearance,  the  amount  of  the  mercury  can  be  increased  by  the  taking 
of  one  or  more  protiodide  pills  with  each  dose. 

In  order  to  relieve  the  stomach  of  the  burden  placed  upon  it,  internal 
treatment  may  be  suspended  at  intervals  of  three  months  and  a  course 
of  inunctions  substituted.  In  general  such  course  should  not  last  for  a 
longer  period  than  two  weeks,  and  should  be  followed  by  a  return  to  the 
protiodide. 

If  it  should  be  found  after  a  thorough  trial  of  the  protiodide  that 
success  cannot  be  obtained  with  its  use,  or  if  it  disagrees  in  any  manner 
with  the  patient,  its  further  administration  should  be  stopped  and  some 
other  preparation  of  mercury  tried  in  its  place.  The  bichloride  is  of 
decided  value  and  can  be  given  as  follows  : 

]^.  Hydrargyri  chloricli  corrosivi,  g^'- j~y  5 

Tincturge  ferri  chloridi, 
Acidi  hydrochlorici  diluti,  da.  f  .^ij ; 

Syrupi  limonis,  f  5ij  ; 

Aquee  destillatse,  q,  s.  ad  f  5vj. — M. 

Sig.  Teaspoonful  in  water  after  each  meal. 

Or  the  above  can  be  given  after  the  first  and  last  meals  of  the  day,  and 
a  pill  containing  one  fifth  grain  of  the  protiodide  after  the  middle  meal 
and  at  night  when  retiring. 

The  biniodide  may  be  tried  in  pill  form  in  the  dose  of  one  fiftieth  to 
one  twenty-fifth  of  a  grain,  or  it  may  be  combined  in  capsule  with  the 
forms  of  iron  given  in  connection  with  the  protiodide. 

Calomel  in  doses  of  one  tenth  of  a  grain  can  be  employed  every  hour 
in  the  day  until  the  cathartic  action  of  the  drug  is  made  manifest,  when 
it  should  be  administered  less  frequently. 

The  gray  powder  in  pill  form  is  sometimes  serviceable  when  the 
others  fail : 

ly.  Hydrargyri  cum  cretse,  .9iv. 

Fiant  pilulse  No.  Ixxx. 
Sig.  One  pill  after  each  meal. 

If  all  these  methods  fail,  resort  must  be  had  to  some  one  of  the  external 
methods.     The  method  by  inunction  is  to  be  preferred. 

Ilercury  hy  Inunction. — This  is  always  a  valuable  method  of  admin- 
istering the  drug,  because  it  relieves  the  stomach  of  an  enormous  burden 
otherwise  placed  upon  it,  and  leaves  it  free  to  perform  its  natural  func- 
tions.    The  great  drawbacks  to  the  more  frequent  employment  of  mer- 


TREATMEST  OF  SY  I'll  I  LIS.  903 

ciiry  by  imiiiction  arc  its  sc'einin<;-  dii'tincss  and  the  disliUc  that  patients 
luive  to  the  labor  iiivolvi'd  in  the  aj)|)liration.  W  lien,  for  any  reason, 
the  st4^^)nuu'h  cannot  be  made  to  tolerate  the  varions  mercurial  prepara- 
tions, or  when  the  })atient  does  not  improve  under  such  treatment,  in- 
unctions should  be  employed.  The  hour  before  retiring  is  the  time  best 
suited  for  their  application.  The  body  may  be  divided  into  as  many 
regions  for  the  purpose  as  suits  the  j)ractitioner's  wishes  or  the  patient's 
convenience,  the  essential  factor  being  to  rub  the  ointment  in  well.  Six- 
divisions  are  usually  suHicient,  and  instructions  may  be  given  as  follows. 
The  patient  is  ordered  on  the  first  night  to  bathe  well  with  soap  and 
warm  water  the  arms  above  the  elbows,  the  shoulders,  and  the  chest 
region  above  the  nipple  line ;  then  to  dry  the  parts  and  to  rub  thorough- 
ly into  them  from  one  half  to  two  drachms  of  mercurial  ointment.  The 
officinal  ointment  of  the  PharmacopaMa  of  50  per  cent,  strengtli  has  stood 
the  test  of  time  and  may  be  used  with  good  results,  but  the  mercurial 
ointment  prepared  by  many  druggists,  in  which  the  metal  in  the  same 
strength  is  incorporated  with  lanoline  as  a  basis,  furnishes  a  preparation 
oifering  decided  advantages  in  the  ease  with  Avhich  it  can  be  applied. 
On  the  following  night  that  part  of  the  anterior  surface  of  the  body 
between  the  nipple  line  and  the  crural  angles  is  treated  in  like  manner, 
and  then  on  succeeding  ni2:hts  the  followinp;  res-ions  in  the  order  named  : 
the  posterior  surfaces  of  the  body  that  can  be  easily  reached  and  the 
buttocks ;  the  lower  limbs  as  far  as  the  knees ;  the  limbs  below  the 
knees ;  and  lastly,  the  soles  of  the  feet.  After  each  inunction  the 
patient  clothes  the  part  subjected  to  the  process  with  some  suitable  gar- 
ment and  retires  to  rest.  Upon  the  upper  segment  of  the  body  the 
night  shirt  protects  the  sheets  in  sufficient  manner.  When  the  lower 
half  is  undergoing  treatment  a  pair  of  drawers  may  be  drawn  on.  If 
at  any  time  before  complete  inunction  of  the  body  is  accomplished  the 
parts  where  the  ointment  has  been  applied  show  signs  of  irritation,  such 
regions  may  be  washed  clean  with  soap  and  warm  w'ater  and  dusted  Avith 
starch  or  finely  powdered  talc.  If  no  signs  of  trouble  appear,  bathing 
should  be  postponed  until  the  seventh  night,  when  the  entire  body 
should  be  cleansed  of  all  traces  of  the  ointment  by  means  of  a  Avarm 
bath.  If  needed,  the  entire  process  may  be  repeated,  beginning  on  the 
following  night,  or  the  inunctions  may  be  continued  on  the  soles  of  the 
feet,  shifting  at  regular  intervals  from  one  foot  to  the  other. 

The  mouth  must  be  Avatched  carefully  while  the  inunctions  are  in 
progress,  and,  if  the  gums  show  signs  of  coming  trouble,  the  process 
must  be  stopped  and  a  bath  ordered. 

Merciinj  by  Fumigation. — This  plan  of  using  mercury  is  of  decided 
value  when  extreme  urgency  in  the  symptoms  calls  for  immediate  action 
on  the  part  of  the  drug.  Fumigation  is  especially  useful  in  those  cases 
of  extensive  syphilodermata  in  which  the  lesions  cannot  be  made  to 
submit  to  ordinary  forms  of  treatment,  or  when  their  rapid  removal  from 
the  face  and  exposed  parts  is  necessitated  by  the  patient's  desire  for 
secresy.  In  the  large  cities  many  of  the  bathing  establishments  furnish 
admirable  facilities  for  giving  mercurial  fumigations,  and  when  con- 
veniently situated  it  is  well  for  the  physician  to  make  use  of  the  ad- 
vantages offered.  In  the  country  or  whore  the  patient  cannot  be 
induced   to  attend  one  of  the  institutions  named  the  practitioner  can 


904  SYPHILIS. 

carry  out  the  treatment  at  the  patient's  own  home  in  the  following 
manner  :  The  individual  is  stripped  naked  and  seated  upon  a  cane- 
bottomed  chair.  A  heavy  woollen  blanket  is  fastened  closely  about 
the  neck,  the  folds  being  allowed  to  fall  to  the  floor  in  the  form  of  a 
tent  completely  investing  the  person.  Underneath  the  chair  a  pan 
of  boiling  hot  water  is  placed  over  a  good-sized  spirit  lamp.  Care 
must  be  taken  not  to  let  the  blanket  come  in  contact  with  the  flame. 
This  can  be  prevented  by  placing  weights  upon  the  edges  resting  on 
the  floor  and  pinning  the  opening  in  the  rear.  The  steam  from  the 
boiling  water  induces  free  perspiration  of  the  body.  As  soon  as  the 
skin  has  become  well  moistened  the  mercurial  chosen  for  sublima- 
tion is  placed  above  an  alcohol  flame  underneath  the  blanket.  The 
receptacle  in  which  the  mercurial  is  contained  may  be  made  of  a 
bit  of  tin  rolled  up  at  the  edges  and  supported  upon  suitable  rests. 
Calomel  and  cinnabar  are  the  two  preparations  of  mercury  best  suited 
for  use  in  fumigation.  They  may  be  used  singly  or  with  better  results 
in  combination.  When  used  alone,  from  a  scruple  to  a  drachm  of  either 
preparation  may  be  employed.  If  in  combination,  it  is  well  to  use 
about  three  parts  of  cinnabar  to  two  of  calomel.  Thus  a  half  drachm 
of  cinnabar  and  a  scruple  of  calomel  may  be  taken.  The  fumigation 
should  continue  for  from  ten  to  thirty  minutes  if  no  untoward  symp- 
toms present  themselves.  If  the  patient  becomes  faint  or  experiences 
unpleasant  sensations,  the  process  must  be  stopped  at  once,  the  body 
wiped  dry,  and  a  stimulant  administered.  It  is  a  good  plan  in  the 
case  of  weak  and  debilitated  patients  to  give  a  small  quantity  of  brandy 
or  sherry  wine  before  beginning  the  operation.  After  the  fumigation 
the  patient  should  retire  to  rest.  Care  must  be  exercised  in  not  per- 
mitting the  body  to  become  chilled  during  or  after  the  operation.  Such 
fumigations  should  not  be  given  oftener  than  every  second  day,  and 
ought  not  to  exceed  four  in  number.  Supportive  and  tonic  treatment 
must  be  continued  while  they  are  being  employed. 

Fumigation  of  the  mouth  cavity  and  nasal  passages  is  frequently 
needed  in  the  case  of  obstinate  syphilitic  lesions  appearing  in  these 
regions.  An  Ermold's  calomel  sublimer  furnishes  an  elegant  and  easy 
method  of  supplying  the  fumes  for  such  purpose.  In  its  place  a  hot 
flatiron  or  fire  shovel  may  be  used.  Five  to  ten  grains  of  calomel  can 
be  placed  on  one  or  the  other,  and  as  the  fumes  rise  they  can  be  drawn 
slowly  into  the  mouth  and  nose  by  inhalation.  Irritation  of  the  bronchi 
must  be  guarded  against  by  not  prolonging  the  process  nor  repeating  it 
at  too  frequent  intervals. 

Treatment  of  Syphilis  by  the  Hypodermic  3IethocL — The  value  of  this 
method  in  the  treatment  of  syphilis  is  not  definitely  decided.  There 
are  some  syphilographers  wlio  give  it  their  hearty  support,  but  they  are 
few.  The  pain  associated  with  the  operation  and  the  occasional  disas- 
trous results  that  have  followed  its  use  interfere  with  its  extensive  em- 
ployment. The  claim  that  great  rapidity  and  certainty  of  cure  can  be 
effected  by  the  method  still  demands  verification.  Only  the  briefest 
outline  can  be  given  here. 

Either  the  soluble  or  insoluble  salts  of  mercury  may  be  used.  Cor- 
rosive sublimate,  as  indicated  in  the  following  formulse,  is  most  fre- 
quently employed  : 


Till-: ATM r.yr  nr  syriiiLis.  905 

^.   Ilydraruvri  clildi-idi  ('((iTo.-ixi,  ^r.  \  ; 

Sodii  cliloridi,  i;t.  'i'  ; 

A(iua'  (lcstillat:i\  f.-^j.— M. 

Sig-.   Jnjcct  IVoiu  one  luill"  to  oiu'  drachm  every  tliird  day. 

1]/.  llydrartivri  ehloridi  corrosivi,  gr.  x  ; 

Acidi  tartariei,  3.ss ; 

A(iu;e  destillatie,  f  5J. — M. 
Sig.  Inject  ten  nnnims  twice  a  week. 

^.  Hydrargyri  chloridi  eorrosivi,  gr.  j  ; 

Glycerin  i, 

AqutB  destillatffi,  da.  f  3j. — M. 
Sig.  Inject  ten  minims  daily. 

Other  solnble  salts  of  mercnry  that  may  be  tried  are  asparagiu-mer- 
<3ury  in  1  or  2  per  cent,  of  mcrcnrial  strength  ;  the  oxycyanide,  gr.  xv 
of  1.25  per  cent,  of  mercnry ;  the  carbolate  of  mercnry,  gr.  ^  to  |^;  and 
the  benzoate,  mercuric  albuminate,  and  peptonate. 

Among  insoluble  preparations,  calomel,  gray  oil,  yellow  oxide,  black 
oxide,  salicylate,  protiodide,  biniodide,  cinnabar,  sulphate,  and  metallic 
mercury  are  a  partial  list  of  the  different  forms  used.  The  use  of  the 
insoluble  salts  is  less  satisfactory  than  is  that  of  the  soluble  varieties. 
The  manner  in  whi(;h  calomel  is  used  can  be  taken  as  the  type  for  most 
of  the  compounds  given.  The  salt  should  be  first  thoroughly  sterilized 
by  subjecting  it  for  at  least  one  hour  on  two  successive  days  to  the  action 
of  steam,  and  then  employing  it  as  in  the  following : 

I^.  Hydrargyri  chloridi  mitis,  gr.  ss  ; 

Glycerini,  T||x ; 

Aquse  destillatse,  TTLx. — M. 
Sig.  Inject  every  four  days. 

The  amount  may  be  increased  so  that  two  grains  a  week  can  be  given. 
Instead  of  the  above  formula  the  following  is  sometimes  used  : 

I^.  Hydrargyri  chloridi  mitis,  gi'- j  ; 

Mucilaginis  acacise,  Tllxx. — M. 

Sig.  Inject  every  four  days. 

In  performing  the  operation  asepsis  is  of  the  greatest  importance. 
The  site  of  operation  must  receive  as  thorough  preparation  as  for  any  sur- 
gical operation,  the  hands  of  the  operator  must  be  alisolutely  clean,  and 
the  instrument  and  preparations  used  be  sterilized.  The  injection  should 
be  made  deeply  into  the  tissues,  the  buttocks  furnishing  a  favorite  site. 
The  patient  should  lie  flat  upon  the  belly  while  the  operation  is  beino- 
performed.  The  needle  used  should  be  about  one  half  longer  than  that 
ordinarily  employed  in  hypodermic  medication.  Care  must  be  exer- 
cised not  to  make  the  injection  into  a  bloodvessel. 

Hydrargyrkm—ThQ  toxic  effects  of  mercury  may  follow  quickly 
upon  its  first  administration  or  appear  only  after  the  druo-  has  been 


906  SYPHILIS. 

given  for  a  long  period  of  time  and  in  very  large  doses.  The  first 
symptoms  are  usnally  manifested  in  soreness  and  sponginess  of  the 
gums.  A  distinet  red  line  is  formed  at  their  border,  and  the  mucous 
membrane  bleeds  readily.  The  teeth  feel  long,  and  unpleasant  sensa- 
tions are  experienced  when  the  jaws  are  brought  forcibly  together. 
There  is  an  increased  flow  of  saliva,  the  tongue  is  heavily  coated  and 
swollen,  and  the  breath  is  decidedly  offensive.  These  symptoms  may 
come  on  slowly  or  rapidly.  If  the  drug  be  continued,  all  of  the  above 
manifestations  become  intensified.  The  saliva  flows  in  a  stream  from 
the  mouth,  the  swollen  tongue  fills  the  mouth  cavity  and  projects  be- 
tween the  lips,  necrosis  of  the  jawbones  takes  place,  the  teeth  fall  from 
their  sockets,  there  is  high  fever,  the  bones  and  joints  ache,  and  pain  and 
distress  are  felt  in  every  part  of  the  body. 

Prophylaxis  consists  in  keeping  the  mouth  perfectly  clean  and 
removing  from  it  every  means  of  irritation.  At  the  first  signs  of 
ptyalism  the  mercury  should  be  promptly  suspended  and  iron  tonics 
1)6  given.  If  severe  symptoms  come  on,  the  patient  must  be  made  to 
remain  quiet,  the  emunctories  of  the  body  be  kept  open,  the  diet  should 
be  nutritious  and  of  easily  digested  foods,  and  the  mouth  treated  with 
soothing  lotions  of  myrrh  and  honey.  The  gums  should  be  gently 
wiped  several  times  a  day  with  a  bit  of  soft  clotli  moistened  in  the 
following  : 

^.  Tincturse  myrrhse, 

Tincturse  cinchonse,  da.  f  5ss. — M. 

Sig.  External  use  on  gums. 

Lotions  of  oatmeal  water  and  honey  are  frequently  grateful,  as  are 
mild  solutions  of  potassium  chlorate.  All  liquids,  either  beverages  or 
washes,  should  be  gently  warmed  before  using.  If  the  case  be  care- 
fully managed,  a  good  recovery  will  usually  be  made.  Often  slight 
salivation  is  of  decided  benefit  in  the  treatment  of  the  disease. 

The  Compounds  of  Iodine. — The  compounds  of  iodine  are  indispen- 
sable in  the  treatment  of  syphilis.  They  cannot,  however,  take  the 
place  of  the  mercurials  in  the  general  measures  instituted  for  the 
relief  of  the  disease.  The  field  in  which  the  iodides  are  found  useful 
is  limited,  and  their  employment  should  be  restricted  within  such  limit- 
ations. No  treatment  of  syphilis  can  be  more  unwise  than  the  indis- 
criminate giving  of  the  iodine  salts,  as  is  often  done  early  in  the  course 
of  the  disease.  There  is  more  of  truth  than  error  in  the  statement  that 
mercury  cures  syphilis,  while  the  iodides  but  check  its  progress.  De- 
pendence must  be  placed  upon  the  salts  of  mercury  to  eradicate  the 
disease  from  the  system,  while  the  iodides  are  useful  in  bringing  under 
subjection  late  symptoms  that  are  to  be  regarded  as  sequelae  rather  than 
actual  manifestations  of  syphilis.  The  iodides  are  indicated  in  the  fol- 
lowing conditions  :  First,  when  gummata  make  their  appearance,  during 
any  stage  of  the  disease,  in  the  skin  or  in  deeper  and  more  vital  organs ; 
second,  in  those  cases  where  the  patient  cannot  be  made  to  tolerate  mer- 
cury in  any  form  ;  third,  where  mercury  has  been  administered  for  a 
long  period  of  time  it  is  frequently  of  value  to  interrupt  the  course  and 
in  the  mean  time  to  give  the  iodides  ;  fourth,  when  syphilitic  lesions 
cannot  be  made  to  respond  to  vigorous  mercurial  treatment. 


TJilUTMhWT  OF  SY  I'll  I  LIS.  907 

When  the  iodides  ;uv  <>iv('n  accordiiio-  to  tlio  nhovc  indications  tlicir 
intelli<i;ent  administration  is  often  attended  hy  Wrilliant  resnlts. 

The  salts  of  iodine  nsnally  eni])loye(l  inchide  the  iodides  of  |)otas- 
sium,  sodinni,  strontium,  lithiinn,  and  rtil)i(nnm.  Of  these  th(!  iochde 
of  jwtassinm  has  the  \\  icU'st  rant>,e  of  usefnhiess,  and  is  the  most  effec- 
tive in  obtainint>-  desired  results.  The  iodide  of  sodium  comes  next  in 
point  of  effieienev. 

The  iodide  of  potassium  may  be  o-iven  in  solution  in  teaspoonfid 
doses  containiuii:  five,  ten,  or  twenty  trains  of  the  salt  three  times  a 
day,  but  it  is  better  ])raetiee  to  p:ive  it  in  droj)  doses  of  a  saturated  solu- 
tion, as  follows  : 

I^.   Potassii  iodidi,  .^j  ; 

Aquse  destillatse,  q.  s.  ad  f  sj. — M. 

Sio'.  Drop  doses  as  directed. 

One  drop  of  the  saturated  solution  represents  nearly  one  grain  of  the 
salt.  In  giving"  the  drug  in  this  manner  its  dosage  can  be  varied  to 
suit  the  conditions  and  necessities  of  the  cavse.  It  is  well  to  begin  its 
administration  in  live  drop  doses  after  each  meal  and  at  bedtime,  increas- 
ing the  dose  one  drop  each  time  or  one  drop  in  the  day  as  the  urgency 
of  the  case  may  demand.  The  increase  should  be  pushed  steadily  until 
relief  is  obtained  from  the  symptoms  or  until  signs  of  iodism  make 
their  appearance.  Often  doses  running  up  each  to  a  hundred  or  more 
grains  are  demanded,  and  are  well  borne  by  the  patient.  The  drug- 
should  be  given  in  milk  or  pure  water,  and  always  after  the  taking  of 
food. 

Oftentimes  the  iodide  can  be  tolerated  better  when  combined  with 
essence  of  pepsin,  as  follows  : 

^.  Potassii  iodidi,  ,^j  ; 

Essencise  pepsini,  5ij. — M. 

Sig.  Drop  doses  as  directed. 

This  represents  the  drug  in  about  one  third  the  strength  of  the  saturated 
solution,  and  its  dose  must  be  correspondingly  increased. 

When  a  fixed  dose  of  the  iodide  is  to  be  given  for  an  extended 
period  of  time,  it  may  be  used  as  in  the  following  formula  : 

I^.  Potassii  iodidi,  5  ss-iiss  ; 

Syrupi  aurantii  corticis,  f.^iij  ; 

Aquse  destillatse,  q.  s.  ad  f.^viij. — M. 

Sig.  Teaspoonful  in  water  after  each  meal. 

The  iodide  sometimes  causes  considerable  distress  in  the  stomach  and 
interferes  greatlv  with  digestion  M'hen  taken  imraediatelv  after  eatino-. 
In  such  cases  it  is  well  to  give  the  following  as  soon  as  the  meal  is 
finished,  and  the  iodide  an  hour  afterward  : 

!^.  Tincturse  nucis  vomicre,  foss; 

Essenciffi  pepsini,  ad  fsvj. — M. 

Sig.  Teaspoonful  in  water  after  each  meal. 


908  SYPHILTS. 

The  iodide  of  potassium  should  always  be  stopped  if  marked  consti- 
pation occurs  during  its  administration  or  if  disturbances  in  the  kidney 
arise.  Measures  for  the  relief  of  such  conditions  should  be  instituted, 
and  the  use  of  the  iodide  should  not  be  resumed  until  the  normal  func- 
tions of  the  parts  have  been  restored. 

lodism. — The  toxic  effects  of  the  iodides  are  more  readily  shown 
than  is  the  case  with  mercury.  Such  results  of  the  drug's  action  may 
be  expressed  in  a  great  variety  of  lesions  appearing  upon  the  skin  or  in 
the  production  of  salivation — a  metallic  taste  in  the  mouth,  coryza,  con- 
stipation, fever,  and  all  of  the  symptoms  of  peritonitis ;  or  it  may  occa- 
sion attacks  of  vomiting  which  increase  in  frequency  and  severity, 
weakness,  anaemia,  and  loss  of  sexual  appetite.  The  commonest  symp- 
tom of  iodism  is  iodic  acne.  The  lesions  appear  upon  the  face,  neck, 
chest,  and  back  with  greatest  frequency,  and  are  difficult  to  distinguish 
from  the  like  symptoms  of  acne  vulgaris.  Frequently  the  smallest 
dose  of  potassium  iodide  will  cause  the  eruption  to  appear,  while  if 
the  drug  be  pushed  properly  the  lesions  will  vanish.  Urticaria  of 
severe  type  is  liable  to  be  produced.  In  case  of  dangerous  symptoms 
arising  the  iodide  should  ahvays  be  stopped  and  a  tonic  be  given. 
Usually  all  manifestations  of  trouble  disappear  readily  when  such  a 
course  is  pursued. 

Mixed  Treatment. — By  this  term  is  meant  the  use  of  the  iodide 
and  the  mercurial  in  combination.  It  is  evident  that  the  combined 
action  of  the  drug  can  be  secured  in  various  ways.  The  iodide  can  be 
given  internally  and  the  mercurial  externally  by  inunction,  fumigation, 
or  injection ;  the  iodide  can  be  given  at  one  time  of  day  and  the  mer- 
curial at  another,  or  the  two  can  be  given  internally  in  the  same  dose. 
To  the  last  method  the  term  "  mixed  "  is  usually  applied.  This  method 
of  medication  is  useful  in  early  stages  of  the  disease,  when  the  develop- 
ment of  tubercles,  gummata,  or  bone  and  brain  lesions  calls  for  the 
administration  of  the  iodides. 

If  the  symptoms  are  urgent,  treatment  should  be  begun  by  giving 
the  iodide  internally  and  the  mercurial  externally.  In  this  way  either 
drug  can  be  increased  or  diminished  as  indications  demand.  When  the 
disease  has  been  brought  well  under  control,  the  two  salts  may  be  com- 
bined as  in  the  following : 

]^.  Hydrargyri  ioclidi  rubri,  gr.  i-ij  ; 

Potassii  iodidi,  .5ss-ij  ; 

Syrupi  glycyrrhizse,  f  §ij  ; 

Aquam  destillatam,  ad  foviij.  —  M. 

Sig.  A  teaspoonful  in  water  after  each  meal. 
Or, 

^i.  Hydrargyri  iodidi  rubri,  gr.  i-ij  ; 

Sodii  iodidi,  .oss-ij  ; 

Syrupi  zingiberis,  giij  ; 

Aquam  destillatam,  ad  sviij. — M. 

Sig.  Teaspoonful  in  water  after  each  meal. 

The  bichloride  may  be  given  in  the  same  manner : 


Tin:  ATM  EST  OF  SY  I'll  I  LIS.  909 

]^.  H\xlrai'nyi-i  cliloridi  corrosivi,  gr.  i-iij  ; 

Potnssii  iotlidi,  .>^'^-'j  ; 

Synipi  <i;lyc'vrrliizoe,  isij  ; 

Aqiue  (Ic'stilhitit',  f[.  s.  lul  t'.5viij. — ^^. 

Sig.  Tea.spoonfiil  in  water  alter  meals. 

This  latter  conibiiiatiou  is  often  hriliiantly  elleetive,  hut,  owin^  to 
the  possibility  of  double  decomposition  taking  place  between  the  mer- 
curic salt  and  the  iodide,  the  combination  is  not  as  trustworthy  as  when 
the  biniodide  is  used. 

A  valuable  method  of  administering  mercury  and  the  iodide  is  to 
give  them  singly  at  (liferent  times  in  the  day.  Tlie  iodide  can  follow 
the  morning  and  the  evening  meal  in  either  a  graduated  or  fixed  dose, 
while  the  mercurial  can  be  given  in  pill  form  after  the  noon  meal  and 
when  going  to  bed,  at  which  time  a  little  food  or  a  glass  of  milk  should 
be  swallowed.  Neither  mercury  nor  the  iodides  should  ever  be  given 
on  an  empty  stomach. 

Local  Treatment. — Proper  local  treatment  of  syphilitic  lesions 
and  conditions  is  of  great  importance.  By  the  help  thus  afforded 
repair  and  resolution  of  the  parts  affected  may  be  much  more  quickly 
accomplished  than  when  reliance  is  placed  entirely  upon  constitutional 
measures. 

In  syphilis  of  the  skin  avoidance  of  anything  that  may  irritate  and 
annov  the  oroan  must  be  carefullv  attended  to.  Light  uncolored  bal- 
briggan  or  cotton  underwear  should  be  worn  next  to  the  body.  Over 
this,  if  the  w^eather  be  cool,  the  patient  should  wear  suitable  woollens, 
but  these  should  never  be  allowed  to  come  in  contact  with  the  skin. 
Tight  wristbands  and  collars  jshould  be  exchanged  for  articles  that  will 
not  chafe  the  parts  nor  interfere  with  the  circulation. 

Usually  syphilodermata  disappear  rapidly  under  appropriate  systemic 
treatment,  but  if  inclined  to  be  sluggish  or  when,  appearing  on  the  face, 
the  lesions  betray  the  patient's  condition,  resolution  may  be  hastened  by 
the  following  measures  : 

The  parts  affected  should  be  sponged  each  night  with  warm  water, 
and  after  drying  be  anointed  thoroughly  with  an  unguent  composed  as 
follows  : 

I^.  Hydrargyri  ammoniati,  gr.  v-x  ; 

Balsami  Peruviaui,  TTlx  ; 

Vaselini  albi,  oj- — M. 
Sig.  External  use. 


Or, 


^.  Unguenti  hydrargyri,  Si-ij  ; 

Unguenti  aquse  rosae,  3vj. — M. 

Sig.  External  use. 


Local  fumigation,  by  exposing  the  parts,  after  softening  with  warm 
water,  to  the  fumes  arising  from  a  few  grains  of  calomel  in  process  of 
sublimation,  is  often  a  valuable  procedure.  Bichloride  lotions,  such  as 
the  following,  are  serviceable  and  agreeable  : 


910  SYPHILIS. 

I^.  Hydrargyri  chloridi  corrosivi,  gr.  i-iv  ; 

Glycerini,  f  .5j  ; 

Tincturse  benzoini,  f  3j  ; 

Spiritus  villi  recti  ficati,  f  gss  ; 

Spiritus  rosmarini,  f  §j  ; 
Aquse  rosse,                                    q.  s.  ad  f  gviij. — M. 
Sig.  External  use. 

Palmar  and  plantar  lesions  if  persistent  are  best  treated  by  inunc- 
tion with  mercurial  ointment  in  50  per  cent,  strength,  or  this  may  be 
combined  with  lanoline  in  varying  proportions.  This  should  be  well 
rubbed  into  the  lesions  after  softening  the  parts  with  warm  water.  If 
there  is  much  scaling  or  thickening  of  the  epidermis,  shampooing  of 
the  surface  with  green  soap  may  precede  the  inunction  with  profit. 
Or  the  following  modification  of  the  well  known  Lassar  paste  may 
be  spread  thickly  over  the  part,  and  a  light  glove  be  drawn  on  to 
prevent  its  removal : 


!i.  Hydrargyri  ammoniati, 

gr.  v-xxx ; 

Zinci  oxidi, 

Talci, 

ad.  3ij  ; 

Vaselini, 

.?ss. — M. 

External  use. 

Sig. 

The  tars  and  mercurials  may  be  combined  and  used  as  in  the  follow- 
ing: 

I^.  Hydrargyri  oxidi  rubri,  gr.  x-xx  ; 

Olei  rusci,  3j  ; 

Vaselini,  §j. — M. 

Sig.  External  use. 

I^.  Unguenti  hydrargyri  nitratis,  3ij  ; 

Olei  cadini,  3j  ; 

Vaselini,  gj. — M. 
Sio-,  External  use. 

If  the  lesions  do  not  yield  readily,  they  may  be  touched  once  a  week 
with  a  strong  solution  of  acid  nitrate  of  mercury  or  with  pure  nitric 
acid.  Care  should  be  taken  not  to  permit  too  free  action  of  the  acid, 
as  by  such  means  much  damage  and  pain  may  result.  An  alkaline 
solution  should  be  at  hand  for  use  if  needed.  After  severe  stimulat- 
ing treatment  of  this  sort  soothing  applications,  such  as  freshly  pre- 
pared benzoinated  zinc  oxide  ointment  or  the  diachylon  ointment  of 
Hebra,  should  be  used. 

Moist  papules,  condylomata,  and  venereal  warts  occurring  near  the 
mucous  outlets  need  to  be  frequently  cleansed  with  warm  borated  lotions, 
and  then  to  be  dusted  with  calomel,  boric  acid,  europhen,  aristol,  iodol, 
or  iodoform.  Bichloride  lotions  in  the  strength  of  1  :  2000  or  mild 
solutions  of  permanganate  of  potassium  are  valuable  when  used  as  a 
wash.  Separation  of  the  parts  should  be  effected  by  pledgets  of  cotton 
and  all  possible  sources  of  irritation  should  be  removed. 

Pustular  lesions  when  appearing  on  the  face  should  be  opened  and 
cleansed  of  their  contents  by  the  use  of  an  antiseptic  wash,  after  which 


TRi:ATMi:.\r  <>f  syriiiijs.  911 

i-acli  cavity  iiiiiy  l)c  filled  with  boric  acid,  ciiroplicii,  oi-  indotorni,  and 
covered  with  a  lii;ht  dressing-,  such  as  a  hit  of  siirireon's  plaster. 
This  can  be  removed  readily  and  the  dressing  i-c|)eated  as  often  as 
needed.  Usually  once  in  twenty-four  houi-s  is  suilicient.  In  the  case 
of  g:umniata  and  tubercles,  spon*>^in^  with  warm  water  and  the  apjdi- 
cation  of  mercurial  ointment  in  fidl  streu<rth  or  reduced,  as  is  th<tu<;ht 
l)i'st,  is  needed.  A  l)it  of  mercurial  plaster  may  be  neatly  sj)read  over 
the  ])art  and  allowed  to  remain.  Care  must  be  taken  not  to  excite  a 
<lermatitis.  Jf  the  oumma  ulcerates,  it  must  be  cleansed  each  day  of 
all  crusts  and  accumulations  of  pus  by  washing  with  warm  solutions  of 
boric  acid,  and,  after  drying,  the  sides  and  Hoor  should  be  brushed  with 
a  strong  preparation  of  silver  nitrate  in  distilled  water,  or  the  pencil  of 
the  same  salt  be  used  freely  over  all  the  parts.  The  cavity  then  may 
be  filled  with  europhen,  iodoform,  or  boric  acid  and  covered  with  a 
snug-fitting  but  absorljent  dressing.  This  is  best  accomplished  In*  put- 
ting over  the  ulcer  a  layer  of  absorbent  cotton  or  bichloride  gauze  and 
fastening  it  in  place  by  adhesive  straps  or  a  neat-fitting  bandage.  On 
the  face  the  dressing  may  be  held  in  place  by  the  use  of  flexible  collo- 
dion. Pressure  exerted  upon  the  ulcer  by  drawing  the  edges  together 
and  holding  them  in  ])lace  with  rubber  plaster  often  hastens  repair.  In 
the  case  of  the  lower  limbs  support  of  the  parts  by  using  the  silk  elastic 
stocking  is  decidedly  serviceable. 

Mixed  treatment  by  the  use  of  the  iodides  internally  and  mercury 
by  inunction  is  called  for  in  the  treatment  of  these  ulcers.  The  iodide 
should  be  given  in  drop  doses  of  the  saturated  solution  and  pushed  until 
the  ulcer  yields.     Tonics  are  usually  indicated, 

AVhen  loss  of  hair  begins  the  scalp  should  be  shampooed  every  third 
night  with  the  following  : 

R.  Tincturse  saponis  viridis,  f.^iij  ; 

Spiritus  lavandulse,  f".5ij, — M. 

Sig.  External  use  with  warm  water. 

The  head  should  be  first  bathed  with  water,  w^arm  as  it  can  be  comfort- 
ably borne,  and  then  while  still  wet,  a  teaspoonful  or  more  of  the  above 
should  be  rubbed  thoroughly  into  all  parts.  The  scalp  is  then  washed 
clean  with  warm  water  and  anointed  with  the  following  : 

I^.  Hydrargyri  sulphidi  rubri,  gr.  j  ; 

Sulphuris  prsecipitati,  3j ; 

Balsami  Peruviani,  TTlx  ; 

Yaselini,  gj. — M. 
Sig.  External  use  at  night. 

Or  the  following  lotion  may  be  used  each  night : 

I^.  Hydrargyri  chloridi  corrosivi,  gr.  ii-iv  ; 

Tincturse  cantharidis,  fiss; 

Spiritus  vini  rectificati,  f  5ij  ; 

Olei  amygdalae  dulcse,  f  .oij  ; 

Spiritus  rosmarini,  f  .^j  ; 
Aquae  rosse,                                     q.  s.  ad  f  5viij. — M. 
Sig.  External  use  on  scalji. 


912  SYPHILIS. 

The  hair  should  be  clipped  close  in  the  case  of  men  in  order  to  make 
the  above-named  preparations  more  easy  of  application. 

In  affections  of  the  nails,  where  the  nail  substance  only  is  attacked, 
the  part  may  be  shampooed  each  night  with  tincture  of  green  soap,  and 
after  drying  be  thoroughly  treated  with  an  unguent  made  of  equal  parts 
of  mercurial  ointment  and  vaseline.  If  inflammation  and  ulceration 
take  place  in  the  tissues  beneath  and  at  the  base  of  the  nail,  the  finger 
or  toe  should  be  immersed  in  a  warm  solution  of  boric  acid  for  ten  or 
twenty  minutes  each  day,  and  then  dried  and  dusted  with  some  suitable 
powder.     The  part  should  be  protected  by  a  linen  cot. 

Syphilitic  lesions  appearing  in  the  mouth  need  the  utmost  care.  All 
parts  of  the  mouth  should  be  kept  scrupulously  clean,  and  nothing 
should  be  allowed  to  pass  the  lips  that  can  in  any  way  irritate  the 
lesions.  Systemic  treatment  suitable  for  the  condition  should  be  pushed 
to  the  point  of  physiological  toleration.  Combinations  of  the  iodides 
and  mercurials  are  frequently  needed.  I^ocally  silver  nitrate  in  solution 
or  by  the  pencil  serves  a  useful  purpose.  Daily  applications  should  be 
made.  Gargles,  such  as  the  following,  should  be  used  at  frequent 
intervals  : 

^.  Potassii  chloratis,  3J  ; 

Aquse  menthse  piperitse,  f^viij. — M. 

Sig.  Gargle.     Reduce  with  tepid  water. 

^.  Potassii  chloratis,  3j  ; 

Mollis  despumati, 

Tincturse  myrrhse,  cid.  f  §j  ; 

Aquse  destillatse,  q.  s.  ad  fgviij. — M. 

Sig.  One  part  to  four  of  tepid  water,  used  frequently  as  a  gargle. 

Bellamy's  iodized  phenol  may  be  used  in  the  case  of  sluggish  lesions 
with  decided  advantage.     The  following  is  the  formula  : 

I^.  Acidi  carbolici,  3J  ; 

Tincturse  iodi,  fsjss  ; 
Glycerini, 

Spiritus  vini  rectificati,  da.  f  ^ij  ; 

Aquse  destillatse,  q.  s.  ad  fij. — M, 

Sig.    Ten  to  fifteen  drops  in  a  half  tumblerful  of  water,  used 
freely  as  a  gargle. 

A  few  grains  of  potassium  chlorate  or  the  five-grain  tablets  sold  in  the 
shops  may  be  allowed  to  dissolve  in  the  mouth  several  times  during  the 
day  with  decided  advantage. 

Gummata,  owing  to  the  rapidly  destructive  course  they  pursue, 
should  be  given  prompt  and  energetic  treatment.  The  iodides  should 
be  pushed  as  rapidly  as  possible  to  their  physiological  limit.  Quinine 
in  two-grain  doses  should  be  given  four  times  a  day.  It  is  best  to  ad- 
minister the  drug  in  its  powdered  form,  the  local  action  of  the  alkaloid 
having  a  decidedly  beneficial  effect  on  the  lesion.  The  pencil  of  silver 
nitrate  should  be  used  freely  and  the  mouth  washes  and  gargles  con- 
tinued. 


'     TREATMENT  OF  SYl'JHLIS.  913 

Albolone  sprays  arc  usel'til  in  sypliilitic  aH'ections  oi"  the  pharynx  and 
larynx  : 

1|'.  Ai'idi  (•arl)()lici,  J^^.j-ij  ; 

Oloi  caryopliyllii,  TTLiij  ; 

Menthol,  gr.  ii-v  ; 

Albolone,  f.SJ. — M. 

Sig.  Use  twice  a  clav  with  compressed-air  atomizer. 

3^.  Extract!  pinus  canadensis  destillati,  3ss; 

Olei  goranii,  V([.iv ; 

Albolene,  f^j.— M. 
Sig.  Spray  for  throat. 

Syphilitic  affections  of  the  nose  refusing  to  yield  to  systemic  treat- 
ment require  fumigation  with  calomel  or  cinnabar.  Stimulation  with 
the  pencil  or  a  solution  of  silver  nitrate  is  of  value  when  the  lesions 
can  be  reached.  Inhalation  of  the  following  vapor  is  often  of  great 
service  : 

]^.  Acidi  carbolici,  5j  ; 

Tincturse  iodi,  fsj  ; 

Aquee  ammonise,  f  Sij  ; 

Spiritus  odorati,  q.  s,  ad  fsj. — M. 

Sig.  Put  in  a  wide-mouthed  two-ounce  bottle  half  filled  with 
cotton.     Inhale  the  vapor  through  the  nose. 

Ozsena  should  be  treated  by  douches  of  mild  potassium  permanga- 
nate solutions  or  borated  lotions.  Thorough  cleanliness  of  the  parts 
must  be  maintained.  Wiping  the  nasal  passages  with  weak  solutions  of 
silver  nitrate  and  then  anointing  them  with  ointment  of  the  white  pre- 
cipitate or  yellow  oxide  of  mercury  should  be  practised. 

Affections  of  the  bones  call  for  the  administration  of  the  iodides  in 
the  fullest  doses.  In  general  it  is  well  to  combine  mercury  by  inunc- 
tion in  the  treatment.  If  the  bone  lesions  are  superficial,  a  small  quan- 
tity of  mercurial  ointment,  either  pure  or  reduced  with  lanoline,  may  be 
gently  rubbed  into  the  part  once  a  day,  or  a  small  piece  of  mercurial 
plaster  may  be  applied  to  the  skin  covering  the  lesion,  and  kept  in  con- 
tact wdth  it  w'hile  it  proves  unirritating. 

Gummata  of  the  rectum  and  anus  call  for  the  iodides  internally. 
Locally,  thorough  cleansing  of  all  exposed  lesions  should  be  attended 
to  each  day,  after  which  they  should  be  stimulated  with  silver  nitrate. 
The  following  ointment  should  be  used  before  each  stool  by  anointing 
the  finger  and  passing  it  well  up  into  the  rectum  : 

I^.  Tincturte  benzoini,  3j  ; 

Vaselini,  5J. — M. 

Sig.  External  use  in  rectum. 

Stricture  of  the  rectum  needs  to  be  treated  by  dilatation  with  rubber 
bougies  or  careful  insertion  of  the  finger  tip.  Rupture  of  the  gut  by  too 
forcible  expansion  must  be  guarded  against. 

Vol.  I.— 58 


914  SYPHILIS. 

Syphilis  of  the  epididymis  and  testicle  needs  vigorous  treatment  by 
the  use  of  the  iodides  internally,  and  mercury  by  inunction.  The  mer- 
curial ointment  or  a  5-10  per  cent,  oleate  of  mercury  should  be  gently 
rubbed  into  the  organ  each  night.  The  testicles  need  to  be  carried  in  a 
neat-fitting  suspensory.  Freedom  from  all  sexual  excitement  must  be 
insisted  upon. 

In  syphilis  of  the  heart  mixed  treatment  is  usually  called  for.  It 
should  be  remembered  also  that  strychnine,  nux  vomica,  digitalis,  and 
nitroglycerin  can  be  used  with  as  much  advantage  as  in  non-specific 
disease  of  the  organ. 

Syphilitic  affections  of  the  nervous  system  in  general  call  for  the 
administration  of  the  iodides  in  increasing  doses.  It  is  well,  however, 
in  instituting  treatment  to  begin  with  small  doses  of  calomel,  given  at 
frequent  intervals  until  the  severity  of  the  symptoms  presented  has 
been  much  reduced.  A  tenth  of  a  grain  may  be  given  during  the 
waking  hours  for  the  first  three  days,  often  with  surprising  benefit. 
The  administration  of  the  iodide  may  be  interrupted  at  intervals  while 
a  short  course  of  the  mild  chloride  is  being  given,  with  good  results. 
A  combination  of  the  iodides  of  sodium  and  potassium  in  equal  parts  is 
sometimes  more  efficient  in  its  action  than  where  either  salt  is  given 
singly.  Tonics  and  supportive  measures  are  always  needed.  Stimula- 
tion of  paralyzed  muscles  by  the  use  of  the  faradic  current  must  be 
resorted  to  at  times  in  order  to  maintain  nutrition  of  such  organs. 
Daily  rubbing  of  the  body  is  often  useful.  Cool  sponging  of  the  entire 
body  surface  with  salt  and  water,  followed  by  brisk  friction  with  the 
flesh-brush  or  a  coarse  towel,  should  be  practised  each  morning.  The 
feet  should  be  kept  warm  and  proper  action  of  all  the  emunctories  must 
be  secured. 

Hereditary  Syphilis. 

Syphilis  is  directly  transmissible  from  the  parent  to  the  child  as  an 
inherited  disease.  The  role  played  by  either  parent  in  such  transmis- 
sion is  still,  however,  somewhat  in  question.  Some  syphilographers 
still  hold  to  the  belief  that  the  child  may  inherit  syphilis  from  the 
father  while  the  mother  remains  sound  and  uninfected.  That  such 
paternal  transmission  can  occur  without  infection  of  the  mother  seems 
extremely  doubtful,  and,  if  it  ever  happens,  does  so  but  rarely.  The 
argument  usually  advanced  in  favor  of  the  theory  is  that  the  mother 
never  shows  any  signs  of  the  disease.  This,  however,  is  hardly  con- 
clusive proof  that  she  is  unaffected.  Colles'  well  known  law  affirms 
that  a  child  suifering  with  inherited  syphilis  is  incapable  of  infecting  its 
mother  at  the  breast,  while  the  infant  can  infect  any  healthy  wet-nurse 
in  such  manner.  This  law  can  be  interpreted  in  but  one  way,  and  that 
is  that  the  mother  is  suffering  with  the  disease.  Why  it  is  that  she 
manifests  no  symptoms  no  one  as  yet  can  tell,  but  the  unquestionable 
fact  remains  that  she  is  the  possessor  of  the  disease  in  a  modified  form, 
and  as  such  possessor  she  can  transmit  it  to  her  offspring.  The  uni- 
versal acceptance  accorded  to  this  law  by  medical  men  is  proof  that  its 
assertions  are  the  statement  of  a  recorded  truth.  Such  being  the  case, 
the  culpability  of  the  father  only  in  the  process  is  seemingly  disposed  of. 

The  cases  on  record  in  which  the  mother,  after  having  given  birth 


TiKiiKinr. \ny  syriiius.  915 

to  a  syphilitic  infant,  lias  acciuircd  a  cliaiici-c  and  later  dcvolopod  truo 
.syphilis,  arc  as  rare  as  the  eases  of"  second  actjiiisition  of  the;  disease,  and 
it  is  hio;hly  probable  that  they  can  be  accounted  for  in  sn(^h  manner. 

If  the  mother  remains  nninfeetcd,  her  child  will  nndonbtedly  esca])e. 
But  if  the  mother  be  sniferin«2:  from  the  disease,  the  pi-obability  is  that 
her  child  will  become  ini'cctcd  also.  Yet  here  the  child  niav  escape. 
The  fact  is  luuh'niable  that  while  both  father  and  mother  are  still  suff'er- 
ini>-  with  the  disease  tiiey  may  at  times  [)ro(lnce  children  that  never  dis- 
play any  symptoms  of  syphilis.  A  syphilitic  woman  may  ])roducc  a 
number  of  syi)hilitic  foetuses,  then  bring  a  healthy  child  into  the  world, 
iind  follow  it  in  successive  pregnancies  with  a  number  of  children  that 
iire  unmistakably  suffering  with  the  disease. 

If  the  mother  be  infected  during  the  course  of  her  pregnanc^y  before 
the  termination  of  the  seventh  month,  the  chances  are  that  her  child 
will  inherit  the  disease.  After  the  seventh  month  the  child  usually 
escapes  unless  it  be  infected  at  birth  by  syphilitic  lesions  in  the 
maternal  passages.  Such  infection  constitutes  the  acquired,  and  not 
the  inherited,  form  of  the  disease,  and  is  classed  as  infantile  syphilid. 

Abortion. — Few  women  suffering  from  active  constitutional  syphilis 
at  the  time  of  their  conception  carry  its  product  to  full  term.  Abortion 
is  the  rule,  though  exceptions  to  it  may  occur.  In  early  stages  of  the 
mother's  disease  the  foetus  is  carried  for  a  short  time  only.  Usually  the 
first  product  of  conception  after  the  development  of  constitutional 
syphilis  is  cast  off  before  the  expiration  of  the  second  or  third  month. 
Successive  pregnancies  are  carried  for  longer  and  longer  periods,  until 
a  viable  child  that  may  live  for  a  few  hours  is  brought  into  the  world. 
Later  the  result  is  the  production  of  a  living  child  that  may  exhibit 
symptoms  of  syphilis  before  the  expiration  of  the  fourth  month  or  re- 
main entirely  free  from  the  disease  throughout  life.  It  is  questionable 
if  syphilis  can  remain  latent  throughout  childhood  and  show  itself  for 
the  first  time  at  the  puberal  epoch.  The  probability  is  that  in  the  cases 
apparently  presenting  such  a  condition  the  early  symptoms  of  the  disease 
were  overlooked  or  misinterpreted.  In  the  great  majority  of  cases  it 
can  be  asserted  with  safety  that  if  the  child  inherits  syphilis,  unmis- 
takable evidence  of  the  disease  will  become  apparent  before  the  end  of 
the  first  year. 

Symptoms  of  Inherited  Syphilis. — A  living  child  the  subject 
of  inherited  syphilis  may  show  no  symptoms  of  the  disease  at  the  time 
of  its  birth.  Usually,  however,  its  features  are  drawn  and  pinched  and 
the  skin  is  wrinkled,  giving  to  the  infant's  face  the  appearance  of  a 
^*  little  old  man  or  woman."  The  child  does  not  grow^,  but  remains 
puny  and  impoverished.  The  weazened  look  deepens  and  the  skin 
assumes  a  sickly  sallow  hue.  Characteristic  lesions  of  syphilis  may 
not  appear  for  weeks  or  perhaps  for  months.  When  they  are  first 
announced  they  usually  show  themselves  about  the  mucous  outlets  of 
the  body,  as  the  mouth  and  anus.  Here  they  are  displayed  in  the  form 
of  moist  papules,  mucous  patches,  and  condylomata.  Fissures  show 
themselves  within  the  mucous  membrane  at  the  angles  of  the  mouth, 
while  the  skin  bordering  the  part  becomes  the  seat  of  similar  lesions  or 
of  scaly  reddened  areas.  Mucous  patches  develop  in  the  mouth  and 
throat,  the  tongue  and  inner  border  of  the  lips  showing  them  often  in 


916  SYPHILIS. 

varying  numbers.  The  borders  of  the  anus  show  moist  papules,  fissures, 
excoriations,  and  condylomata.  The  umbilicus  may  be  aifected  in  like 
manner.  Coryza  develops.  Chief  among  the  symptoms  are  snuffles. 
These  are  diagnostic  of  inherited  syphilis.  The  discharge,  at  first  thin 
and  serous  in  nature,  later  grows  profuse  and  becomes  thick  and  muci- 
laginous. Swelling  of  the  nasal  membranes  closes  the  passages.  The 
process  interferes  greatly  with  nursing,  and  may  wholly  prevent  it. 
The  child  experiences  great  difficulty  in  breathing.  Extension  of  the 
inflammation  from  the  nasal  passages  into  the  pharynx  and  larynx 
occurs,  giving  rise  to  a  peculiar  husky  cry.  Destruction  of  the  bones 
of  the  nose  may  take  place,  with  complete  removal  of  that  organ. 
Dry,  scaling  patches  appear  on  the  body,  chiefly  in  the  neighborhood 
of  the  buttocks.  These  dry  patches  are  readily  converted  into  moist 
lesions,  owing  to  the  warmth  of  the  parts  and  the  tenderness  of  the 
infant's  skin.  The  condition  changes  from  bad  to  worse.  Nutrition 
is  but  feebly  carried  on,  marasmus  intervenes,  and  death  closes  the  scene. 

The  above  is  the  picture  often  seen  in  inherited  syphilis.  But  in 
the  inherited  form  of  the  disease,  as  in  the  acquired  form,  syphilis 
varies  greatly  in  the  manner  and  severity  of  its  expression.  Especially 
is  this  true  if  treatment  be  instituted  early  and  carried  on  with  vigor 
and  under  intelligent  direction.  The  worst  forms  of  the  malady  may  be 
changed  for  the  better  and  a  great  degree  of  improvement  produced. 
It  should  be  remembered  that  mercury  is  not  contraindicated  in  a 
pregnant  w^oman  who  is  suffering  with  syphilis,  and  that  in  the  admin- 
istration of  the  drug  exists  the  only  measure  that  in  any  wise  affords 
her  a  guarantee  of  producing  a  living  child  and  of  giving  that  child  a 
chance  to  reach  maturity. 

If  the  malady  is  not  to  pursue  the  severe  course  outlined  above,  the 
symptoms  of  the  disease  are  apt  to  be  delayed.  The  child  is  well  nour- 
ished at  birth,  increases  in  weight,  and  is  plump  and  apparently  healthy. 
Symptoms  of  syphilis  usually  become  apparent  before  the  end  of  the 
fourth  month,  but  may  not  show  themselves  until  somewhat  later. 
They  arise  first,  as  in  the  severe  form,  about  the  mucous  orifices,  and 
are  declared  in  the  different  varieties  of  moist  lesions.  Characteristic 
snuffles  soon  appear.  An  erythematous  eruption  of  a  part  or  the  whole 
of  the  body  surface  may  ensue.  This  rapidly  becomes  coppery  in  hue, 
and  papules  may  develop.  If  unchecked,  the  skin  lesions  may  take  on 
any  of  the  forms  seen  in  acquired  syphilis,  and  their  subsequent  be- 
havior is  in  accord  with  the  course  that  is  there  pursued.  Dry  papules 
arise  upon  the  hands,  feet,  and  face.  Moist  papules  and  condylomata 
appear  about  the  anus  and  in  all  moist  localities.  Nodes,  exostoses,  and 
gummata  develop  within  the  bones,  often  resulting  in  great  deformity 
of  these  structures.  The  brain,  heart,  lung,  liver,  eye,  and  testicle  may 
become  the  seat  of  gummatous  infiltration. 

Treatment  of  Ixheeited  Syphilis. — Treatment  of  a  child  liable 
to  be  the  subject  of  inherited  syphilis  should  begin  while  it  is  still  in 
the  womb  of  its  mother.  This  is  done  by  subjecting  the  mother  to  vig- 
orous antisyphilitic  measures.  The  sooner  such  a  course  is  instituted 
after  conception  has  taken  place,  and  the  more  energetically  it  is  pushed, 
the  better  will  be  the  child's  chances  of  coming  into  the  world  free  from 
symptoms  of  the  disease  and  remaining  healthy  afterward. 


IIEIIKDITARY  SYPHILIS.  917 

The  plan  of  treatment  best  suited  for  mother  and  eliild  undcM-  sueli 
conditions  is  that  of  mercurial  inunetion.  This  should  be  j)ush('d  at 
varying-  intervals  to  the  point  of  produeinn'  distinct  constitutional  symp- 
toms, care  being  taken  noi  to  cause  actual  salivation.  With  the  first 
sign  of  systemic  effects,  such  as  the  formation  of  a  red  line  at  the  border 
of  the  gums,  factor  of  the  breath,  or  a  marked  metallic  taste  in  the 
mouth,  the  inunction  should  be  stopped  and  mixed  treatment  by  the 
combined  use  of  potassium  iodide  and  l)iniodide  of  mercurv  be  substi- 
tuted. This  latter  course  may  be  continued  for  from  two  weeks  to  one 
month  as  seems  best  to  the  judgment  of  the  j)hysician,  when  the  inunc- 
tion should  again  be  resorted  to.  During  this  time  hygienic  and  other 
measures  calculated  to  improve  the  mother's  health  should  not  be  neg- 
lected. 

The  mercurial  preparations  found  useful  in  the  internal  treatment  of 
syphilis  can  be  employed,  but  not  with  the  advantage  to  be  obtained 
from  the  inunction.  When  used  care  must  be  exercised  not  to  push 
their  action  sufficiently  to  bring  on  intestinal  irritation  and  diarrhoea,  as 
by  such  a  course  abortion  may  be  brought  about. 

If  the  mother  be  suffering  from  late  forms  of  the  disease,  such  as 
gummata  of  bone,  brain,  or  skin,  potassium  iodide  should  be  given 
interna  11 V  in  full  doses,  while  the  inunction  is  being  continued  exter- 
nally. 

Lesions  in  the  vagina,  such  as  mucous  patches  and  ulcers,  need  care- 
ful attention.  The  parts  should  be  subjected  each  day  to  warm  douches 
of  boric  acid  or  permanganate  of  potassiiun  solution,  extreme  caution 
being  used  in  not  throwing  the  stream  too  forciblv  against  the  uterine 
neck,  as  by  such  procedure  premature  labor  may  be  excited.  Frequent 
application  by  the  physician  of  a  solution  of  silver  nitrate  to  the  lesions 
is  of  decided  value  in  promoting  their  resolution. 

When  the  child  is  born  with  unmistakable  symptoms  of  s^-philis  or 
develops  such  symptoms  shortly  after  birth,  its  treatment  must  be  begun 
at  once.  Great  care,  however,  must  be  exercised  by  the  physician  in 
determining  that  the  infant  is  actually  suffering  from  syphilis.  The 
offence  is  unpardonable  on  the  part  of  the  practitioner  to  pronounce 
every  ailment  of  early  childhood  due  to  syphilis  because  the  parents  are 
suffering  from  the  malady.  Many  children  of  parents  who  are  the  sub- 
jects of  syphilis  never  show  the  slightest  taint  of  the  disease,  and  this 
is  particularly  apt  to  be  the  case  when  the  mother  has  been  given  care- 
ful and  energetic  treatment. 

Treatment  of  the  child  may  be  by  the  internal  or  external  method 
as  seems  to  the  physician  best  suited  to  the  case.  External  treatment 
should  be  by  inunction,  and  is  to  be  chosen  in  preference  to  the  internal 
administration  of  mercurials  when  the  tender  skin  of  the  infant  can  be 
made  to  tolerate  the  applications.  This  can  be  accomplished  in  most 
cases  by  exercising  thorough  care  in  the  cleanliness  of  the  child  and  by 
shifting,  at  frequent  intervals,  the  places  to  which  the  ointment  is  being 
applied.  Mercurial  ointment  may  be  used  in  the  form  of  the  offici- 
nal preparation  or  it  may  be  combined  with  equal  parts  of  pure  vase- 
line or  lanoline.  Brodie's  method  furnishes  decidedly  the  best  means 
of  applying  the  unguent.  This  is  done  by  spreading  the  ointment 
freely  upon  the  child's  bellyband  and  keeping  this  in  close  contact  with 


918  SYPHILIS. 

the  skin.  The  part  must  be  watched  carefully,  in  order  that  a  derma- 
titis may  not  be  excited.  At  the  first  appearance  of  redness  the  oint- 
ment must  be  applied  to  some  other  portion  of  the  body.  This  can  be 
easily  done  by  putting  a  band  about  one  of  the  infant's  limbs  and  spread- 
ing this  with  the  ointment,  as  in  the  case  of  the  bellyband.  In  this 
manner  the  inunction  can  be  continued  for  quite  long  jieriods  of  time. 
It  is  often  of  great  service  to  suspend  the  external  treatment  as  occa- 
sion demands  and  resort  to  internal  measures  during  the  interval. 

Where  inunction  is  contraindicated  or  impossible,  internal  medication 
may  be  instituted.  Any  of  the  mercurials  used  in  the  treatment  of 
syphilis  may  be  employed,  but  some,  as  calomel  and  the  gray  powder,, 
seem  productive  of  better  results  than  others.  Calomel  is  to  be  pre- 
ferred in  beginning  the  course,  and,  if  it  is  found  effectual  in  its  action,, 
should  be  continued.  It  may  be  given  in  doses  varying  from  one  twen- 
tieth to  one  half  of  a  grain  three  times  a  day.  The  calomel  may  be 
combined  in  powder  form  with  sugar  of  milk,  or  one  of  the  tablet  trit- 
urates supplied  by  all  drug  houses  may  be  rubbed  up  fine  and  given  in 
a  little  milk.  It  should  always  be  administered  after  the  child  has  been 
fed  either  at  the  breast  or  from  the  bottle.  The  gray  powder  may  be 
given  in  the  same  manner  as  the  calomel  and  in  doses  varying  from  one 
tenth  to  one  grain.  The  bichloride  can  be  tried  when  the  above  do  not 
answer  the  purpose.  It  can  be  given  in  solution  in  doses  of  one  two 
hundredths  to  one  fiftieth  of  a  grain.  A  teaspoonful  of  this  can  be 
administered  in  milk  three  or  four  times  a  day.  The  protiodide,  binio- 
dide,  and  black  oxide  may  be  tried  in  doses  suited  to  the  child's  age,  but 
are  not  often  well  tolerated  by  the  infant's  stomach.  The  mercurial 
given  internally  must  be  promptly  stopped  upon  the  appearance  of 
diarrhoea. 

Tonics  and  cod-liver  oil  are  frequently  needed  in  the  treatment  of 
the  infant.  Iron  may  be  given  in  the  form  of  the  citrate  of  iron  and 
quinine,  as  follows  : 

I^.  Ferri  et  quininse  citratis,  3j  ; 

Syrupi  aurantii  florium, 

Aquae  destillatse,  da.  f  5J. — M. 

Sig.  Three  to  five  drops  in  milk  twice  a  day. 

Cod-liver  oil  is  indicated  when  the  child  does  not  increase  in  weight,, 
but  remains  puny  and  poorly  nourished.  The  pure  oil  should  be  given. 
None  of  the  much  vaunted  emulsions  can  be  trusted  not  to  disturb  the 
stomach.  The  dose  of  oil  should  begin  with  ten  drops,  given  best  in 
milk,  twice  a  day.  This  amount  should  be  increased  slowly  as  the  little 
patient  becomes  tolerant  of  its  action,  until  as  much  as  a  teaspoonful  is 
being  given  two  or  three  times  a  day. 

When  brain,  bone,  or  visceral  lesions  arise,  potassium  iodide  is 
indicated,  and  should  be  given  three  times  a  day  in  doses  varying  from 
one  half  to  four  grains  each.  The  drug  is  extremely  apt  in  these  little 
sufferers  to  produce  its  peculiar  acne  and  other  forms  of  iodic  rashes. 
Often  the  iodide  can  be  given  better  combined  with  the  biniodide  of 
mercury,  as  indicated  in  the  formula  for  mixed  treatment  (page  908) 
From  three  to  ten  drops  of  the  mixture  can  be  given  in  milk  three 
times  a  day  after  the  infant  has  taken  food. 


SYPHILIS  AND  MARRIAGE.  019 

Local  treatinc'iit  of  sy})liili(ic  lesions  is  indicated  as  in  the  adult,  and 
the  means  described  as  iiseliil  in  .such  cases  can  be  employed  here  if 
modified  to  suit  the  tender  conditioji  of  the  infant's  tissues.  Mucous 
patches  in  and  about  the  mouth  should  recreive  special  care.  The  mouth 
should  be  kej)t  thorouiihly  clean,  and  be  treated  freely  each  day  with  a 
mixture  of  honey  and  boric  acnd  aj)plied  on  a  raj^  wrapped  about  tlu> 
end  of  the  finger.  Snuffles  should  be  treated  by  thoroughly  cleansing 
the  nose  with  warm  boric  acid  solution,  drying,  and  then  painting  the 
nasal  ])assages  lightly  with  a  weak  solution  of  silver  nitrate.  After- 
ward the  parts  may  be  sprayed  with  liquid  albolene.  A  drop  or  two  of 
Bellamy's  iodized  phenol  in  an  ounce  of  albolene  can  be  used  with 
advantage  in  spraying  the  throat.  The  anal  and  umbilical  regions  should 
be  kept  scrupulously  clean.  If  condylomata  make  their  appearance  in 
such  places,  they  should  be  cleansed  with  warm  water  or  boric  acid 
solution,  and  then  dusted  thickly  with  calomel  and  talc  in  the  propor- 
tion of  1  :  4. 

The  treatment  of  the  mother  should  be  continued  in  the  form  suited 
to  her  case.  If  possible,  this  should  be  by  means  of  the  mercurials,  as 
potassium  iodide  is  capable  of  suppressing  the  flow  of  milk.  Such  an 
accident  is  of  serious  import  in  the  treatment  of  the  child. 

The  child  should  always  be  nursed  at  its  mother's  breast,  never  at 
the  breast  of  another  Avoman.  If  for  any  reason  the  mother  cannot 
supply  the  nourishment  needed,  the  child  may  be  fed  on  pasteurized 
cow's  or  goat's  milk. 

Syphilis  and  Marriage. 

The  length  of  time  that  must  elapse  between  the  date  of  infection 
and  the  time  when  marriage  can  be  safely  permitted  depends  entirely 
upon  the  course  pursued  by  the  disease.  In  some  severe  cases  marriage 
ought  never  to  be  contracted.  The  number  of  such  cases,  however,  is 
limited.  In  the  majority  of  individuals  infected  in  early  life  a  time 
comes  when  it  is  safe  for  the  patient,  whether  man  or  woman,  to  marry. 
For  the  individual  who  is  sound  and  healthy  at  the  time  of  infection, 
and  who  enters  upon  a  thorough  and  effective  course  of  treatment  at 
once,  following  it  faithfully  for  a  period  of  two  and  a  half  or  three  years, 
marriage  can  be  safely  entered  into  between  the  third  and  fourth  years. 
This,  however,  should  not  be  done  unless  the  disease  has  shown  no 
manifestations  during  a  period  of  at  least  six  months,  in  which  all  medi- 
cation has  been  suspended.  In  no  case,  no  matter  how  slight  may  be 
the  earlier  symptoms,  should  the  physician  give  his  consent  to  marriage 
before  two  years  from  the  time  of  infection,  and  this  only  when  vigorous 
antisyphilitic  measures  have  been  followed  during  the  greater  part  of 
that  period. 

The  vouno:  man  eng-ao-ed  to  marrv  at  the  time  of  contracting  the  dis- 
ease  should  be  urged  to  make  a  frank  statement  of  his  condition  to  the 
woman  in  question,  and  to  ofier  her  a  release  from  the  agreement.  She 
should  be  told  fully  the  danger  of  her  contracting  the  disease,  even  if 
she  chooses  to  condone  the  fault  and  to  continue  the  engagement,  and 
the  restrictions  that  will  have  to  be  placed  upon  her  actions  with  refer- 
ence to  caresses  and  like  approaches.  Complete  separation  of  the  parties 
interested  is  advisable  under  such  circumstances. 


920  SYPHILIS. 

In  the  case  of  husband  and  wife  the  same  frankness  on  the  part  of 
either  should  be  required.  Here,  where  the  husband  is  so  often  at 
fault,  a  free,  honest  confession  of  his  sin  to  his  partner  nearly  always 
results  in  forgiveness  and  the  continuance  of  the  marriage  bond.  Sepa- 
ration by  living  at  a  distance  from  each  other  for  a  period  of  two  or 
more  years  is  the  most  desirable  plan  to  be  followed  in  such  cases.  If 
such  a  course  cannot  be  pursued,  cohabitation  should  be  strictly  forbid- 
den and  the  occupying  of  separate  beds  be  insisted  upon. 


LEPROSY. 

By  ISADORE  DYER,  M.  D. 


Synonyms. — Lepra  ;  Elephantiasis  Graecorum,  Hebrseorum  ;  Leon- 
tia.sis  ;  Satyriasis  ;  Ophiasis  ;  Tzaraath  (Hebr.) ;  Kushta  (Ind.) ;  Juzam 
Dalfil  (Arab.);  Fa-Fung  and  Ta-ma-fung  (Chin.);  Boasi  (So.  Am.); 
Lebbra  (Ital.);  Radesyge,  Spekalshed  (Xorweg. ). 

Definition. — Leprosy  is  an  endemic,  infectious,  constitutional  dis- 
ease, due  to  a  special  bacillus,  ^vhich  in  its  development  gives  rise  to 
structural  changes  of  the  skin  and  mucous  membranes,  nerves,  bone, 
and  other  tissues,  attended  with  general  symptoms,  anaesthesia,  loss  of 
tissue,  and  final  deformity  or  death. 

History  and  Distribution. — At  the  time  of  Christ  leprosy  was 
prevalent  in  the  East.  Before  this  era  the  history  of  leprosy  is  quite 
obscure.  Indefinite  references  are  made  in  the  Bible  in  the  books  of 
Exodus  ( iv.  6 ) ;  Leviticus  (xiii.  24,  25,  43,  52) ;  Numbers  (i.  and  xii.), 
and  Deuteronomy  (xii.).  It  existed,  probably  confined  in  the  early  his- 
tory of  the  world  to  Egypt  and  the  Orient.  In  India  the  disease  was 
recognized  as  early  as  fifteen  hundred  years  before  Christ.  Six  hundred 
years  before  Christ  the  Persians  instituted  measures  to  rid  the  country 
of  the  disease  (Leloir).  Celsus  describes  the  condition  in  detail  as  early 
as  the  year  25  a.  d.  At  this  time  Greece  and  Italy  had  been  invaded. 
Giilen  in  the  second  century  chronicles  the  further  spread  of  leprosy 
into  Spain,  France,  and  Germany.  As  early  as  636  a.  d.  lazarettos  were 
established  in  Italy.  In  the  tenth  century  England  and  Scotland  were 
afflicted.  In  the  eleventh  and  twelfth  centuries,  during  the  Crusades, 
the  disease  spread  all  over  Europe,  reaching  then  the  acme  of  its  force 
and  determining  the  subsequent  measures  for  its  control.  At  this  time 
(at  the  death  of  Louis  VIII.,  1229)  it  was  estimated  that  there  were 
nineteen  thousand  leprosaries  in  Europe  and  two  thousand  in  France 
alone.' 

Yielding  to  this  enforced  control,  the  disease  gi-adually  disappeared 
from  the  fifteenth  to  the  seventeenth  century,  surviving  only  in  a  few 
isolated  districts. 

AVitli  the  disappearance  of  the  disease  in  Europe  it  began  in  the  col- 
onies of  the  Americas  and  the  islands  of  the  Pacific  and  Indian  oceans. 
Xo  country  or  climate  has  been  spared  in  the  gradual  distribution  of  the 
disease.  It  has  spread  wherever  it  has  been  introduced.  Its  appearance 
in  a  new  country  has  always  been  directly  traceable  to  importation  from 
an  affected  countr}'. 

It  is  endemic  in  Xorthern  and  Eastern  Africa,  Madagascar,  Arabia, 
Persia,  India,  China  and  Japan,  Russia,  Norway  and  Sweden,  Italy, 

'  Leloir,  Traite  de  la  Lepre,  Paris,  1885. 

921 


922  LEPROSY. 

Greece,  France,  Spain,  in  the  islands  of  the  Indian  and  Pacific  oceans. 
It  is  prevalent  in  Central  and  South  America,  Mexico,  in  the  West 
Indies,  the  Hawaiian  Islands,  Australia,  and  New  Zealand.  It  is  found 
also  in  New  Brunswick,  Canada.  In  the  United  States  the  majority  of 
cases  occur  in  Louisiana  and  California,  while  from  many  other  States 
cases  are  occasionally  reported,  notably  from  New  York,  Ohio,  Penn- 
sylvania, Minnesota,  Missouri,  the  Carolinas,  and  Texas.  In  Louisiana 
leprosy  has  been  gaining  foothold  since  1758,  when  it  was  introduced  by 
the  Acadians. 

Varieties. — The  varieties  of  leprosy  usually  described  are  three : 

1.  The  tubercular ; 

2.  The  ansesthetic ; 

3.  The  mixed. 

In  the  development  of  the  bacilli  of  leprosy  in  the  economy  there 
are  evolved  neoplastic  growths  to  which  Leloir  has  given  the  name  of 
"^  lepromes"  These  may  occur  at  any  part  of  the  body  and  are  respon- 
sible for  the  lesions  of  the  disease.  As  they  occur  in  the  skin,  in  the 
mucous  membranes,  or  in  the  nerves,  muscles,  bones,  etc.,  so  the  affection 
is  determined.  For  purely  clinical  reasons  the  disease  attacking  the 
skin  and  mucous  membranes  is  given  the  name  tubercular  or  cutaneous 
leprosy,  while  that  attacking  the  nerves  is  called  nerve  leprosy,  or  the 
anaesthetic  leprosy,  or  tropho-neurotic  leprosy. 

The  mixed  is  the  "complete"  type  sharing  the  physical  charac- 
teristics of  both  of  the  above.  Another  variety  is  sometimes  separated,, 
the  "  macular."  This  may  as  well  be  called  a  type,  as  each  is  but  a 
stage  in  the  development  of  the  entire  disease,  and  it  is  indeed  difficult 
to  draw  the  fine  lines  necessary  to  the  separation  of  the  mixed  from  the 
merging  ansesthetic  and  tubercular  types.  It  is  rare,  moreover,  to  observe 
a  case  in  which  the  pure  tropho-neurotic  or  the  pure  tubercular  type  is 
maintained  to  the  conclusion  of  the  case. 

Etiology. — The  direct  cause  of  leprosy  is  the  bacillus  lejwoe  ;  the  in- 
direct, contagion.  This  position  needs  some  discussion,  as  the  question 
of  the  contagiousness  of  leprosy  is  still  an  open  one. 

The  contagiousness  of  leprosy  is  difficult  of  demonstration,  because 
it  is  impossible  to  determine  the  period  of  incubation,  and  as  yet  no- 
primary  lesion  has  been  discovered.  Of  all  bacillary  diseases,  it  alone 
is  discriminated  against  by  the  anti-contagionists,  and  that  with  no  posi- 
tive argument.  It  is  accepted  as  a  bacillary  disease  and  as  infectious 
by  many  wdio  will  not  admit  contagion  for  lack  of  actual  evidence.  It 
resembles  bacillary  infectious  diseases,  especially  tuberculosis  and  syphi- 
lis, in  its  methods  of  development.  Further  than  this,  there  are  evi- 
dences of  contagion  which  cannot  be  combated — namely  : 

1.  The  undoubted  spread  of  the  disease.  This  is  particularly  nota- 
ble in  the  Sandwich  Islands  and  in  Louisiana. 

2.  Its  recrudescence  after  years  of  quiescence,  even  after  apparent 
eradication,  as  in  Brittany  in  France, 

3.  The  history  of  individual  cases  of  the  disease  in  persons  foreign 
to  the  region  or  climate  who  had  contracted  the  disease  when  exposed,, 
as  Father  Damien,  Father  Boglioli  (Professor  Jones's  case  in  New 
Orleans),  and  numerous  instances  of  nurses  and  attendants. 

4.  The  accidental  contagion,  as  in  the  medical  student  (reported  by 


ETIOLOGY.  923 

Van   Dyke   Carter  from   Dr.   Ilatcli's  notes)  in   India  who  was  aoci- 
dentally  cnt  while  makinj:;  a   post-mortem  on  a  le})er. 

5.  Several  members  of  the  same  family  affected  and  successively 
with  no  history  of  ancestral  leprosy.  The  author  has  4  instances  of 
this  in  point:'  1,  granddaujrhter  and  grandmother  (Germans),  the 
former  affected  two  years  before  the  latter ;  2,  two  brothers  (native 
Creoles),  one  affected  several  years  before  the  other;  .'],  mother  and 
daughter  (negro  Creoles),  daughter  affected  seven  years  before  the 
mother;  4,  father  and  daughter  (Irishj,  daughter  affected  seven  years 
before  the  father.  Xo  history  of  exposure  or  of  family  tendencies  in 
any  of  these  cases. 

6.  The  origin  of  the  disease  in  single  members  of  a  family  living  in 
a  leprous  community. 

7.  The  effect  of  isolation  or  segregation  on  the  spread  of  the  disease. 
( Vide  Sandwich  Islands  in  1885,  4500  cases  ;  Norway  and  Sweden  in 
1895,  approximated  2500  cases  ;  etc.J 

8.  The  fact  that  neither  age  nor  sex  nor  race  is  spared,  while  poverty 
and  overcrowding  and  conditions  of  inferior  hygiene  seem  to  determine 
the  selection  of  the  lower  social  strata,  as  with  many  other  infectious 
diseases. 

9.  Inoculation  has  been  successful  in  one  case  (Arning),  even  if 
there  may  have  been  family  predisposition. 

10.  Experiments  with  animals  reproduce  the  disease  in  loco,  if  not 
systematically. 

11.  The  bacillus  is  capable  of  culture  on  suitable  soil  (Byron  et  ah). 

12.  Leloir  tabulates  cases  of  direct  infection  between  husband  and 
vn.{e  in  17  cases,  also  tabulates  cases  of  suggested  infection  from  clothes 
and  from  the  occupancy  of  houses  formerly  used  by  lepers  (op.  cit.). 

13.  The  disease  can  be  traced  from  one  country  to  another. 

14.  The  bacillus  is  found  in  leprous  tissue  and  nowhere  else.  There 
are,  besides,  certain  predisposing  or  general  factors  in  the  production  of 
leprosy  which  must  be  considered.  Chief  among  these  is  heredity.  The 
fact  that  the  disease  occurs  in  successive  generations  and  collaterally 
argues  some  force  in  heredity  as  a  factor.  Leprosy  has  never  been 
proved  hereditary  or  congenital,  most  cases  occurring  at  ages  precluding 
such  an  hypothesis. 

The  Report  of  the  British  Leprosy  Commission  in  India,  after  the 
examination  of  2000  cases  (1893),  concludes  "  thcit  leprosy  in  India 
cannot  he  considered  an  hereditary  disease,  and  they  ivould  even  venture 
to  say  that  the  evidence  ivhich  exists  is  hardly  sufficient  to  establish  an 
inherited  predisposition  to  the  disease  by  the  offspring  of  leprous  patients 
to  an  appreciable  degreed  If  the  child  is  removed,  leprosy  is  only 
rarely  developed,  and  then  it  cannot  be  proven  that  there  was  no 
exposure  to  a  possible  infection  (ibid.).  In  many  so-called  hereditary'' 
cases  the  child  was  affected  first.  A  child  often  becomes  leprous  without 
family  history  and  with  no  subsequent  development  in  parents.  The 
author  has  recorded  2  such  cases:  1.  A  girl  child  of  twelve  with  the 
disease  two  years ;  2.  A  boy  of  six  with  the  disease  one  year  and  a  half. 
It  is  rare  to  see  leprosy  under  the  fifth  or  sixth  year. 

Indi\ddual  predisposition  is  to  be  regarded  among  this  class  of  gen- 
eral causes,  as  it  must  explain  the  exemption  of  one  person  while  another 


924  LEPROSY. 

is  attacked.  Among  the  contributing  causes  are  the  constitutional  con- 
ditions, among  which  are  syphilis,  malaria,  tuberculosis,  scurvy,  alcohol- 
ism, and  sexual  immorality.  Bad  nutrition,  bad  hygiene,  fish  diet,  espe- 
cially in  districts  where  half-raw  fish  is  eaten,  pork  diet,  changes  of 
temperature,  a  moist  climate,  and  vaccination  (?)  are  further  probable 
elements  in  the  production  and  propagation  of  this  disease. 

The  majority  of  those  affected  are  males,  while  the  age  ranges  indefi- 
nitely from  six  to  seventy-five,  but  cases  are  more  numerous  between  the 
ages  of  thirty  and  fifty  (Leloir  and  British  Leprosy  Commission). 

Pathology. — The  bacillus  of  leprosy  in  its  development  gives  rise 
to  certain  exudative  changes,  which  begin  ordinarily  in  the  corium  and 
are  associated  with  changes  in  the  lymph  vessels  or  the  bloodvessels 
themselves.  The  nerve  lesions  show  a  proliferation  in  the  interstitial 
connective  tissue.  All  these  neoplasms  (says  Neisser)  show  a  corre- 
sponding structure — a  cell  mass  separated  by  sparse  fibrillary  interme- 
diate tissue.  The  cellular  elements,  like  lymph  corpuscles,  gradually 
grow  in  size  until  they  are  four  or  five  times  the  original  volume.  The 
cells  are  spheroidal,  spindle-shaped,  or  rounded. 

The  tumors  in  leprosy  are  granulation  tissue,  made  up  of  cells  which 
grow  and  form  the  "  giant "  cell  of  the  disease,  finally  breaking  down 
and  disappearing,  leaving  behind  masses  of  connective  tissue,  fibrillary 
in  character,  most  marked  in  the  regions  where  the  nerve  is  affected. 
These  cells  are  grouped  as  well  around  the  bloodvessels,  causing  them 
to  hypertrophy  and  become  varicose  and  much  thickened.  Ultimately 
the  leprous  tissue  is  absorbed  or  eliminated,  or  it  may  be  destroyed  by 
some  ulceration  brought  about  by  external  factors. 

The  bacillus  leprce  was  discovered  in  1868  by  Hansen,  but  the  descrip- 
tion of  it  was  not  published  until  1880,^  and  confirmed  by  Neisser  in 
1879.^  Others  to  describe  the  bacillus  were  Cornil,  Thoma,  Hillairet, 
John  Hillis,  Kobner,  Atkinson,  Koch,  Unna,  and  Thin. 

The  bacillus  leprce  is  described  as  a  small  rod  bacillus,  from  one  half 
to  three  quarters  of  the  diameter  of  a  red  corpuscle  in  length,  and  in 
breadth  about  one  fifth  that  length.  It  is  straight  or  slightly  curved, 
with  pointed  or  rounded  extremities.  It  occurs  in  short  chains  or  beads 
resembling  the  tubercle  bacilli  (Byron),  and  may  have  its  extremities 
clubshaped  (Fig.  53,  p.  925).  The  bacillus  is  readily  stained  with  the 
anilines  and  by  Gram's  method.^ 

The  bacilli  are  seen  either  contained  within  the  "giant"  cell  or  dis- 
tributed in  irregular  groups  in  the  granulation  tissue. 

The  bacilli  occur  in  all  leprous  tissues  of  the  body.  They  are  found 
in  the  secretions,  with  the  exception  of  the  urine.  Kobner  alone  claims 
to  have  found  them  in  the  blood.  Arning  claims  to  have  found  the 
bacilli  in  the  earth  from  a  leper's  grave  (quoted  in  British  Leprosy 
Commission).  Various  specimens  of  earth  were  examined  by  the  Brit- 
ish Leprosy  Commission  in  India,  and  in  several  instances  the  germ  was 
found.  Various  fish  have  been  examined  for  the  bacillus,  but  with 
negative  results. 

^  Quart.  Journ.  Microscop.  Science,  Loudon,  1880,  N.  S.  xx.  92-102;  Virchow's  Arch., 
1880,  Bd.  79,  p.  31. 

^  Breslauer  Artzl.  Zeitschrifl,  179,  Nos.  20,  21 ;  Virchow's  Archiv,  Bd.  84,  p.  514. 
^  Sternberg,  3fan.  of  Bacteriology,  1892,  New  York. 


symptoms:  925 

Among'  otliors,  livruii  nuidc  :i  |)iirc  culture  ol"  the  biu-illus  in  agar- 
agar.     This  he  has  descriluMl   in   (h'tail.' 

In  1884,  Arning  inocuhited  Kcaiiii,  a  Hawaiian,  with  leprosy,  which 
was  foUowcd  in  six  inontiis  by  a  w<'ll  marked  h'prons  tnbereh'  at  tlie  site 
of  the  iii<)cul:itii)ii.     'Hiree  years  later  ICeaiui  had  well  marked  le|)rosy. 


Fig.  o3. 


Bacillus  lepras  (Byron). 


Discredit,  however,  is  cast  upon  this  experiment  because  the  nephew, 
son,  and  maternal  first  cousin  of  Keanu  Avere  lepers. 

In  animals  Damsch,  Campana,  and  Vossius  have  succeeded  in  repro- 
ducing the  disease  in  loco,  but  not  elsewhere.  Melchior  and  Ortmann^ 
succeeded  in  distributing  the  disease  to  the  visceral  organs,  etc.,  follow- 
ing the  introduction  of  a  freshly  extirpated  leprous  tubercle  into  the 
anterior  chamber  of  a  rabbit's  eye. 

Symptoms. — All  cases  begin  with  the  same  preliminary  manifesta- 
tions, and  it  is  only  a  small  differentiation  which  determines  the  several 
stages.  The  incubation  of  leprosy  is  not  definite.  It  is  variously  esti- 
mated at  from  a  few  weeks  to  twenty  or  even  forty  years,  and  the  time 
is  often  wrongly  reckoned  from  the  possible  exposure  at  a  remote  period, 
when  it  may  have  occurred  far  more  recently.  There  are,  however,  cer- 
tain prodromal  manifestations  wdiich  may  determine  the  period  of  inva- 
sion. The  one  most  constant  symptom  is  the  occurrence  of  fever,  inter- 
mittent or  irregular  in  periods  and  in  type.  Among  the  other  notable 
symptoms  are  malaise,  anorexia,  dyspepsia,  epistaxis,  dryness  of  the 
nasal  passages  and  respiratory  tract,  vertigo,  headaches  and  neuralgias, 
rheumatic  pains,  articular  pains,  and  exaggerated  functions  of  the 
cutaneous  fat  and  sweat  glands.  The  latter  especially  is  a  notable 
symptom  in  developing  lejjrosy,  the  sw^eating  being  almost  periodical 
and  associated  rather  with  nervous  than  with  febrile  disturbances. 
There  is  in  all  instances  a  sense  of  anxiety,  of  anticipated  calamity. 

1  Research.  Loomis  Lab.,  1892,  ii.  87-90. 

■^Berlin.  Hin.  Wochen.,  1885,  No.  13;  1886,  No.  9. 


926  LEPROSY. 

There  may  be  pruritus  or  hyperesthesia  of  the  skin,  with  neuralgic 
pains  in  all  locations.  These  are  the  premonitory  evidences  of  leprosy, 
often  associated  with  indefinite  eruptions  of  erythematous  patches  at 
various  and  irregularly  selected  parts  of  the  body.  Eed  at  first,  these 
spots  become  brownish,  the  borders  white  and  occasionally  thickened. 
These  fade,  and  reappear  in  the  same  or  other  parts  of  the  body,  some 
fading,  while  others  are  making  their  appearance.  Some  persist  for 
days,  weeks,  or  months,  finally  fading,  often  quite  rapidly. 

This  is  the  macular  stage  of  leprosy,  really  only  a  group  of  symp- 
toms of  the  premonitory  stage.  Xow  there  may  appear  bullae  on  the 
extremities,  at  the  knees  and  elbows,  wrists  and  ankles,  but  most  often 
over  the  articulations  of  the  phalanges  of  the  fingers  and  toes.  These 
may  come  in  groups  of  bullee,  none  larger  than  a  spHt  pea,  or  in  single 
lesions  the  size  of  half  a  pigeon's  egg,  which  appear  as  clear  blisters 
filled  with  a  yellowish  white,  semi-translucent  fluid.  Quickly,  however, 
they  become  cloudy  and  pustular  if  they  do  not  break  through  their 
thin  walls.  They  heal  quite  rapidly,  leaving  behind  a  faint  pigmenta- 
tion or  a  superficial  scar.  Successive  eruptions  may  recur  for  months  or 
years  before  the  determinate  symptoms  of  confirmed  leprosy  appear. 
These  may  be  characteristic  at  the  start. 

The  tubercles  may  appear  at  once,  and  they  vary  in  phvsical  charac- 
teristics. They  may  be  described  as  spherical  or  rounded  nodosities, 
varying  from  the  size  of  a  pin's  head  to  that  of  a  hazelnut,  hard  and 
■elastic  to  the  touch,  pale  or  red  brown  in  color,  at  times  copper  colored, 
smooth,  and  telangiectatic. 

In  the  negro  these  tumors  are  shiny  and  dusky  brown,  with  a  marked 
tue  of  red,  the  surrounding  skin  being  much  darker  in  color,  especially 
immediately  proximate  to  the  periphery  of  the  lesion.  The  lesions  are 
•discrete  and  form  distinct  individual  nodosities,  or  they  mav  become 
•confluent,  forming  irregular  oblong  or  gyrate  bunched  masses. 

Often  the  eruption  begins  quite  differently.  The  macules  of  the  pre- 
monitory eruption  may  remain  or  other  patches  form,  which  vary  in 
size,  averaging  the  size  of  the  palm.  Usually  simply  hyperaemic  or 
wine  colored,  they  may  be  violaceous,  livid,  brown,  yellow,  or  almost 
black.  The  centre  is  sometimes  darker  than  the  margin,  sometimes 
depressed,  free  from  color,  an  annulated  lesion  forming  the  patch. 

1.  The  Tubercular  Type. — In  these  patches  the  tubercles  now  form. 
There  is  a  sudden  rise  of  temperature,  persisting  irregularly.  The 
patches  thicken  and  grow  elevated,  become  nodulated  and  bunched, 
forming  irregular  nodosities  which  gradually  assume  shape.  They  may 
remain  under  the  skin,  but  more  often  grow  until  they  are  much  enlarged 
and  cause  deformity  by  their  prodigiousness.  This  constitutes  the 
tubercular  form  of  leprosy.  The  most  frequent  seats  of  the  lesions  are 
the  face,  the  hands,  the  feet,  the  forearms,  and  the  lower  extremities. 
The  face  oifers  the  favorite  location  for  the  eruption,  and  it  is  selective 
of  the  forehead,  the  eyelids,  the  nose,  lips,  chin,  cheeks,  and  ears.  The 
nose  is  flattened,  infiltrated,  hypertrophied,  lobulated.  The  cheeks  are 
likewise  thickened,  bunched,  and  nodulated.  The  ears  become  leathery, 
thickened,  many  times  enlarged,  and  the  lobules  hang  pendulous,  often 
a  mass  of  highly  developed  tubercles.  The  tubercles  tend  to  confluence. 
They  also  tend  to  grow,  and  may  become  immensely  hypertrophied. 


SVMI'TfJMS.  927 

* 

exfoliate,  or  become  compliciited  with  (imIlmiki.  Spontaneous  retrogres- 
sion may  obtain.  Then  tlu'  lesions  soften,  sink  into  the  skin,  shrivel, 
and  finally  disappear,  leaving  a  })igniented  spot  to  mark  the  site.  More 
often,  however,  the  process  is  different.  They  become  inflamed,  sup- 
purate, and  slough  in  part  or  entirely.  They  may  ulcerate  in  a  sujK'r- 
ficial  way,  gnidiially  destroying  the  suljjacent  tissues,  attacking  in  turn 
the  tendons,  ligaments,  and  l)ones.  (Jn  the  mucous  membranes  the 
tubercK's  ulcerate  readily,  producing  at  tirst  disturl)ances,  then  destruc- 
tion of  the  affected  region.  Within  the  nasal  cavity  the  septum  gives 
way  to  the  process,  and  early  in  the  disease  disfigurement  results,  with 
a  consequent  interference  with  speech  and  smell.  Leprous  deposits 
likewise  form  in  the  conjunctiva,  gradually  extend  into  the  cornea,  and 
affect  the  vision,  finally  causing  ulceration  and  blindness.  The  glands 
are  much  enlarged  in  all  regions,  but  particularly  in  the  submaxillary 
and  cervical. 

The  mental  faculties  are  not  much  affected,  excepting  that  there  is  a 
constant  anxiety  on  the  patient's  part,  anticipating  some  unknown  and 
inapprehensible  misfortune. 

The  testicles  gradually  atrophy,  and,  if  the  disease  begins  before 
puberty,  the  physical  development  is  greatly  retarded.^ 

Tubercular  leprosy  develops  rapidly,  and  is  liable  to  attack  any 
region  of  the  body.  The  destructive  process  attendant  upon  the  ulcer- 
ating lesions,  especially  of  the  extremities,  is  more  than  likely  to  result 
in  mutilation  and  deformity,  in  which  this  does  not  differ  from  the  type 
presently  to  be  described. 

2.  The  Ancesthefic  Type. — The  anaesthetic  or  tropho-neurotic  form  of 
leprosy,  or,  as  Leloir  calls  it,  the  "  systematic  nervous  leprosy,"  differs 
in  no  respect  from  the  tubercular  in  its  period  of  invasion.  The  bullous 
eruption,  however,  usually  appears  as  the  single  lesion,  incessantlv 
re-forming,  until  finally  there  is  only  an  ulcer  left,  which  becomes  obsti- 
nate and  persists  with  constant  destruction  of  tissue.  From  this  periph- 
eral lesion  anaesthetic  or  nerve  leprosy  may  start.  Beginning  on  one 
finger,  the  balance  of  the  digits  of  the  affected  hand  will  one  by  one  be 
attacked,  followed  by  those  of  the  hand  on  the  other  side.  The  feet 
may  follow  or  present  lesions  at  the  same  time.  This  is  often  the  his- 
tory. The  ulcer  becomes  a  trophic  one,  with  a  localization  in  the  fleshy 
part  of  the  heel,  great  toe,  or  the  ball  of  the  foot.  It  is  painless 
and  persistent.  It  is  characterized  by  the  sharply  cut  edges,  the  sur- 
rounding infiltrated  and  thickened  skin,  and  the  typical  nauseous 
discharge. 

The  anaesthesia  starting  from  these  lesions  extends  up  the  hand  and 
arm,  associated  with  loss  of  sense  of  heat  and  cold,  pain,  and  even  touch 
at  times.  Then,  or  before,  the  macules  of  anaesthetic  leprosy  appear. 
The  characteristic  and  most  important  lesion  of  this  type  is  the  macular 
patch,  with  a  well  defined  pigmented,  usually  brown,  periphery  around 
an  atropine  centre,  free  of  color  or  of  a  parchment  yellow  hue.  The 
edges  are  often  thickened  and  elevated.  The  patches  are  often  serpigi- 
nous or  gyrate  as  a  result  of  confluence.  These  patches  are  always 
markedly  amesthetic,  the  discolored  parts  being  most  anaesthetic  and 
proportionate  to  the  degree  of  color. 

'  Neisser,  in  v.  Ziemssen's  Cyclopcedia. 


928  LEPROSY. 

*■ 
These  are  the  lesions  of  the  eruptive  stage  of  the  ansesthetic  type,  or 
Leloir's  "  period  of  invasion."  The  patches  themselves  may  anoma- 
lously become  hypersesthetic,  or  points  of  hypersesthesia  develop  at  other 
parts  of  the  body.  Likewise,  anaesthesia  may  occur  without  any  deter- 
mining lesions.  Neuralgic  pains  are  common,  and  marked  thickening 
of  certain  nerves  occurs,  notably  the  ulnar. 

Just  here  an  almost  constant  symptom  is  evident.  This  is  the 
anaesthesia  of  the  little  finger,  which  is  present  even  before  any  lesions 
have  appeared  on  the  hand. 

Following  the  eruptive  stage  is  the  permanent  stage  or  the  stage  of 
degeneration.  It  is  marked  clinically  by  trophic  disturbances,  atrophies, 
paralyses,  etc.  Motor  paralyses  of  the  face,  hands,  and  feet  are  soon 
evident.  Insensibly  the  patient  loses  the  power  of  grasping  objects,  the 
sense  of  touch,  as  well  as  loss  of  muscle  control,  being  gone.  There 
follows  muscle  atrophy  of  the  face,  distorting  it,  and  of  the  hand, 
causing  contractures.  Ectropion  of  the  lower  lids  results,  so  that  the 
eyes  cannot  be  closed.  The  lips  become  flabby  and  the  lower  one  drops. 
The  extensor  and  flexor  muscles  of  the  forearm  contract,  and  the  "  claw- 
hand  "  results.  The  muscles  of  the  lower  extremities  are  aflected  in  the 
same  way.  A  shuffling  gait,  due  to  inability  to  raise  the  feet,  and  final 
incapacity  of  motion,  result.  Then  come  atrophy  of  the  skin,  shrinking  of 
the  skin,  and  a  general  appearance  of  senility.  There  are  numerous  trophic 
disturbances,  such  as  falling  of  the  hair,  loss  of  pigment  of  the  liair,  loss 
of  teeth,  shedding  of  the  nails,  ulceration  of  the  gums  and  of  the  nasal 
passages.  The  ulcers  over  the  articulations  of  the  phalanges  extend  to 
the  articulation,  cause  the  phalanges  to  fall,  or,  occurring  in  the  middle 
phalanges,  cause  shortening  or  contraction.  Dry  gangrene,  or  necrosis, 
occurs ;  absorption  of  the  bone  and  deformity  result.  The  mutilating 
process  may  progress  to  the  loss  of  the  entire  hand  or  foot. 

3.  The  Mixed  Tfpe. — The  "  mixed  "  type  of  leprosy  is,  as  its  name 
suggests,  a  combination  of  the  two  varieties  just  described.  It  is  the 
complete  development  of  these  two  stages,  with  the  symptoms  and  cha- 
racteristics of  each.  It  may  begin  with  the  ansesthetic  macule  and  the 
prominent  tubercle,  both  well  defined  and  occurring  simultaneously. 
More  often  one  variety,  usually  the  tubercular,  assumes  the  type  of  the 
other.  In  this  form  of  the  disease  the  lesions  are  perhaps  more  promi- 
nent and  the  symptoms  are  more  profound.  Oedema  of  the  extremi- 
ties is  quite  common  ;  the  fingers  lose  their  shape,  become  tense  and 
shining,  looking  as  if  the  skin  would  burst.  The  course  and  the  result 
of  mixed  leprosy  are  the  same  as  with  the  other  stages. 

Diagnosis. — The  diagnosis  of  leprosy  can  be  made  readily  when  the 
disease  is  well  developed.  Tubercular  and  ansesthetic  leprosy  can 
scarcely  be  differentiated  until  the  lesions  have  matured.  In  the  former 
the  early  bullous  eruption  is  more  often  in  groups ;  in  the  latter,  in  a 
single  recurring  lesion. 

The  folloAving  list  contains  the  determining  points  in  the  diagnosis 
of  all  stages  and  types  : 

1.  Habitat,  whether  community  or  family  domicile  ; 

2.  History  of  contact  with,  or  exposure  to,  the  disease ; 

3.  Anaesthesia  ; 

4.  Trophic  disturbances ; 


PROGNOSIS— TREA  TMKNT.  929 

5.  Eruptions  of  biillie  in  successive  crops  or  of  a  single  one  recurring ; 

6.  Porforutin<i'  ulcers  of  the  liaiids  oi-  the  feet; 

7.  Muscle  atvo|)Iiv  ; 

8.  Tiie  "claw-haiKl  ;" 

9.  Clul)be(l  iiuiicrs  ; 

10.  Discoluivcl  and  blunted  nails  ; 

11.  Cliaractcristic  anaesthesia  of  the  little  finger,  an  early  sign; 

12.  The  leonine  face  ; 
18.  Leathery  ears  ; 

14.  Ectropion  of  eyelids  and  lower  lip ; 

15.  Persistent  mutilating  ulcers  at  the  articulations  of  phalanges  of 
fingers  and  toes  ; 

16.  Deformity  of  fingers  and  toes  from  loss  of  phalanges; 

17.  Hunted,  anxious  look  ; 

18.  Loss  of  expression  in  the  face ; 

19.  Einding  of  lepra  bacillus. 

From  morpJura  the  anaesthesia  and  color,  with  the  absence  of  the 
areola,  diagnose  leprosy.  Si/philis  is  diagnosed  by  the  color,  course  in 
development,  and  the  amesthesia.  lodism  is  differentiated  by  the  anaes- 
thesia and  absence  of  pustulation.  Sarcoma,  by  the  number  of  the  lesions 
and  the  anaesthesia.  Molhiseum  fibrosurn,  by  the  consistence,  size,  color, 
and  duration  of  the  lesions.  Lichen  planus  is  diagnosed  by  the  color 
and  absence  of  subjective  symptoms  ;  pemphigus,  by  the  location  and 
sequelae  of  the  bullous  lesion.  Dt/sidrosis,  l)y  the  location  of  the  lesions 
and  the  recurrence  independent  of  season  and  of  treatment. 

Jlorvan^s  Disease. — If  this  is  not  regarded  as  a  variety  of  leprosy, 
or  if  leprosy  is  not  considered  one  of  the  causal  elements,  it  is  difficult 
of  diagnosis,  and  only  the  finding  of  Hansen's  bacillus  will  determine 
the  differentiation. 

PPtOCxXosis. — The  average  duration  of  leprosy  is  about  eight  vears. 
The  mixed  and  the  tubercular  are  the  more  rapidly  concluded — in  from 
four  to  twelve  years  unless  shortened  by  some  intercurrent  disease.  The 
spontaneous  involution  of  lesions  may  be  followed  by  no  recurrences, 
but  this  is  usually  only  a  process  in  the  final  result,  though  the  longevitv 
of  the  individual  may  be  increased  by  this  remission. 

Death  is  the  ordinary  conclusion  of  every  case,  which  may  come  (in 
38  per  cent,  of  cases)  from  the  exhaustive  effects  of  the  disease,  from 
an  almost  necessary  septicaemia,  or  from  some  intercurrent  disease,  as 
nephritis  (in  22.5  per  cent.) ;  from  pulmonary  diseases,  including 
phthisis  (in  17  per  cent.),  diarrhoea  (in  10  per  cent.),  anaemia  (in  5  per 
cent.),  remittent  fever  (in  5  per  cent.),  peritonitis  (in  2,5  per  cent.).' 

Treatment. — The  treatment  of  leprosy  has  been  attempted  accord- 
ing to  almost  every  conceivable  method,  without  marked  results.  The 
Pharmacopoeia  has  been  exhausted  in  the  search  for  remedies  having 
specific  effect  in  the  control  and  cure  of  the  disease.  The  disease  stares 
us  yet  in  the  fiice,  unconquered  and  unabating. 

The  indications  for  treatment  follow  certain  well  defined  lines.  AVe 
must  consider — (1)  the  tonic;  (2)  the  palliative;  (3)  the  specific;  (4) 
the  tentative  ;  and,  finally,  (5)  the  prophylactic  treatment  of  the  disease. 
Recognizing  leprosy  as  an  as  yet  incurable  disease,  tonic  treatment  must 

^  Hillis'  table,  quoted  by  Niesser,  loc.  cit. 
Vol.  I.— 59 


930  LEPROSY. 

be  directed  at  maintaining  the  strength  of  the  individual  and  at  con- 
tributing as  far  as  possible  to  the  supply  to  meet  the  necessary  waste. 
Strychnine,  arsenous  acid,  iron,  quinine,  cod-liver  oil,  hypophosphites, 
hoang-nan,  etc.  are  among  the  remedies  suggested  and  used.  Dietary 
and  hygienic  care  must  be  included  among  the  tonic  measures  employed. 
Regular  baths,  cold  or  hot,  vapor  or  medicated,  are  also  included  in  this 
definition.  It  is  well  to  adopt  some  one  or  more  tonic  remedies,  and  to 
persist  in  them  throughout  the  treatment.  The  author  insists  upon  the 
prolonged  administration  of  strychnine  sulphate  or  of  arsenous  acid. 
Palliative  measures  are  employed  for  the  symptoms  which  may  arise 
in  the  course  of  any  given  case  when  ordinary  judgment  is  required. 
Neuralgias,  rheumatism,  diarrhoeas,  or  kidney  disturbances  must  be 
treated  appropriately. 

By  specific  treatment  we  mean  the  so-called  cures  and  remedies 
advanced  as  visibly  and  materially  checking  or  removing  the  patent 
symptoms  of  the  disease.  The  list  of  these  is  legion,  but  some  of  estab- 
lished value  should  be  mentioned.  Chaulmoogra  oil,  Gynocardia  odorata, 
is  perhaps  the  one  remedy  of  this  class  for  which  most  is  claimed.  It 
is  used  both  externally  and  internally,  but  is  best  given  in  capsule  or  in 
milk.  The  dose  varies  from  two  drops  to  as  much  as  the  stomach  of 
the  patient  will  allow,  and  it  is  best  given  after  eating. 

Gurgun  oil,  Dipterocarpus  turbinatus,  is  likewise  used.  It  is  usually 
given  with  lime  water.  Cashew-nut  oil  is  still  another  of  a  large  num- 
ber of  native  oils  employed  in  India. 

Unna  claims  to  have  cured  two  cases  with  ichthyol  internally,  using 
ichthyol,  pyrogallic  acid,  and  resorcin  externally. 

Salol  and  salicylate  of  soda  have  attained  a  degree  of  favor  recently, 
especially  in  the  Hawaiian  Islands.  Goldschmidt  of  Madeira  has  used 
europhen  by  hypodermic  injection  into  the  nodules  and  patches,  and 
claims  results.  The  europhen  was  incorporated  in  oil.  Tuberculin  was 
used  extensively  in  a  tentative  way  at  the  time  of  its  introduction,  but 
with  no  appreciable  benefit,  and  with  some  instances  of  decided  harm. 
The  author  recalls  one  case  in  which  death  was  materially  hastened  by 
its  employment. 

Since  Carreau's  monograph  on  the  use  of  chlorate  of  potash  in  the 
treatment  of  leprosy  I  have  employed  this  drug  tentatively  in  several 
cases.  The  first  case  was  enabled  to  take  as  much  as  380  grains  a  day, 
with  absolutely  no  intoxication  from  the  drug ;  the  quantity  of  urine 
was  undiminished  and  the  bowels  were  constipated.  The  drug  was 
found  in  the  urine,  but  there  was  no  evidence  of  kidney  disturbance. 
This  treatment  was  carried  on  diiferently  from  Carreau's.  He  began 
with  large  doses,  and  increased  them ;  I  began  with  small  doses,  and 
increased  them  gradually  to  a  tolerant  point,  being  guided  in  this  by 
the  urine  and  the  condition  of  the  intestinal  canal.  In  no  instance  was 
it  necessary  to  stop  under  180  grains  a  day,  and  in  the  instance  quoted 
a  maximum  of  380  grains  was  reached.  In  this  patient  marked  ame- 
lioration was  produced,  but  only  after  a  change  of  climate  was  made. 
He  continued  this  line  of  treatment,  however,  and  for  a  period  of  over 
six  months  averaged  over  two  hundred  grains  of  chlorate  of  potash 
a  day.^     Of  2  other  cases,  one  responded  for  nearly  six  months,  but 

^  Dr.  J.  C.  HoUiday's  (Hot  Springs,  Ark.)  notes  of  the  case. 


TREATMENT.  O.'il 

relapsed  into  a  worse  condition  tli:iii  hcforc,  and  the  other  died  with 
aente  parencliyniatons  ii('|)lirili>.  One  case  <jt"  enre  (?)  occurred,  and 
is  wortiiy  of  report  : 

H (J ,  colored,  tubercular  type,  aged  lil'ty,  horn  in  Mis- 
sissippi ;  lived  since  eighteen  years  old  in  Louisiana  ;  worked  several 
years  in  Mississi])pi  on  river  boats,  sto})ping  at  various  ])oints,  some 
leprous  centres  ;  a  cooper  by  trade.  AVas  seen  first  on  the  '2 -1th  of"  l*'ebi-u- 
ary,  1893.  At  this  visit  a  careful  examination  showed  the  following 
condition  :  A  tall  negro,  probably  six  feet  in  height,  African  in  type, 
rather  under  weight,  fairly  muscular  generally.  Presented  lesions  of 
marked  type  on  face.  In  the  intcrpalpelu'al  space  and  on  both  cheeks 
were  tubercles  varying  in  size  from  a  sj)lit  })ea  to  a  hazelnut,  telangi(;c- 
tatic,  firm  in  consistency,  shining,  and  each  one  anaesthetic.  There  were 
several  macular  lesions  on  the  trunk.  On  the  left  arm  there  were  three 
or  four  macular  patches,  not  elevated,  but  infiltrated,  well  defined,  how- 
ever, against  the  surrounding  skin.  On  the  hand  there  were  several 
small  tubercles.  There  was  already  loss  of  sense  of  touch,  with  pain, 
in  this  hand.  The  hand  could  not  be  closed  nor  could  any  object  be 
held  for  even  a  few  moments.  There  was  a  paralysis  of  the  muscles 
of  the  arm  and  forearm,  and  the  patient  had  to  be  assisted  in  undress- 
ing for  the  examination.  He  complained  of  frequent  paroxysmal 
"  rheumatic  "  pains  in  the  arm  affected.  Xo  bacteriological  examina- 
tion was  made,  and  no  photograph  could  be  had  on  account  of  the 
inclement  weather.  Ichthyol  was  prescribed  internally  in  doses  of  5 
drops  t.  i.  d.,  and  also  in  3  per  cent,  ointment;  benzoinated  lard  was 
used  for  local  inunction. 

On  ]\larch  3d  the  local  application  was  changed  to  the  officinal  iodide 
of  lead  ointment. 

March  28th.  Since  last  visit  the  patient  has  had  an  eruption  of 
bulhe  on  arm,  some  of  which  have  left  small  ulcers.  Advised  oxide  of 
zinc  ointment  to  arm.     Ichthyol  continued. 

April  4th.  Arm  improved.  Stopped  ichthyol  and  prescribed  chlor- 
ate of  potash,  gr.  xv,  t.  i.  d.,  in  sweetened  water. 

April  11th.  Lesions  on  face  smaller,  better  use  of  hands,  arms  bet- 
ter, lesion  on  arm  healed.  General  sensation  improved  in  hand.  Bowels 
very  loose  ;  several  actions  daily,  "  almost  white."  Diuretic  action 
marked.  Pain  in  left  ankle.  Discontinued  potassium  chlorate.  Bis- 
muth subnitrate,  gr.  x,  t.  i.  d.,  internally. 

April  22d.  Tubercles  on  face  still  smaller,  flatter,  and  softer.  Other 
lesions  (macules)  smaller  and  no  longer  ansesthetic.  Resumed  potassium 
chlorate  (gr.  xx,  t.  i.  d.). 

April  27th.  Better,  feels  weak,  anorexia,  bowels  loose.  Discon- 
tinued chlorate  of  potash.     Ordered — 

^.  Tincturae  nucis  vomicae,  .5j  ; 

Tincturae  cinchona  compositae,  SJss  ; 

Tincturae  gentianjc  compositae,  q.  s.  ad  siij. — M. 
Sig.  Teaspoonful  three  times  a  day. 

June  15th.  Tubercles  on  face  gone  ;  slight  pigmentation  remaining 
in  loco.     Ordered  strychnine  sulphate  -^  grain  three  times  a  day. 


932  LEPROSY. 

July  15th.  No  lesions  anywhere  visible ;  patient  has  complete  use 
of  hands.  Has  resumed  his  occupation.  Feels  well.  Some  anaesthesia 
of  left  arm  and  hand. 

October,  1893.  Patient  reports  for  observation.  No  symptoms 
whatever  of  leprosy.  No  indication  of  former  lesions  beyond  the  pig- 
mented spots  in  the  site  of  the  former  tubercles  on  the  face.  (It  is  com- 
mon among  the  negroes  to  find  pigmentation  following,  often  permanently, 
any  inflammatory  conditions.) 

Carreau  has  emphasized  the  possible  advantages  in  this  drug,  but  in 
his  two  cases  reported  there  were  such  violent  toxic  symptoms  that  he 
desisted.  As  early  as  1800,  Chisholm'  reports  the  cure  of  one  case  with 
the  oxygenated  muriate  of  potash,  administered  in  doses  of  30  grains  per 
diem,  effected  in  "about  six  weeks."  The  accidental  poisoning  of  a 
patient  of  Carreau's  by  a  bite  from  a  native  venomous  snake  led  him  to 
use  the  drug,  and  he  was  apparently  ignorant  of  its  earlier  usage, 
although  Chisholm's  field  of  observation  was  also  in  Jamaica. 

It  is  a  popular  belief  among  the  natives  of  South  American  coun- 
tries that  the  bite  from  a  venomous  snake  will  result  in  the  cure  of 
leprosy.  Carreau's  observation^  would  give  this  legend  some  color,  for 
in  his  case  the  nodules  of  confirmed  tubercular  leprosy  disappeared  as 
the  victim  recovered  from  the  influence  of  the  snake  venom. 

Winslow'^  gives  a  very  graphic  description  of  a  fatal  result  in  a  case 
in  which  the  patient  subjected  himself  to  the  bite  of  a  mature  rattle- 
snake. 

The  recent  experiments  of  Fraser*  and  of  Calmette  would  place  the 
possibility  of  experiment  in  this  line  within  reach.  The  author  believes 
that  the  investigation  of  the  effect  of  "  antevenene,"  or  attenuated  snake 
venom,  upon  the  leprous  subject  might  result  in  a  new  therapeutic 
measure  for  leprosy. 

It  is  insisted,  however,  that  the  tonic  treatment  of  leprosy  must 
be  constantly  employed,  even  at  the  risk  of  depreciating  the  value  of 
the  latter  experiments,  as  the  patient  is  the  first  consideration.  Within 
the  past  year  Dr.  Juan  de  Carrasquilla  of  Bogota,  U.  S.  of  Colombia, 
has  published  a  report  of  several  cases  treated  with  serum  derived  from 
leprous  lesions.  From  his  report,  marked  improvement  occurred  in  all 
types  treated.^ 

Surgical  procedures  are  often  indicated  in  the  course  of  the  disease, 
but  ordinarily  these  are  met  by  the  customary  surgical  judgment. 
Nerve  stretching  for  the  relief  of  the  peripheral  neuralgias  or  with  a 
view  of  interrupting  the  leprous  process  is  sometimes  resorted  to.  Am- 
putation of  an  extremity  or  digits  affected  is  suggested,  as  giving  a 
possible  chance  in  aborting  the  disease. 

Prophylaxis. — The  prophylactic  treatment  is  directed  to  two  points  : 
First,  individual  isolation  in  its  strictest  sense  would  preclude  the  pos- 
sibility of  spreading  the  disease.  This,  however,  is  scarcely  practicable. 
Individual  caution,  then,  is  the  next  best  measure.     Here  cleanliness, 

^  Edinburgh  3Ied.  and  Surg.  Journ.,  1800,  p.  399. 

^  Observation  au  Traiienient  de  la  Lepre,  Pte.-a-Pitre,  Jamaica,  1892. 

'^  Lancet  Clinic,  Cincinnati,  1874,  vol.  vi.  p.  130. 

*  Brit.  J\Jed.  Journ.,  June,  1895. 

^  JSew  Orleans  Med.  and  Surg.  Journ.,  Nov.,  1896. 


TREA  TMENT.  933 

duo  protoetion  of  open  lesions,  the  use  of  individual  utensils  in  the  house- 
hold and  of  individual  sleei)ini2:  apartments,  (•lothin<.'',  heddinfr,  etc.,  with 
absolute  j)rohil)ition  of  the  family  and  social  osculation  and  oi'the  sexual 
relation,  are  the  indications,  thout;li  dillicult  to  maintain. 

Second,  Ptihl'n-  Profcctioii. — There  should  be  some  protection  ofi'cred 
the  public.  Moses  promulgated  stringent  laws  which  today  seem 
inhuman,  while  the  popular  horror  of  the  disease  has  in  no  way  abated. 
In  this  age  of  multiplying  calamities,  however,  it  needs  more  than  a 
passing  appeal  to  stimulate  the  public  s})irit  to  an  active  interest  in  a 
possible  danger,  apparently  on  the  increase.  Leprosy  is  a  preventible 
disease,  even  though  the  question  of  infectiousness  is  still  .an  open  one. 
This  prevention  must  come  through  State  or  national  intervention. 
Where  the  control  depends  npon  political  State  boards  of  health,  with 
only  a  subsidiary  idea  of  the  demand  and  necessities  of  an  exposed 
public,  there  must  be  conspicuous  failure. 

Xorwayand  Sweden  have  settled  the  question  by  national  legislation. 
The  Sandwich  Islands  have  like\^'ise  systematically  improved  their 
methods  of  controlling  the  disease.  Louisiana  for  years  has  made 
abortive  attempts  at  the  control  of  the  disease,  and  within  a  year  has 
created  a  State  board  of  control,  with  only  restricted  functions,  and 
these  further  restricted  by  an  apathetic  public.  California  has  not  yet 
succeeded  in  this,  exposed  as  she  is  to  a  constant  source  of  infection  from 
the  Sandwich  Islands,  China,  and  Japan. 

At  best,  State  legislation  only  temporizes.  As  each  State  adopts  laws 
for  the  segregation  of  the  afflicted,  these  poor  creatures  only  make  mat- 
ters worse  by  removing  to  a  neighboring  State  which  is  without  laws 
of  either  protection  or  extradition. 

It  is  a  vital  and  pregnant  c^uestion  for  the  National  Congress  to  dis- 
cuss and  dispose  of  before  the  need  becomes  a  crying  one,  and  before 
the  disease  becomes  so  disseminated  that  a  more  than  active  effort  yv\\l 
be  required.  The  question  of  State  rights,  it  is  contended,  would  oppose 
national  interference.  It  would  only  require  the  passage  by  each  State 
of  an  act  granting  the  national  government  requisition  upon  an  alleged 
leper.  More  than  this,  State  boards  of  health  could  be  forced  to  re- 
mand recognized  lepers  to  a  national  asylum.  In  this  way  systematic 
organized  segregation  would  result,  placed  in  the  hands  of  those  capable 
and  empowered  to  care  for,  control,  and  investigate  the  disease. 


TETANUS. 

By  JAMES  STEWART,  M.  D. 


Definition. — Tetanus  is  an  acute  infectious  disease  of  the  nervous 
system,  characterized  by  persistent  tonic  spasm  of  certain  muscles,  with 
violent  exacerbations. 

Eti()LO(tY. — Tetanus  is  due  to  infection  by  the  tetanus  bacillus. 
This  bacillus  M'as  first  discovered  by  Nicolaier  of  Gottingen  in  1885  in 
garden  earth.  Kitasato  in  1889  was  the  first  to  make  a  pure  culture 
of  it.  It  is  a  slender  rod  with  rounded  ends.  It  is  only  slightly 
motile.  It  develops  best  at  the  normal  temperature  of  the  body. 
Exposed  to  a  temperature  of  42°  or  43°  C,  it  quickly  presents  invo- 
lution forms,  and  at  a  temperature  of  60°  C,  it  is  promptly  destroyed. 

It  is  distinctly  anaerobic,  the  presence  of  oxygen  quickly  destroying 
it.  If  protected  from  air  and  light,  the  spores  in  a  culture  remain 
virulent  for  more  than  a  year.  At  a  blood  temperature  in  thirty  hours, 
and  at  the  temperature  of  an  ordinary  room  after  a  week,  spores  develop. 

Fig.  54. 


<< 


A  B 

Tetanus  bacillus:  .4,  vegetative  stage,  from  gelatin  culture;  5,  spore  stage,  showing  pin  shapes 

(Abbott). 

The  rods  swell  at  one  end,  forming  characteristic  pinshaped  bodies.  The 
spore  formation  is  devoid  of  motility.  It  is  also  much  more  resistant 
to  the  action  of  heat  and  antiseptic  agents  than  the  vegetative  form,  the 
former  resisting  the  action  of  a  5  per  cent,  solution  of  carbolic  acid  for 
fifteen  hours  and  1.10  per  cent,  of  corrosive  sublimate  for  three  hours. 

Our  present  exact  knowledge  of  the  nature  of  the  action  of  the  teta- 
nus poison  has  been  derived  chiefly  from  experimental  work  on  mice 
and  rabbits.  The  symptoms  of  tetanus  in  these  animals  are  similar  to 
those  met  with  in  man. 

The  period  of  incubation  varies  considerably,  depending  on  the 
quantity  and  virulence  of  the  poison  and  the  susceptibility  of  the  ani- 
mal. In  rabbits  it  is  about  the  same  as  in  the  human  subject,  from 
eight  to  fourteen  days,  while  in  the  mouse  it  is  seldom  longer  than  three 
days.     The  spasms  appear  in  the  lower  animals  first  in  those  muscles 

935 


936  TETANUS. 

situated  in  the  immediate  neighborhood  of  tlie  part  which  is  the  seat  of 
injection.  They  soon,  however,  spread  and  involve  the  entire  muscular 
system.  AVhen  the  poison  is  injected  into  the  veins  or  into  the  peri- 
toneal cavity  the  spasms  are  at  once  of  a  general  character. 

In  man  the  source  of  the  tetanus  poison  can  usually  be  discovered  or 
rendered  highly  probable.  It  has  been  recognized  for  many  years  that 
wounds  contracted  in  a  certain  manner  were  more  liable  to  be  followed 
by  tetanus  than  others.  For  instance,  wounds  inflicted  with  splinters  of 
old  wood,  old  rusty  nails,  and  those  contaminated  with  earth  or  with  the 
excrement  of  horses  were  known  to  be  especially  dangerous  in  this 
respect.  This  knowledge  was  common  long  before  the  discovery  of  the 
tetanus  bacillus,  and  before  even  it  was  considered  possible  for  tetanus  to 
be  due  to  a  living  outside  poison.  The  tetanus  bacillus  and  spores  have 
been  frequently  demonstrated  in  garden  earth  and  in  all  kinds  of  earthy 
matter,  in  the  dust  of  streets  and  houses,  in  splinters  from  the  flooring, 
doors,  and  windows  of  houses.  In  fact,  the  poison  may  be  said  to  be  so 
abundant  that  one  naturally  is  surprised  how  comparatively  rarely  the 
disease  is  met  with.  This  is  explainable  when  we  recollect  that  the 
poison  is  quickly  destroyed  on  its  exposure  to  oxygen,  a  few  hours' 
sunlight  being  sufficient  to  destroy  its  toxic  properties.  It  therefore 
extremely  rarely  develops  except  in  deep,  penetrating  wounds.  Teta- 
nus, so  far  as  is  known,  is  only  developed  from  the  introduction  of  the 
bacilli  poison  into  a  wound.  Experimentally  it  cannot  be  induced  in 
the  lower  animals  through  the  stomach  or  respiratory  tract.  As  far  as 
is  known,  the  same  is  true  of  man.  To  account  for  cases  of  what  was 
formerly  known  as  idiopathic  tetanus  it  is  necessary  to  assume  some 
trifling  lesion  of  the  surface  in  some  part  which  has  escaped  notice.  It 
now  and  then  happens  that  the  tetanus  poison  is  introduced  alone,  and 
in  such  a  case  a  trifling  abrasion  may  heal  by  first  intention.  As  the 
tetanus  bacillus  has  no  pyogenic  proj^erties,  no  pus  or  other  discharge 
will  be  present.  In  the  present  state  of  our  knowledge  we  must  con- 
clude that  the  poison  of  tetanus  is  always  introduced  through  an  actual 
lesion  of  the  skin  or  mucous  membrane,  the  lesion  in  some  cases  being 
so  trifling  that  it  may  have  healed  completely  before  the  symptoms  of 
the  disease   have  developed. 

It  has  been  clearly  proven  that  the  symptoms  of  tetanus  are  not 
brought  about  by  the  bacillus  directly,  but  through  the  action  of  a 
poison  generated  by  it  at  the  seat  of  the  wound.  The  filtrate  of  a 
tetanus  bouillon  culture  which  is  perfectly  free  from  the  bacillus  can 
induce  the  same  symptoms  as  the  injection  of  the  bacillus  itself:  this 
shows  that  the  poison  exists  as  some  chemical  substance  separable  from 
the  bacillus. 

A  filtrate  made  from  a  tetanus  culture  of  four  weeks'  growth  placed 
in  a  weakly  alkaline  grape-sugar  bouillon  contains  the  poison  or  poisons 
in  a  very  active  state,  a  quantity  not  exceeding  the  0.000005  c.cm.  of 
this  filtrate  being  sufficient  to  kill  a  white  mouse.  If  kept  in  a  cool 
place  and  protected  from  the  light,  the  filtrate  retains  its  poisonous 
properties  unchanged  for  many  months.  Brieger  has  obtained  two 
basic  bodies  from  such  filtrate,  to  which  he  has  given  the  names  of  tetanin 
and  tetanotoxin,  each  of  which  he  found  were  capable  of  causing  death 
in  animals  with  all  the  symptoms  of  tetanus ;  but  very  large  quantities 


PATHOLOGICAL  ANATOMY.  937 

ol"  both  were  iiceossarv  to  iiKluci.'  the  syiiiptoins  of  tetanus;  hence  it  i.s 
to  be  concluded  that  neither  of  these  bodies  is  the  active  chemical  agent, 
seeing  that  the  very  smallest  (jiiantity  of  the  filtrate  is  siiiriciciit  to 
induce  a  fatal   result. 

l>ri('ger  and  b^riiukel  have  obtainetl  a  to.valhiunin  through  j)reeij)ita- 
tion  with  aleoliol,  wiiich  they  found  much  more  active  than  the  basic 
bodies  discovered  by  the  former.  Even  this  toxalbumin  is  much  less 
poisonous  than  the  Ultrate  itself.  Further  experiments  in  this  direction 
have  not  as  yet  led  to  any  definite  knowledge  as  to  the  composition  of 
this  remarkable  [)oison.  It  probably  is  not  an  albuminous  l)ody,  as  it 
develops  readily  in   matter  free  from  albumin. 

Tetanus  occurs  at  all  periods  of  life.  It  is  met  with  in  newly-born 
children  (tetanus  neonatorum)  and  in  advanced  life.  It  is  more  frequent 
in  males,  on  account,  no  doubt,  of  their  greater  exposure  to  the  exciting 
causes.  It  is  considered  to  be  more  frequent  in  the  dark-skinned  than 
white  people,  even  in  the  same  country.  It  has  long  been  recognized 
that  it  is  much  more  frequent  in  hot  than  in  cold  countries.  In  the 
East  Indies,  Central  America,  and  the  West  Indies  it  is  much  more 
common  than  in  Europe  or  North  America. 

The  development  of  the  tetanus  bacillus  is  favored  by  its  being 
introduced  in  company  with  other  bacilli,  especially  those  having  pyo- 
genetic  properties  (streptococci,  staphylococci,  etc.).  It  was  formerly 
taught  that  cold  was  an  exciting  cause  of  the  so-called  idiopathic  form, 
but  in  the  light  of  recent  researches  this  idea  must  be  given  up.  The 
not  infrequent  appearance  of  tetanus  in  soldiers  wounded  in  battles  can 
be  more  readily  explained  by  the  contamination  of  the  wounds  with  earth 
than  by  supposing  that  cold  is  an  active  agent. 

In  all  probability  mental  anxiety,  alcoholism,  and  other  debilitating 
causes  have  a  more  or  less  predisposing  influence,  as  they  lessen  the 
resisting  power  of  the  tissues  in  general. 

Puerperal  tetanus,  a  not  uncommon  variety  in  hot  countries,  but 
extremely  rare  in  temperate  climates,  is  one  of  the  most  serious  forms  in 
which  the  disease  is  met  with.  It  occurs  after  abortion,  and  also  after 
labor  at  or  near  the  full  time.  It  generally  occurs  where  there  has  been 
some  complication,  either  during  or  after  the  expulsion,  hemorrhage, 
conditions  requiring  the  use  of  the  forceps,  adhesion  of  the  placenta 
being  the  most  frequent.  It  is  not  necessary  to  assume  that  in  puerperal 
tetanus  there  is  any  special  cause  or  factor  at  work  other  than  the  bacillus. 

Tetanus  neonatorum,  like  the  puerperal  variety,  is  a  disease  essen- 
tially of  tropical  countries.  There  is,  however,  one  striking  exception 
to  this  rule  :  in  the  island  of  Heimacy,  near  Iceland,  the  population  at 
one  time  was  kept  up  only  by  immigration,  almost  all  the  children 
dying  from  tetanus.^ 

The  infection  in  tetanus  neonatorum  occurs  through  the  umbilical 
wound.  Tetanus  occurs  also  after  the  operation  of  circumcision  in  hot 
countries. 

Pathological  Anatomy. — In  a  few  cases  of  tetanus  slight  changes 
have  been  found  in  the  central  nervous  system.  It  is,  however,  ex- 
tremely doubtful  whether  they  have  any  significance,  being  probably 
the  result  of  the  fever  and  convulsions  directly,  rather  than  the  effects 

^  Gowers' Z^iseases  of  Nervous  System,  vol.  ii.  p.  G79. 


938  TETANUS. 

of  the  poison.  Dilatation  of  the  bloodvessels  with  slight  capillary- 
extravasations  are  the  most  frequent  changes  described.  In  several 
cases  examined  within  the  past  few  years,  and  according  to  modern 
methods,  no  lesions  have  been  detected.  No  constant  changes  have 
been  found  in  the  peripheral  nerves.  In  a  few  cases  the  nerves  at  the 
seat  of  infection  and  for  some  distance  have  been  inflamed.  The  changes 
found  in  the  heart  and  lungs  depend  on  the  immediate  cause  of  death, 
and  have  no  connection  with  the  action  of  the  poison.  The  muscles  in 
some  cases  are  torn  as  the  result  of  the  violent  contraction ;  frequently 
they  are  also  the  seat  of  small  hemorrhages.  The  wound  which  is  the 
seat  of  infection  may  be  found  cicatrized  or  in  a  state  of  suppuration. 
Usually  the  tetanus  bacillus  can  be  discovered  after  death  in  the  wound. 

Symptoms. — The  period  of  incubation  varies  between  one  and 
twenty-two  days.  In  a  case  of  accidental  inoculation  with  a  filtrate 
of  the  tetanus  bacillus  in  the  left  hand  the  first  symptoms  were  expe- 
rienced on  the  fifth  day.  In  the  great  majority  of  cases  the  period 
varies  between  five  and  ten  days. 

As  a  rule,  the  onset  is  slow,  the  first  symptom  usually  complained 
of  being  a  sense  of  stiffness  in  the  movements  of  the  neck  or  jaw. 
Some  hours  or  a  day  or  two  may  supervene  before  any  special  difficulty 
is  experienced  in  opening  the  jaws.  In  a  few  cases  the  first  tetanic 
symptoms  set  in  in  the  part  nearest  the  seat  of  infection.  In  the  case 
just  quoted  of  accidental  inoculation  in  the  left  hand  the  first  tetanic 
spasms  began  in  the  same  extremity. 

The  rule,  however,  is,  at  least  in  the  human  subject,  for  the  first 
tetanic  symptoms  to  appear  in  the  masseters  or  in  the  muscles  of  the 
neck.  It  is  rare  for  difficulty  of  swallowing  (tetanic  spasms  of  the 
oesophagus)  to  be  the  first  symptom  complained  of. 

The  rigidity  of  the  muscles  gradually  increases,  and  soon  involves 
those  of  the  face,  producing  the  condition  known  as  the  risus  sardonicus. 
The  angles  of  the  mouth  are  drawn  outward  and  downward,  the  upper 
lip  being  firmly  pressed  against  the  teeth,  giving  rise  to  the  peculiar 
appearance.  The  rigidity  of  the  muscles  of  mastication  prevents  the 
patient  from  being  able  to  open  the  mouth,  hence  the  terms  "trismus" 
and  "  lockjaw." 

The  rigidity  of  the  muscles  of  the  neck  causes  retraction  of  the  head, 
and,  as  the  spasm  gradually  involves  the  muscles  of  the  back  and  lower 
extremities,  causing  an  arching  forward  of  the  trunk,  when  the  rigidity 
of  the  muscles  of  the  trunk  and  lower  extremities  is  pronounced,  as  it 
nearly  always  is  in  severe  cases,  the  patient  lies  with  only  the  back  of 
the  head  and  heels  touching  the  bed  (opisthotonos).  It  is  extremely 
rare  for  the  body  to  be  arched  forward  (emprosthotonos)  or  to  one  side 
(pleurothotonos).  The  chest  is  more  or  less  fixed  in  a  state  of  expira- 
tion, and  the  abdomen  is  retracted.  The  abdominal  rectus  can  be  felt 
in  thin  persons  contracted  into  hard  tumorlike  masses. 

Not  infrequently,  from  rupture  of  vessels  in  the  muscle  masses, 
sanguineous  tumors  are  formed.  The  lower  limbs  are  usually  rigid  in 
the  form  of  extensor  spasm.  The  muscles  of  the  upper  limbs  are 
seldom  rigid.  Symptoms  pointing  to  rigidity  of  the  diaphragm  are  not 
unusual,  as  severe,  cramplike  pain  in  the  epigastrum  and  feeble  voice 
or  total  aphonia. 


innuornouic  tetanus.  939 

The  rio:iclity  <>t"  the  (lillcrcnt  iniisclcs  is  an  almost  constant  condition 
(hirin<2:  the  j)ro^i'Css  of  the  disease,  vtrryin^,  however,  from  hour  to  hour. 
It  often  ceases  (hiriny'  sleep,  whether  hron^ht  about  spontaneously  or 
artificially  (chloral,  oj)iuni,  ehlorolurm).  The  muscles,  however,  at 
once  assume   their  rii^id  state  when  the  j)atient  awakes. 

In  addition  to  the  constant  rigidity,  in  nearly  all  severe  cases  are 
sudden  exacerbations,  coming  on  with  great  suddenness  and  lasting  from 
a  few  seconds  to  two  or  three  minutes.  The  jnx'vioiis  muscular  distor- 
tions are  greatly  intensified.  The  (;ontractions  of  the  filatures  are  fright- 
ful to  behold.  The  face  and  extremities  become  livid.  The  tongue 
may  be  caught  between  the  teeth.  These  intermittent  })aroxysms  may 
arise  spontaneously  or  from  some  outside  irritation,  such  as  a  draught 
of  cold  air,  the  least  touch,  or  a  voluntary  effort.  The  suffering  of  the 
patient  is  agonizing  in  the  extreme.  During  all  this  suffering  the 
mind  remains  clear. 

The  temperature  varies  much  in  different  cases.  Frequently  it  has 
been  fonnd  normal  throughout  the  entire  course  of  the  disease.  As  a 
rule,  there  is  a  moderate  pyrexia,  from  101°  to  102°  F.  In  fatal  cases 
the  temperature,  if  not  elevated  in  the  earlier  stages,  generally  rises  to 
103°  or  104°  F.  before  death.  In  those  cases  where  pyrexia  is  present 
throughout  it  is  usually  found  that  there  is  no  morning  fall  or  evening 
rise.  Sometimes  a  slight  rise  during  the  period  of  exacerbation  has  been 
noticed.  Again,  very  sudden  and  very  irregular  changes  occur  in  the 
course  of  the  pyrexia.  Hyperpyrexia  is  not  infrequent  in  the  fatal 
cases,  the  temperature  rising  for  some  time  after  death.  Temperatures 
of  110°,  111°,  112°,  113°,  and  even  114°  F.,  have  been  recorded. 

The  cause  of  the  pyrexia  is  not  fully  established.  No  doubt  the 
excessive  muscular  work  is  an  important  factor.  The  writer  has  met 
with  hyperpyrexia  in  a  fatal  case  of  strychnine-poisoning.  One  hour 
before  death  the  temperature  was  found  to  be  108°,  and  in  half  an  hour 
it  had  reached  109°  F.  The  same  cause  being  at  work  in  tetanus — 
muscular  overaction — will  account  for  some  cases.  It,  however,  must 
be  remembered  that  in  pontine  and  cervical  cord  lesions  hyperpyrexia 
is  a  fairly  common  symptom. 

The  pulse  is  slightly  quickened,  especially  during  the  acme  of  the 
paroxysms.  It  is  often  small  (vasomotor  spasm).  In  fatal  cases  it 
becomes  very  weak  and  rapid,  160  to  200  in  the  minute. 

In  severe  cases  the  skin  is  bathed  with  perspiration.  The  urine  is 
usually  scanty  and  high  colored.  The  amount  of  nitrogen  excreted  is 
said  not  to  be  increased,  even  when  pyrexia  is  present.  The  patient 
may  be  unable  to  pass  urine,  owing  to  the  spasms  of  the  abdominal 
muscles.     Obstinate  constipation  from  this  cause  is  the  rule. 

Cephalic  Tetanus  or  Hydrophobic  Tetanus. — Under  this  heading 
it  is  necessary  to  describe  a  rare  variety  of  tetanus  which  was  first 
observed  by  Rose.  It  results  from  wounds  in  the  region  innervated 
by  the  cranial  nerves,  especially  the  fifth.  The  special  feature  of  this 
variety  is  that  the  trismus  is  associated  with  paralysis  of  the  face  on 
the  same  side  as  the  injury.  Usually  there  is  also  marked  spasm  of 
the  pharynx  and  oesophagus,  hence  the  term  hydrophobic  tetanus.  In 
addition  to  the  ])aralysis  of  the  seventh  nerve,  paralysis  of  the  third 
and  fourth  nerves  has  been  met  with. 


940  TETANUS. 

The  paralysis  of  the  facial  has  the  distribution  of  a  peripheral  palsy, 
but  it  is  not  attended  with  any  changes  in  the  electrical  reactions.  In  the 
few  cases  examined  after  death  no  inflammatory  or  degenerative  changes 
have  been  found  in  the  nerve.  These  facts,  together  with  the  observa- 
tion that  in  some  cases  the  paralysis  has  disappeared  after  a  few  days, 
while  the  tetanus  symptoms  have  steadily  progressed  to  a  fatal  ending, 
lend  strong  support  to  the  view  that  it  is  brought  about  in  a  reflex 
manner,  and  is  not  due  to  any  coarse  lesions  in  the  nerve  trunk. 

Cephalic  tetanus  runs,  as  a  rule,  a  feverless  course. 

Course  of  Tetanus. — The  duration  of  the  disease  is  very  variable. 
In  very  rare  cases  a  slight  but  temporary  rigidity  of  the  muscles  of  the 
neck  and  jaw  is  the  only  manifestation  of  the  poison.  Cases  presenting 
such  a  course  have  been  called  abortive  forms.  It  is  more  than  doubt- 
ful whether  it  can  be  fully  established  that  such  cases  are  really  tetanus. 

In  very  severe  cases  death  may  take  place  within  two  or  three  days 
or  even  in  a  shorter  period.  The  duration  in  a  fatal  case  is,  however, 
usually  from  eight  to  twelve  days.  In  the  cases  that  recover  the  dis- 
ease ends  very  gradually,  the  intermittent  spasms  disappearing,  and 
then  more  slowly  the  persistent  rigidity  ceases. 

Recovery  is  usually  complete  in  from  three  to  six  weeks.  In  the 
case  already  alluded  to  of  accidental  inoculation  with  a  tetanus  filtrate  the 
symptoms  had  all  disappeared  on  the  fort}"-first  day  in  the  same  order 
in  which  they  appeared.     True  relapses  are  unknown  in  tetanus. 

Death  may  be  brought  about  in  various  Avays.  In  the  acutest  cases 
it  is  usually  produced  through  spasm  of  the  respiratory  muscles,  death 
being  due  to  asphyxia  through  the  arrest  of  respiration.  Sudden  death 
may  also  arise  from  cardiac  failure  during  a  paroxysm. 

Death  may  be  slow,  due  to  gradual  exhaustion.  Cases  are  reported 
where  the  patient  succumbed  from  exhaustion  even  after  all  spasm  had 
ceased. 

Diagnosis. — During  the  first  few  days  there  may  be  uncertainty  as 
to  the  nature  of  the  disease.  The  stiflhess  of  the  neck  may  be  mistaken 
for  rheumatism,  but  it  is  soon  followed  by  the  trismus,  which  clearly 
points  to  tetanus.  In  trismus  from  dental  irritation,  tonsillitis,  or  in- 
flammation of  the  temporo-maxillary  joint  there  can  be  no  difficulty  in 
making  a  differential  diagnosis. 

The  characters  of  the  developed  disease  may  be  simulated  by  strych- 
nine-poisoning, hydrophobia,  hysteria,  and  tetany.  In  strychnine-poi- 
soning the  onset  is  sudden,  the  spasm  being  general.  In  tetanus  the 
onset  is  slow  and  progressive,  the  spasms  beginning  in  the  jaws  and 
neck  and  involving  the  trunk  muscles  after  some  hours  or  even  days. 
In  strychnine-poisoning  the  muscles  of  the  extremities  are  more  affected 
than  those  of  the  trunk ;  the  contrary  is  the  case  in  tetanus,  the  upper 
extremities  being  very  rarely  the  seat  of  spasm.  The  reflex  excitability 
in  strychnine-poisoning  occurs  early,  while  it  is  a  late  event  in  tetanus. 
In  the  former  death  or  recovery  takes  place  in  a  few  hours,  while  in  the 
latter  it  is  usually  a  question  of  many  days.  The  differences  are  so 
striking  that  ordinary  care  in  examination  should  prevent  a  mistake. 

In  hydrophobia  the  first  symptoms  are  attacks  of  difficult}'  of  breath- 
ing from  attempts  to  swallow.  There  is  no  rigidity  of  any  of  the  mus- 
cles in  the  early  stages  of  the  disease.     In  the  later  stages  the  tetanoid 


r/iO(;.\()s[s^  Tin:,  i  tmf.st.  941 

attacks  do  not  n'senihlc  those  <•!'  tclamis.  Tlic  diU'crciu'c  in  the  iiien- 
bation  period  and  the  previous  liistory  afford  in  themselves  sufficient 
evidence,  in  the  jj^reat  majority  of  eases,  to  eh'arly  (hlTcreiitiate  hetween 
the  two  diseases. 

Trismus  histin<i,-  a  few  hours  or  days  is  sometimes  met  with  in  iiys- 
teria,  but  it  is  not  aeeompanied  with  the  otlier  symptoms  of  tetamis. 
If  there  is  «>eneral  tonie  sj)asm,  it  alternates  with  ticneral  convulsions. 
Its  onset  is  sudden,  as  is  also  its  disappearance.  Further,  there  will  be 
a  history  of  similar  previous  attacks,  together  with  the  stigmata  of 
hysteria. 

The  positions  of  the  hands  antl  arms  in  tetany  are  sufficiently  charac- 
teristic to  prevent  any  mistake  being  made  in  diagnosis. 

Prognosis. — In  all  the  different  types  of  tetanus  tiie  mortality  is 
very  high.  It  is  greatest  in  the  puerperal  type,  extremely  few  cases 
recovering.  It  is  said  that  recovery  is  almost  unknown  in  tetanus  after 
abortion.  In  the  otlier  varieties  it  ranges  between  45  and  90  per  cent., 
as  a  rule  being  nearer  the  latter  than  the  former  figure.  The  severer 
the  injury  the  graver  the  j^rognosis.  Tetanus  following  lacerated  wounds 
or  compound  comminuted  fractures  is  more  serious  than  that  following 
slight  wounds.  In  suppurating  wounds  the  danger  is  greater  than  in 
those  that  heal  by  first  intention.  The  sooner  the  symptoms  supervene 
after  the  infliction  of  the  wound  (infection),  the  greater  the  danger. 
Probably  not  more  than  3  or  4  per  cent,  of  cases  recover  where  the 
symptoms  arise  before  the  end  of  the  tenth  day.  If  the  incubation 
period  is  from  two  to  three  weeks  or  more  in  duration,  then  the  chances 
of  recovery  are  much  greater  (25  to  50  per  cent.). 

Exposure  to  cold  at  the  time  of  infection  lessens  the  chances  of 
recovery.  Unfavorable  symptoms  are  early  general  muscular  rigidity, 
difficulty  in  swallowing,  and  considerable  pyrexia.  In  tetanus  neona- 
torum the  prognosis  is  the  better  the  longer  the  interval  after  birth. 

Treatment. — Preventive. — In  all  cases  of  wounds  contaminated 
with  earth,  manure,  etc.  it  should  be  a  rule  to  make  a  thorough  bac- 
teriological examination  for  tetanus  bacilli.  Splinters  of  M'ood,  etc. 
removed  from  wounds  should  also  be  examined  with  the  same  end  in 
\'iew.  If  such  procedures  were  common  practice,  there  can  be  no  doubt 
that  in  some  cases  tetanus  might  be  prevented.  If  some  of  the  suspected 
material  is  injected  under  the  skin  of  a  mouse,  and  if  the  animal  dies 
in  two  or  three  days  with  the  symptoms  of  tetanus,  it  should  be  suffi- 
cient warning  to  make  a  most  thorough  disinfection  of  the  wound  and 
place  the  patient  on  the  special  serum  treatment  which  will  be  presently 
fully  referred  to. 

It  is  here  unnecessary'  to  dwell  on  the  importance  of  thorough  cleans- 
ing of  wounds,  no  matter  how  simple  they  may  appear  at  the  time.  In 
deep-seated  wounds  this  precaution  is  especially  necessary,  as  it  is  in  this 
class  of  injuries  that  the  tetanus  bacillus  finds  the  appropriate  conditions 
for  its  development.  If  it  has  been  demonstrated  that  the  secretions  of 
a  wound  contain  the  tetanus  bacillus,  then  it  may  be  a  justifiable  prac- 
tice to  excise  the  infiltrated  parts,  or  even  to  amputate  if  the  wound  is 
situated  on  an  extremity.  If  the  symptoms  of  the  disease  have  set  i)i, 
experience  shows  that  nothing  is  gained  by  either  cauterization,  excision, 
or  amputation.      In   the   uncommon   cases  -where   the   symptoms   first 


942  TETANUS. 

develop  in  the  immediate  neighborhood  of  the  wound  it  would  be  sound 
practice  to  remove  a  portion  of  the  peripheral  nerve  leading  to  the 
wound  area.  Several  cases  are  on  record  where  this  procedure  has  been 
successful  in  preventing  the  further  development  of  the  disease. 

Treatment. — The  treatment  of  the  developed  disease  will  be  con- 
sidered under  the  following  heads  : 

1.  By  antitoxin  serum  ; 

2.  Ordinary  medicinal  agents ; 

3.  General  management. 

The  Antitoxin  Serum  Treatment. — It  has  been  clearly  shown  by 
Kitasato,  Behring,  Roux,  and  Vaillard  that  the  blood  serum  of  animals 
rendered  immune  to  the  tetanus  poison  has  marked  therapeutic  powers. 
Kitasato  and  Behring  first  showed  that  it  was  possible  to  confer  com- 
plete immunity  against  the  tetanus  poison,  even  in  animals  the  most 
susceptible  to  it.  Mice,  rabbits,  and  horses  are  very^  susceptible  to 
tetanus.  Behring's  method  of  conferring  immunity  in  these  animals 
consists  in  injecting  a  bouillon  culture  weakened  with  trichloride  of 
iodine  at  intervals  of  three  to  eight  days.  On  the  first  day  the  bouillon 
culture  is  diluted  with  0.25  per  cent,  of  the  trichloride ;  on  the  second 
day,  with  0.20  per  cent. ;  on  the  third  day,  with  0.15  per  cent. ;  and  on 
the  fourth  day,  with  the  undiluted  culture.  The  injections  are  continued 
at  intervals  in  gradually  increasing  doses  until  complete  immunity  is 
obtained. 

The  blood  serum  of  an  animal  rendered  immune  after  the  above 
method  is  capable  when  injected  into  another  animal  of  conferring  im- 
munity to  the  action  of  the  tetanus  poison.  It  has  been  proved  by 
Behring  that  mice  when  injected  with  a  certainly  fatal  dose  of  tetanus 
poison  can  be  saved  by  the  use  of  the  immunizing  serum,  provided 
this  has  been  effected  within  five  hours  of  the  first  appearance  of  the 
symptoms  of  tetanus.  If  twelve  hours  have  elapsed  before  the  serum 
has  been  injected,  then  it  has  been  found  to  have  no  controlling  influ- 
ence. He  also  demonstrated  that  the  injection  of  the  immune  serum  a 
quarter  of  an  hour  after  the  injection  of  the  tetanus  poison  had  much 
less  effect  than  when  used  immediately  before.  He  found  that  it  required 
a  serum  a  hundred  times  more  potent  to  have  the  same  eifect  when 
injected  a  quarter  of  an  hour  after  as  when  used  before  the  introduction 
of  the  poison. 

As  to  the  results  of  the  antitoxic  serum  in  the  tetanus  of  man,  expe- 
rience up  to  the  present  has  not  been  sufficiently  extensive  to  fully 
demonstrate  its  usefulness.  A  number  of  cases  have  been  recorded 
where  it  apparently  proved  eifective  in  saving  life,  but  as  a  certain  num- 
ber of  cases  recover  under  all  forms  of  treatment,  it  would  be  prema- 
ture to  assign  to  the  serum  treatment  a  directly  antidotal  action.  Prac- 
tically, a  very  great  difficulty  is  met  with  in  the  treatment  of  tetanus 
by  this  method ;  that  is,  the  disease  is  fully  established  before  the  treat- 
ment is  resorted  to.  From  Behring's  experiments  on  animals  referred 
to  above  it  is  clear  that  the  immune  serum  is  only  effective  when  it  is 
administered  very  soon  after  the  first  appearance  of  the  symptoms. 
There  is  every  reason  to  believe  that  the  same  holds  good  in  the  human 
subject,  and  that  to  be  effective  it  should  be  used  early  (within  a  few 
hours). 


TREATMENT.  943 

It  has  l)een  (jiiestioned  whether  tlie  aiitituxie  .seruiii  iicl.s  (jji  th(!  .saiuo 
tissues  as  the  tetanus  poison.  Tiie  action  of  the  latter  is  chiefly  on 
the  central  nervous  system  when  the  (liseas*(>  is  fully  established,  while 
it  is  contended  that  the  serum  has  no  direct  iiiHiience  on  these  tissues. 
If  these  eontentions  were  true,  it  would  fully  exj)laiu  why  (he  results 
are  so  slij2;ht  once  the  disease  is  fully  estahlished. 

In  carrying  out  the  treatment  of  tetanus  with  antitoxin  Tizzoni- 
Cattani's  preparation  has  been  chiefly  employed,  for  the  reason  that  it 
is  a  much  more  stabile  compound  than  others.  It  is  an  aseptic  serum 
in  a  desiccated  state.  It  can  be  kejit  for  an  indefinite  length  <tf  time 
when  ]U'otected  from  moisture,  while  the  other  tetanic  antitoxins  gen- 
erally undergo  decomposition. 

The  desiccated  powder,  according  to  Merck,  is  to  be  dissolved  in 
distilled  water  in  the  proportion  of  ten  parts  by  weight  to  one  of  the 
desiccated  serum.  All  the  appliances  used  in  making  the  solution 
should  be  thoroughly  disinfected  by  heat,  but  allowed  to  cool  previous 
to  bringing  them  into  contact  with  the  antitoxin,  as  the  latter  decom- 
poses at  high  temperatures.  As  imported  from  Italy  by  Merck,  the 
desiccated  serum  is  in  small  bottles,  and  it  is  recommended  to  inject  the 
contents  of  half  a  bottle  for  a  first  dose,  while  the  remainder  is  divided 
into  four  equal  quantities  and  injected  at  intervals  depending  on  the 
result  of  the  first  dose  and  the  symptoms  of  the  disease.  If  the  incu- 
bation period  has  been  very  short  and  the  symptoms  pronounced,  indi- 
cating a  severe  infection,  it  is  recommended  to  inject  the  contents  of  one 
bottle  for  a  first  dose,  and  to  follow  this  by  further  injections,  the  length 
of  the  intervals  to  be  governed  by  the  action  of  the  first.  In  children 
one  half  the  adult  dose  is  considered  to  be  sufficient. 

Tetanic  antitoxin  is  considered  to  be  free  from  danger.  As  pre- 
pared by  Tizzoni  and  Cattani  it  is  obtained  from  the  blood  of  horses 
and  dogs.  "  Its  power  of  rendering  immune  is  ascertained  on  rabbits — 
viz.  on  the  basis  of  infectious  or  tetanic  intoxications,  which  kill  control 
animals  in  four  or  five  days.  The  quantity  of  dry  serum  contained  in 
each  bottle  is  inversely  proportionate  to  its  power  of  rendering  immune, 
and  always  considerably  larger  than  that  which,  according  to  the  experi- 
ments on  animals,  would  have  to  be  considered  as  the  minimum  cura- 
tive dose  for  man  "  (Merck). 

As  already  mentioned,  sufficient  evidence  is  not  as  yet  at  hand 
to  enable  us  to  give  a  decided  opinion  as  to  the  value  of  antitoxic 
serum.  There  is  a  general  consensus  of  opinion,  chiefly  foimded  on 
experimental  work  in  small  animals,  that  it  has  a  very  powerful  pro])hy- 
lactic  action.  We  further  believe  that  there  is  more  or  less  proof  that 
it  is  also  effective  in  cases  in  man  where  it  has  been  used  early  and 
where  the  tetanus  runs  a  subacute  or  chronic  course.  It  has  been  used 
in  a  considerable  number  of  cases,  but  rarely  alone,  other  agents  being 
also  employed.  It  is  difficult  on  this  account  to  determine  what  effect 
it  has  had.  In  eases  that  run  a  very  acute  and  severe  course  its  action 
has  been  slight,  if  not  nil.  From  this  it  would  appear  as  if  it  had  no 
counteracting  influence  on  the  poison  already  absorbed,  but  from  its 
action  in  animals  it  is  clear  that  it  has  great  power  in  preventing  the 
development  of  the  poison.  It  should  therefore  be  resorted  to  when- 
ever there  is  the  least  symptom  suggesting  the  possibility  of  tetanus. 


944  TETANUS. 

The  Treatment  of  Tetanus  by  Ordinary  Medicinal  Agents. — Among 
the  remedies  usually  recommended  in  tetanus  the  following  may  be 
mentioned  :  chloral,  opium-,  the  bromides,  Calabar  bean,  curare,  carbolic 
acid,  Indian  hemp,  chloroform,  atropine,  etc. 

Cases  are  recorded  where  recovery  has  followed  the  employment  of 
each  of  the  different  agents  mentioned.  Of  no  drug  can  it  be  said  that 
it  has  a  marked  effect  for  good  in  severe  cases,  and,  as  recovery  follows 
all  possible  modes  of  treatment  in  mild  attacks,  it  is  natural  to  conclude 
that  the  drug  treatment  of  tetanus  is  far  from  satisfactory. 

Of  all  agents  employed,  chloral  hydrate  is  probably  the  most  effi- 
cient. It  should  be  given  in  large  doses — from  one  to  two  drachms  in 
the  twenty-four  hours.  Many  cases  of  recovery  from  tetanus  are  on 
record  where  chloral  and  morphia  have  been  given  in  combination,  and 
also  where  chloral  and  bromide  of  potassium  have  been  given. 

Calabar  bean  and  its  alkaloid,  physostigmine,  have  apparently  been 
successful  in  preventing  death  in  a  number  of  cases.  The  dose  of  the 
officinal  extract  is  about  one  sixth  of  a  grain.  It  should  be  given  hourly 
until  the  physiological  effects  of  the  drug  are  induced.  There  is  great 
tolerance  of  this  as  well  as  most  other  motor  depressants  in  tetanus. 
The  salicylate  of  physostigmine  may  be  employed  instead  of  the  officinal 
extract  of  the  crude  drug  in  doses  of  one  twentieth  of  a  grain  every 
hour  or  two. 

Curarine,  the  active  principle  of  curare,  can  be  employed  in  doses 
of  one  two-hundredth  of  a  grain.  It  should  be  given  hypodermically, 
as  it  possesses  but  little  action  as  a  depressant  on  the  motor  end  appara- 
tus when  given  by  the  stomach. 

General  Management. — The  patient  should  be  kept  perfectly  quiet  in 
a  dark  room.  Visitors  should  be  absolutely  excluded.  The  diet  should 
be  hquid,  and  if  the  trismus  is  so  marked  as  to  prevent  the  patient  from 
opening  the  jaws,  he  should  be  fed  by  the  rectum,  or  by  the  stomach  by 
means  of  a  long  tube  passed  through  the  nose.  The  practice  of  giving 
chloroform  to  relax  the  trismus  in  order  to  feed  the  patient  is  hardly  to 
be  commended,  as  its  action  is  very  frequently  followed  by  an  increased 
intensity  in  the  tonic  spasm. 

If  death  is  immediately  threatened  by  spasm  of  the  respiratory  mus- 
cles, chloroform  may  be  administered  or  artificial  respiration  performed. 


INFECTIOUS  FEVERS  OF  OBSCURE  NATURE. 

By   WALTER   B.  JAMES,  M.  D. 


A  CERTAIN  number  of  cases  of  febrile  disease  are  met  with  whose 
clinical  histories  suggest  that  they  are  infectious,  but  whose  classification 
has  not  yet  been  perfectly  established. 

The  existence  of  these  as  individual  diseases  is  doubted  by  many 
observers,  and,  indeed,  of  no  one  of  them  can  it  be  said  that  its  right  to 
a  permanent  place  in  medical  classification  has  been  demonstrated. 
Yet  it  seems  wise  to  give  some  place  to  a  discussion  of  them  in  a  treatise 
such  as  the  present  one,  more  with  a  view  to  the  encouragement  of  a 
systematic  effort  to  clear  up  their  obscure  features  than  with  the  idea  of 
dogmatically  establishing  their  individual  existence. 

Weil's  Disease. 

Defixition. — A  disease  which  is  apparently  infectious  and  which 
is  characterized  by  fever,  intense  prostration,  jaundice,  and  disturbance 
of  the  gastro-intestinal  functions. 

Attention  was  first  called  to  this  disorder  by  AVeil  in  1886.  He 
described  it  as  it  occurred  in  a  limited  epidemic.  Many  cases  have  since 
then  been  reported  in  Europe  and  a  few  in  America.  It  is  sometimes 
called  "  acute  infectious  icterus." 

Etiology. — Regarding  its  etiology  we  have  no  definite  knowledge, 
but  the  behavior  of  the  disease  indicates  that  it  is  probably  an  infection. 
Of  the  nature  of  the  poison  we  know  nothing,  nor  of  its  source  and 
mode  of  entrance  into  the  body.  It  has  occurred  in  a  number  of 
instances  in  limited  epidemics  in  prisons,  workhouses,  and  barracks, 
thus  suggesting  that  crowding  and  unsanitary  surroundings  are  factors 
in  its  production.  Jaeger  claims  that  it  is  due  to  infection  with  a  proteus, 
the  bacillus  jrrofeus  fluorescens.  The  relation  of  the  disease  to  simple 
catarrhal  jaundice  is  interesting.  Some  have  claimed  that  the  cases 
described  as  Weil's  disease  are  really  only  gastro-duodenitis  with  pro- 
nounced constitutional  symptoms.  Others  believe  that  a  large  number 
of  the  cases  generally  described  as  catarrhal  jaundice  are  examples  of 
Weil's  disease.  In  the  cases  hitherto  reported  there  is  a  uniformitv  in 
symptoms  and  a  general  resemblance  to  the  infectious  diseases  that  make 
it  seem  best  to  classify  it  as  a  distinct  disease  under  the  above  title. 

Pathological  AxATo:NrY. — In  the  autopsies  that  have  been  made 
there  have  been  found  only  the  lesions  that  are  common  to  all  the  infec- 
tious fevers.  Acute  degeneration  of  the  liver  and  kidney  is  generallv 
present.     Bacteriological  examinations  have  yielded  no  positive  result. 

Sy'MPTOMS. — Weil's  disease  attacks  men  rather  more  often  than 
women,  and  is  most  prevalent  in  the  summer  months.     There  is  generally 

Vol.  I.— 60  .   945 


946  INFECTIOUS  FEVERS  OF  OBSCURE  NATURE. 

no  prodromal  period,  the  disease  beginning  suddenly.  It  is  in  many 
cases  ushered  in  by  a  chill.  The  temperature  rises  rapidly  and  early 
reaches  its  highest  point.  Sometimes  on  the  fourth  or  fifth  day  there  is 
a  remission  of  the  fever,  but  after  an  interval  of  two  or  three  days  it 
recurs.  The  fever  lasts  from  eight  to  ten  days,  and  disappears  gradu- 
ally, without  a  well  marked  crisis.  In  some  cases,  after  an  interval  of 
from  one  to  eight  days,  there  is  a  distinct  relapse,  the*  fever  returning 
and  lasting  a  variable  number  of  days,  subsiding  again  gradually.  ^  The 
pulse  is  rapid  and  full,  later  on  becoming  slower  when  the  jaundice  is 
well  marked.  Generally,  from  the  very  beginning,  there  is  intense 
prostration,  which  is  often  the  patient's  chief  complaint.  There  is  some 
mental  dulness  and  apathy.  There  may  be  delirium  and  coma.  There 
may  be  intense  muscle  pains,  generally  in  the  back  of  the  neck  and  in 
the  legs.  These  occur  in  about  50  per  cent,  of  the  cases.  Gastric 
symptoms  are  generally  present  and  occur  early.  The  tongue  is  coated 
and  may  be  dry.  There  is  vomiting.  There  may  be  either  constipation 
or  diarrhoea. 

There  is  enlargement  of  the  liver  in  about  50  per  cent,  of  the  cases, 
and  the  organ  is  tender  to  pressure.  The  spleen  is  enlarged  in  75  per 
cent.,  and  this  occurs  early  in  the  disease. 

Jaundice  is  ahvays  present,  and  commonly  comes  on  early,  though  it 
may  appear  first  when  the  temperature  and  other  symptoms  are  subsid- 
ing. It  varies  much  in  intensity  in  different  cases,  and  is  believed  to 
be  due  to  biliary  obstruction. 

The  urine  is  diminished  in  amount,  contains  bile  pigment,  and  in 
more  than  50  per  cent,  of  cases  contains  albumin  and  hyaline  and 
granular  casts.     There  is  sometimes  hsematuria. 

Complications  and  Sequelae. — The  complications  and  sequelae 
are  those  common  to  the  infectious  fevers  in  general.  In  some  cases 
there  is  a  more  or  less  severe  catarrhal  inflammation  of  the  throat. 
Sometimes  there  occurs  during  the  disease  a  purpuric  eruption.  The 
itching  which  belongs  to  the  jaundice  may  be  severe.  In  some  cases 
parotiditis  has  been  present. 

Diagnosis. — The  disease  is  most  apt  to  be  mistaken  for  typhoid 
fever  with  jaundice,  and  for  simple  catarrhal  jaundice.  From  the 
former  it  is  to  be  distinguished  by  its  sudden  onset  with  the  absence 
of  prodromata,  by  the  characteristic  remissions,  the  absence  of  the 
eruption,  and  by  the  shortness  of  its  course.  From  the  latter  the  differ- 
ential diagnosis  is  difficult,  and  in  many  cases  impossible. 

Prognosis. — The  prognosis  is  generally  good,  though  a  few  deaths 
have  occurred. 

Treatment. — In  the  early  stages  calomel  may  be  given  in  small 
doses,  or  castor  oil.  The  use  of  violent  purgatives  should  be  avoided. 
Alkaline  mineral  waters,  such  as  Carlsbad,  are  often  used.  Irrigation 
of  the  large  intestine  with  cold  water  is  sometimes  of  service.  The  diet 
should  be  of  milk. 

Malta  Fever. 

Synonyms. — Rock  fever  ;  Mediterranean  fever  ;  Neapolitan  fever. 
Etiology. — Malta   fever   occurs   with   greatest   frequency   on   the 
island  of  Malta.     It  has  also  been  met  with  in  various  Mediterranean 


MILIARY  FEVER;  SWEATING  FEVER.  947 

ports,  especially  Naples.  It  is  siipiwsed  to  he  identical  with  a  local 
fever  that  has  been  observed  at  Cyprus  and  in  sonic  of  the  Red  Sea 
ports.  It  has  never  been  described  as  occurrino;  in  t\w  Western  Hemi- 
sphere. In  Malta  it  develops  with  greatest  fre(iuency  during  th(i  hot 
season.  It  attacks  large  numbers  of  the  garrison,  also  many  sailors  in 
ships  at  anchor  in  the  harbor.  It  shows  \u>  j)rcdik'cti<)n  of  age  or  sex, 
but  selects  by  j)ret"erence  newcomers  to  the  island. 

Regarding  the  nature  of  the  disease  we  are  uncertain.  It  is  possible 
tliat  it  is  a  modified  form  of  typhoid  fever,  but  many  observers  who  have 
studied  it  believe  that  it  is  a  specific  fever  with  a  definite  poison  of  its 
own. 

The  infection  of  the  disease  is  apparently  conveyed  tiirough  the  air. 
There  is  no  evidence  that  it  is  communicated  by  food  or  drinking  water. 

Pathological  Anatomy. — There  are  no  characteristic  lesions 
found  after  death.  The  lesions  of  typhoid  fever  are  not  present.  Bruce 
has  found  in  the  spleen  a  micrococcus  which  has  been  called  micrococcus 
Melitensis.  This  has  been  cultivated,  and  by  it  the  disease  has  been 
reproduced  in  monkeys. 

Symptoms. — The  period  of  incubation  is  about  fourteen  days. 

The  onset  is  gradual.  There  are  malaise,  headache,  anorexia,  and 
sleeplessness.  These  may  last  from  one  to  four  weeks.  Then  follows 
a  period  of  improvement,  during  which  the  patient  apparently  enters 
upon  convalescence.  In  a  few  days,  however,  the  symptoms  recur  and 
with  greater  severity.  The  headache  now  is  intense.  There  may  be 
chills.  The  temperature  is  from  101°  to  104°  F.  The  temperature 
curve  is  very  irregular.  It  may  be  remittent  in  type,  or  it  may  be 
intermittent,  or  it  may  resemble  closely  that  of  typhoid  fever.  The 
tongue  is  coated  and  moist.  There  is  anorexia.  There  may  be  nausea 
and  vomiting.  In  some  cases  there  is  diarrhoea.  Sometimes  there  are 
cerebral  symptoms,  apathy,  or  delirium.  Headache  is  generally  well 
marked.  After  continuing  from  five  to  six  weeks  there  is  a  remis- 
sion of  the  above  symptoms,  and  again  the  patient  begins  to  convalesce. 
After  from  ten  to  twelve  days  there  may  again  be  a  relapse.  In  many 
cases  the  remissions  and  relapses  are  less  clearly  marked.  The  disease 
shows  a  tendency  to  continue  for  from  one  to  six  months.  There  are 
generally  very  marked  anaemia  and  debility.  Late  in  the  course  of  the 
disease  there  are  commonly  very  severe  neuralgic  pains  in  the  back  and 
limbs.  These  are  often  the  most  pronounced  features.  There  may  be 
swelling  of  the  joints.  Convalescence  when  it  sets  in  is  often  very 
slow,  and  in  many  cases  two  or  three  years  elapse  before  the  patient 
regains  his  normal  good  health.  The  death  rate  is  about  2  per  cent. 
The  average  stay  in  hospital  is  from  seventy  to  eighty  days. 

The  prognosis  is  fairly  good.     The  mortality  is  about  2  per  cent. 

The  treatment  consists  of  rest  in  bed  and  fluid  diet,  and  in  some 
cases  quinine  has  been  given  in  considerable  doses. 

Miliary  Fever  ;  Sweating  Fever. 

Definition. — An  infectious  disease  occurring  in  epidemics  of  vary- 
ing intensity  and  duration.  The  disease  was  first  described  in  1485  in 
London,  where  a  severe  epidemic  occurred  in  that  year.     It  was  called 


948  INFECTIOUS  FEVERS  OF  OBSCURE  NATURE. 

sudor  Anglicus.  In  this  outbreak  it  was  characterized  by  symptoms  of 
great  severity,  and  a  large  proportion  of  the  cases  were  fatal.  It 
occurred  several  times  in  the  seventeenth  century  in  France  and  Ger- 
many. In  1887  a  severe  epidemic  of  the  disease  took  place  in  France 
in  the  department  of  Vienne. 

Etiology. — The  etiology  of  the  disease  is  unknown.  It  is  supposed 
to  be  due  to  a  micro-organism.  The  period  of  incubation  is  variable, 
and  may  be  very  short,  less  than  twenty-four  hours.  Susceptibility  is 
universal,  and  is  the  same  for  all  ages  and  both  sexes.  One  attack  does 
not  produce  future  immunity. 

Symptoms. — The  attacks  generally  begin  with  acute  gastric  distress 
and  a  sense  of  lassitude.  These  in  some  cases  precede  the  appearance  of 
the  other  symptoms  by  several  days.  Generally,  however,  in  the  night 
following  the  onset  of  these  prodromata  the  patient  is  awakened  by  a 
profuse  perspiration. 

In  the  early  stages  there  are  fever,  sweating,  great  debility,  and  a 
variety  of  nervous  symptoms.  There  is  often  paroxysmal  dyspnoea, 
with  no  discoverable  lesion  of  the  lungs.  There  may  be  a  sense  of 
constriction  in  the  epigastrium.  Sometimes  there  are  restlessness  and 
delirium.  There  may  be  muscular  cramps.  The  tongue  is  coated,  the 
appetite  is  absent,  and  the  bowels  are  constipated.  Later,  there  is 
generally  cough,  and  in  some  cases  epistaxis,  w^hich  is  sometimes  profuse. 

An  eruption  generally  appears  on  the  fourth  day,  and  with  this  the 
other  symptoms  are  apt  to  become  less  marked.  The  eruption  itself  con- 
sists of  a  rash  which  may  be  in  crescentic  patches,  resembling  that  of 
measles,  or  may  be  diffuse  and  like  that  of  scarlatina,  or  it  may  be  pur- 
puric. But  in  each  case  there  is  superimposed  upon  it  the  miliary 
eruption  proper,  consisting  of  numerous  miliary  pa])ules  which  gradually 
change  to  vesicles  that  then  discharge  and  desquamate. 

As  the  eruption  becomes  more  marked  the  sweating  diminishes,  the 
temperature  falls,  and  the  debility  and  headache  become  less.  At  this 
time  the  cough  commonly  becomes  more  frequent,  and  bronchial  rales 
are  heard  on  auscultation.  Constipation  persists.  The  urine  is  dimin- 
ished, but  contains  no  albumin.  In  some  cases  there  are  hsemoptyses. 
In  a  few  eases  intestinal  hemorrhage  occurred. 

Next  following  comes  the  stage  of  desquamation.  Convalescence 
begins  on  the  ninth  or  tenth  day,  and  generally  proceeds  slowly.  It  is 
marked  by  great  prostration  and  anemia,  and  is  often  much  prolonged. 

Cases  of  miliary  fever  differ  much  in  their  severity.  Sometimes  the 
patient  is  not  ill  enough  to  have  to  go  to  bed.  In  other  cases  the 
disease  begins  suddenly  and  with  great  severity,  and  is  rapidly  fatal. 
Anomalous  forms  of  the  disease  are  described  in  which  the  eruption  and 
sweating  are  wanting. 

The  PROGNOSIS  depends  probably  upon  the  character  of  the  epidemic. 
In  some  epidemics  the  death  rate  is  very  high. 

The  TREATMENT  is  entirely  symptomatic. 

Simple  Continued  Fever. 

Definition. — From  time  to  time  cases  of  disease  are  met  with  in 
which  an  elevation  of  the  temperature  is  the  only  symptom  or  is  the 


SIMPLE  CONTINUED  FEVER.  949 

most  prominent  symptom,  and  which  ilo  in^t  achnit  of  heing  classed  with 
any  of  the  well  recognized  diseases.  It  has  become  the  habit  of  many 
observers  to  gronp  these  cases  together  under  the  name  simple  continued 
fever,  and  to  assume  that  they  represent  a  -^peciilc  disease  of  unknown 
causiition,  but  admitting  of  classification  u])on  a  purely  clinical  basis. 
Hence  in  medical  literatnre  are  found  a  luuuber  of  descriptions,  in  more 
or  less  detail,  of  a  disease  variously  called  simple  continued  fever,  febric- 
ula,  ephemeral  fever,  or  catarrhal  fever.  Clinical  study  of  the  cases  thus 
named  and  of  the  literature  of  the  subject  discloses  the  fact  that  thev  are 
far  from  uniform  in  their  manifestations,  and  brings  the  conviction  that 
so-called  simple  continued  fever  in  most  cases  is  not  a  specific  disease, 
but  is  a  group  of  clinical  phenomena  comprising  irregular  cases  of  many 
different  maladies. 

Etiology. — Many  of  the  cases  thus  described  are  typhoid  fever  of 
mild  or  abortive  type  ;  others  are  ptomaine-poisoning  from  the  intestine ; 
others  are  cases  of  mild  tuberculosis  where  the  tubercular  focus  is  not 
to  be  found  by  clinical  investigation. 

Then  there  are  the  many  kinds  of  poisoning  by  the  streptococcus 
pyogenes,  where  the  local  symptoms  may  be  so  little  marked  that 
they  are  entirely  overshadowed  and  masked  by  the  general  syiliptoms. 
This  is  especially  apt  to  occur  in  a  streptococcus  inflammation  of  the 
throat,  where  sometimes  the  local  trouble  may  be  entirely  unnoticed  by 
the  patient,  and  may  be  discovered  only  by  a  searching  examination  of 
the  fauces.  These  cases  sometimes  present  the  clinical  picture  of  so- 
called  simple  continued  fever. 

Leaving  out  of  consideration  all  of  the  above  mentioned  cases,  there 
are  left  remaining  a  considerable  number  of  instances  of  continued 
fever  whose  causation  cannot  be  explained.  These  cases,  however,  vary 
so  much  in  their  mode  of  onset,  their  duration,  and  their  associated 
conditions  that  it  is  impossible  to  regard  them  as  one  and  the  same  dis- 
ease. For  clinical  purposes  they  may  be  divided  into  three  groups, 
according  to  their  duration : 

First,  those  of  short  duration,  lasting  only  a  few  days  ; 

Second,  those  of  moderately  long  duration,  from  one  to  three  weeks ; 

Third,  those  of  long  duration,  lasting  for  many  weeks  or  months. 

Symptoms. — The  first  set  of  cases  is  very  often  met  with,  especially 
in  hospital  practice.  The  patients  complain  of  lassitude,  sometimes  of 
headache.  The  temperature  is  from  100°  to  102°  F.  The  pulse  is 
moderately  rapid,  80  to  90.  The  symptoms  regularly  subside  in  from 
two  to  five  or  six  days  if  the  patient  remains  in  bed. 

Many  of  these  cases,  especially  as  met  with  in  hospitals,  are  appar- 
ently due  to  fatigue  or  exposure — some  to  exposure  to  heat,  but  not 
severe  enough  to  give  rise  to  sunstroke.  This  moderate  disturbance 
of  the  heat-regulating  function  of  the  body  seems  capable  of  being 
brought  about  by  a  large  variety  of  causes.  These  cases  require  only 
rest  in  bed  and  good  nursing. 

The  second  set  of  cases,  those  of  longer  duration,  are  less  often  seen. 
In  these  the  onset  is  gradual.  The  patient  complains  of  malaise  and 
headache.  The  tongue  is  coated.  The  bowels  may  be  moderately  con- 
stipated. The  temperature  is  slightly  elevated  in  the  morning,  99.5°  to 
100.5°  F.     It  is  from  one  to  two  degrees  higher  in  the  afternoon.     The 


950  INFECTIOUS  FEVERS  OF  OBSCURE  NATURE. 

pulse  is  somewhat  more  rapid  than  normal.  The  spleen  is  not  enlarged. 
There  is  no  eruption.  The  examination  of  the  blood  is  normal.  The 
disease  la.sts  for  from  one  to  three  weeks  or  sometimes  longer,  and  the 
symptoms  disappear  gradually.  At  no  time  is  the  patient  very  ill.  The 
course  of  the  disease  is  not  influenced  by  quinine. 

The  nature  of  these  cases  is  obscure.  Some  of  them  may  be  cases 
of  very  mild  typhoid  fever.  In  many  epidemics  of  typhoid,  cases  of 
mild  fever  like  the  above  are  met  with,  or  they  may  be  cases  of  infec- 
tion with  the  poison  of  influenza.  It  is  believed  by  some  observers 
that  they  form  a  specific  disease  produced  by  a  special  poison,  probably 
a   micro-organism. 

The  cases  of  the  third  variety,  those  of  long  duration,  seem  to 
depend  upon  locality.  They  have  been  described  by  Delafield  as  occur- 
ring in  New  York  City.  The  patients  feel  tolerably  well  in  the  morn- 
ing, at  which  time  the  temperature  is  normal  or  it  may  be  slightly 
above  normal.  In  the  afternoon  there  are  lassitude  and  slight  headache. 
The  pulse  is  moderately  rapid.  The  temperature  is  from  100°  to 
101°  F.,  or  it  may  be  a  little  higher.  There  is  no  marked  loss  of  weight 
nor  of  strength.  The  patients  regularly  go  about  their  usual  occupa- 
tions, but  feeling  always  not  perfectly  well.  The  tongue  may  be  coated, 
and  there  may  be  some  dyspepsia  and  constipation.  The  disease  is  not 
affected  by  quinine  or  other  medication. 

The  duration  is  indefinite.  The  symptoms -generally  continue  until 
the  patient  is  removed  to  a  different  climate. 

The  nature  of  the  disease  is  entirely  unknown.  It  is  often  supposed 
to  be  malarial,  but  there  is  no  reason  for  supposing  that  it  is  due  to  the 
malarial  poison.  It  has  also  been  ascribed  to  sewer-gas  poisoning  and 
to  chronic  poisoning  by  arsenic,  as  from  wall  paper. 

The  only  treatment  that  avails  is  the  removal  of  the  patient  from 
the  place  where  he  acquired  the  disease. 


INDEX. 


ABATTOIRS  and  tuberculosis,  839 
Abbott  on  enteric  fever,  170 
on  malarial  pigment,  22 
on  pyamia,  47  S 
Abdominal  scrofula,  764 
symptoms  of  dysentery,  365 
tenderness  in  enteric  fever,  189 
typhus.     See  Enteric  Fever. 
Abortion  and  syphilis,  915 
Abortive  enteric  fever,  183,  200 
Abscess  of  liver,  dysenteric,  353 
of  lung  in  dysentery,  354 
metastatic,  in  pvwmia.  488 
in  plague.  395,  396 
in  pyfemia,  480 
in  relapsing  fever,  263 
in  typhoid  fever,  197 
Acclimatization  and  yellow  fever,  274 
Achalme  on  erysipelas,  452,  453 
Acid,  hydrochloric,  in  cholera,  327 
Acquired  svphilis.  849 
Acute    hydrocephalus.       See     Tuberculous 
MeningUi.*. 
miliary  tuberculosb,  751 
and  peritonitis,  771 
tuberculosis.     See  Miliary  Tubereulom. 
tuberculous  meningitb,  754 
Adenitis,  tuberculous,  760 
Adenoid  growths  and  tuberculosis,  840 
Adeno-typhoid.     See  Malta  Fever. _ 
Adhesive  tuberculous  pleurisy,  767,  768  ^ 
Adirondack  Sanitarium  and  tuberculosis,  742 
Adirondacks  and  tuberculosis,  843 
Adrenal  glands  in  malaria,  89 
.£stivo-autumnal  fever,  99,  106 
blood  in,  119,  126 
diagnosis,  141 
leucocytosis,  126 
prognosis,  144 
quinine  in,  151 
parasites,  35,  36,  47 
Afanassiew  on  pertussis,  714 
Afebrile  enteric  fever,  200 
Age  and  cholera,  304 
dysentery,  340 
enteric  fever,  168 
influenza,  404 
measles,  625 
parotiditis,  725 
pertussis,  713 
relapsing  fever,  259 
revaccination,  565 
rubella,  639 
scarlet  fever,  579 


Age  and  smallpox,  515 
tetanus,  937 
tuberculosis,  745 
typhus  fever.  236 
varicella,  569 
Ague,  17 
cake,  89 
dumb,  17 
Air,  exposure  to,  in  malaria,  145 
Aitken  on  dvsentery,  369 
Alabama  Insane  Hospital  and  tuberculosis, 

742 
Albumin  in  tuberculosis,  841 
Albuminuria  in  enteric  fever,  195 
and  erysipelas,  468 
in  malaria,  123 
and  measles,  633 
in  tvphus  fever,  248 
in  yellow  fever,  285,  290 
Alcohol  in  enteric  fever,  213-215 
and  syphilis,  896 
and  tuberculosis,  841 
Algid  pernicious  malaria,  diagnosis,  142 
',      tvpe  of  pernicious  malarial  fever,  115 
Alimentary  canal  in  cholera,  314 

system,  tuberculosis  of,  810 
Alopecia,  syphilitic,  866 
Altitude  and  malaria,  81 
and  tuberculosis,  843 
and  yellow  fever,  269 
Ambulatory  typhoid,  199 
Amceba  dysenterica,  344 
Amoebie  coli,  plate  of,  348 
in  dysenteric  stools,  364 
of  malaria,  37,  44,  48 
Amcebic  dysentery,  clinic-al  course,  361 

dysentery,  symptoms,  361 
Amceboid  bodies  in  malaria   26 
j      hvaline  bodies  in  malaria.  58 
I  Amyloid  degeneration  after  malaria,  131 
1  in  chronic  malaria.  95 

in  malarial  kidneys,  94 
I  Anaemia,  chronic,  in  malaria,  130 
I      and  chronic  phthisis,  786 
!      complicating  dysentery,  366 
in  dysentery,  363 
in  enteric  fever,  186 
explanation  of,  in  malaria,  71 
and  influenza,  418 
of  malarial  cachexia,  93.  94 
of  malarial  fever,  125 
malarial,  treatment  of,  153 
post -malarial,  130 
diagnosis  of,  143 

951 


952 


INDEX. 


Ansemia  of  scarlet  fever,  624 
secondary  to  malaria,  130 
Anatomy.     See  Pathological  Anatomy. 
morbid,  of  fibroid  phthisis,  804 
of  phthisis,  775 
of  septicemia,  500 
of  tubercle,  746 
of  tuberculosis,  731 
Anders  on  erysipelas,  456 
Anaesthesia  in  leprosy,  927 
Ansesthetic  leprosy,  922 
Angelini  on  malarial  fever,  57 
Angina  in  enteric  fever,  186 
and  rubella,  642 
scarlatinal,  588,  589 
Animal  inoculations  of  diphtheria,  651 
Animals,  dysentery  in,  346 
scarlet  fever  in,  586 
tuberculosis  in,  731,  738 
Anorexia  in  chronic  phthisis,  802 

in  enteric  fever,  187 
Anthrax  and  septicemia,  498 
Antipyretics  in  enteric  fever,  216 
in  influenza,  422 
in  septicfemia,  511 
in  yellow  fever,  297 
Antipyrine  and  pertussis,  723 
Antisepsis,  intestinal,  in  enteric  fever,  222 
Antiseptic  treatment  of  cholera,  326 
Antiseptics  in  dysentery,  384 
in  erysipelas,  474 
in  pyemia,  493 
in  smallpox,  550 
Antitoxic  blood  in  diphtheria,  668 
Antitoxin  in  diphtheria,  692,  693 
beneficial  results,  700 
conclusion,  707 
ill  effects,  701 
limitations  of,  702 
for  erysipelas,  472 

mortality  in  diphtheria,  697,  699,  700 
serum  in  tetanus,  942 
in  yellow  fever,  295 
Antoiisei  on  malaria,  34,  42,  57,  62,  71 
Anuria  in  cholera,  316 
Anus,  syphilis  of,  880 
Apathy  in  enteric  fever,  192 
Aphasia  in  enteric  fever,  194 
Appendicitis  and  enteric  fever,  206 
Appendix  in  enteric  fever,  175 
Armies  and  dysentery,  341 
Army,  data  of  revaccination,  557 
Arning  on  leprosy,  923,  925 
Arsenic  in  malaria,  153 
and  tuberculosis,  845 
Arsenical  poisoning  and  cholera,  321 
Arsenious  acid  in  leprosy,  930 
Arterial  sclerosis,  syphilitic,  874 
Arteries,  gummata  of,  873 

tuberculosis  of,  833 
Arthritic  pains  in  dengue,  160 
Arthritis,  pyemic,  483 
Arthropathies,  dysenteric,  372 
Ascites  and  tuberculous  peritonitis,  773 
Ascoli  on  malaria,  127 
Asheville  and  tuberculosis,  843 
Asia,  cholera  in,  321 


Asiatic  cholera,  301 
Asphyxia,  choleraic,  321 

and  tuberculosis,  809 
Asthenia  in  enteric  fever,  219,  221 

in  influenza,  415 

and  tuberculosis,  809 
Astringents  in  dysentery,  383 
Ataxia,  acute,  after  malaria,  132 
Atmosphere  and  tuberculosis,  843 
Atrophy  of  gastro-intestinal   mucosa  after 

malaria,  131 
Atropine  in  tuberculosis,  846 
Aufrecht  on  cerebro-spinal  meningitis,  447 
Auscultation  in  chronic  phthisis,  797 
Autopsies  of  cholera  cases,  313 

in  tuberculosis,  834 
Autumnal  fever,  17,  106 

BABES  on  diphtheria,  648 
Baccelli  on  estivo-autumnal  fever,  111 
toxic  theory  of  malaria,  71 
Bacilli  in  cerebro-spinal  meningitis,  425 
in  erysipelas,  451,  452 
of  miliary  tuberculosis,  751 
tubercular,  in  chronic  phthisis,  790 
in  yellow  fever,  272 
Bacillus  coli  communis,  272 
comma,  305-311 
of  Koch,  301 
of  diphtheria,  647 
growth  of,  668 
life  outside  of  the  body,  668 
of  enteric  fever,  169 
of  influenza,  406 
lepre,  922,  924,  925 
of  pertussis,  714 
pseudo-,  of  diphtheria,  658 
pyocyaneus,  cultures  in  enteric  fever,  230 

in  septicemia,  497,  498 
of  syphilis,  852,  853 
tuberculosis,  733 
biology,  733 
deleterious  agents,  736 
methods  of  growth,  735 
morphology,  733 
staining  reaction,  733 
tussis  convulsive,  714 
typhi  abdominalis,  169 
typhosus,  169,  233 
of  typhus  fever,  233 
Bacteria  in  cholera,  308 
of  erysipelas,  451-455 
of  pyemia,  478 
pyogenic,  498 
in  septicemia,  496-500 
in  yellow  fever,  281 
Bacteriology  of  pseudo-diphtheria,  670 
of  smallpox,  518 
of  yellow  fever,  271 
Bacterium  coli  commune  in  scarlet  fever, 
589 
of  syphilis,  852 
Baer  on  tuberculosis,  742 
Baginsky  on  diphtheria,  697,  698 
Ball  on  dysentery,  339,  369,  381 
Balanitis,  syphilitic,  874 
Barallier  on  typhus  fever,  246 


INDEX. 


953 


Barker  on  cerebru-spinal  meningitis.  A'l^\ 

on  malarial  cirrhosis,  96 
spleen,  86 

on  tuberculosis,  810 
Barthez  on  tuberculosis,  763,  764 
Bastianelli   on    malarial    fever,  49,  53,  57, 
61,  62 
germs,  68 
pigment,  67 
Baths,  cold,  in  relapsing  fever,  264 
in  scarlet  fever,  616,  617 
in  smallpox,  549 
in  typhus  fever,  254 
water,  in  enteric  fever,  222-229 

hot,  in  cholera,  334,  335 
Batt  on  enteric  fever,  224 
Baumgarten  on  dysentery,  316 

on  tuberculosis,  737,  738,  821 
Bayle  on  chronic  phthisis,  788 
Beck  on  diphtheria,  656 
B^court  on  tuberculosis,  817 
Bedding,  disinfection  of,  in  tuberculosis,  839 
Bedor  on  mammary  tuberculosis,  833 
Bedsores  and  enteric  fever,  197,  220 
Beebe  on  diphtheria.  650 
Behring  on  tetanus,  942 
Beinstock  on  tubercle  bacillus,  734 
Beneke  on  tuberculosis,  745 
Benoit  on  malarial  kidneys,  87 
Berenger  Feraud  on  yellow  fever,  282,  285 
Bergmann  on  septictemia,  495 
Bernheim  on  tuberculosis,  739 
Beulenpest,  391 
Bible  on  leprosy,  921 
Bignami  on  liver  in  chronic  malaria,  92 

on  malaria,  25,  27,  53.  61,  62 

on  malarial  germs,  37,  49,  51,  57,  68,  73 
pigment,  67 

on  quinine  in  malaria,  147 
Bilious  fever  and  yellow  fever,  288,  291 

haemoglobinuric  fever,  117 

type  of  pernicious  malarial  fever,  115 

typhoid,  262 
Billings  on  antitoxin,  701 

on  malarial  leucocytosis,  126 
Biniodide  and  syphilis,  902 
Binz  on  malaria,  146 
Birds  and  malarial  pai'asites,  74,  75 

and  tuberculosis,  739 
Bismuth  in  dysentery,  384 
Bisulphate  of  quinine  in  malaria,  149 
Black  measles,  631 
Black  vomit,  267,  276,  286 
Bladder,  catarrh  of,  in  enteric  fever,  177 

syphilis  of,  876 

tuberculosis  of,  821 
Blair  on  vellow  fever,  273 
Blattern,"513 
Blaxall  on  malaria,  97 
Blood  in  cestivo-autumnal  fever,  119 

antitoxic,  in  diphtheria,  668 

and  bacillus  leprae,  924 

in  cholera,  317 

in  chronic  malaria,  129 
phthisis,  801 

corpuscles  in  malaria,  21,  25,  71,  72 

examination  of,  in  malaria,  137 


Hlood,  examination  of,  in  miliary  tubercu- 
losis, 753 

in  intermittent  fever,  103 

in  malarial  cachexia,  93 
fevers,  125 

in  pernicious  malarial  fever,  119 

in  pyaimia,  479 

in  quartan  fever,  105 

in  (luotidian  intermittent  fever,  104 

in  septicu'mia,  501 

serum  of  horse,  848 

in  tetanus,  942 

transfusion  in  enteric  fever,  230 

tubercle  bacilli  in,  753 

tubercular  infection  through,  819 

in  urine  in  vesical  ttil)erculosis,  825 

of  yellow  fever,  275 
Bloodletting  in   cerebro-spinal  meningitis, 

446 
Bloodvessels  in  enteric  fever,  177 

in  tetanus,  938 

syphilis  of,  872,  873,  891 
Blumer  on  tuberculosis,  731 

on  urine  in  enteric  fever,  196 
Bock  on  relapsing  fever,  258 
Bollinger  on  tuberculosis.  818 
Boltz  on  tuberculosis,  738 
Bone  diseases  in  enteric  fever,  197 

marrow  in  chronic  malaria,  93 
in  malaria,  54,  55,  64,  89 
Bones,  syphilis  of,  881 
Boophilus  bovis,  82 
Botazzi  on  malarial  urine,  124 
Bouchard  on  cholera.  326 

on  intermittent  fever,  102 
Boulay  on  cerebro-spinal  meningitis,  426 
Boulland  on  tuberculosis,  774 
Bouveret  on  enteric  fever,  229 
Bovine  lymph,  549 

Bowditch,   Vincent,    on    tuberculosis,   744, 
844 
on  tuberculous  pleurisy,  765 
Bradycardia  in  enteric  fever,  186 
Brain  in  cerebro-spinal  meningitis,  433 

in  cholera,  311 

in  malaria,  83 

syphilis  of,  884 

tuberculosis  of,  831 

in  yellow  fever,  276,  292 
Brand  on  enteric  fever,  222,  226 
Break-bone  fever,  155 
Brehmer  on  tuberculosis,  844 
Bribram  on  tuberculosis,  831 
Brieger  on  enteric  fever,  229 

on  erysipelas,  454 

on  tetanus,  937 
British  Leprosy  Commission,  report,  923 

Medical    Association,   tuberculosis    com- 
mittee, 743 
Bromoform  and  pertussis,  723 
Brompton  Consumption  Hospital,  742 
Bronchi  in  chronic  phthisis,  784 

in  phthisis,  776 
Bronchial  glands  and  tuberculosis,  742,  760, 

762 
Bronchitis  and  chronic  phthisis,  786,  800 

in  enteric  fever,  186,  220 


954 


INDEX. 


Bronchitis  and  influenza,  415,  416 

and  miliary  tuberculosis,  754 

and  pertussis,  718 

in  relapsing  fever,  263 

and  tuberculosis,  745 
Broncho-pneumonia  in  enteric  fever,  187 

and  influenza,  415,  416 

with  malaria,  132 

in  measles,  632 

and  pertussis,  720 
Broncho-pneumonic  form  of  phthisis,  777, 

779 
Brown  on  diphtheria  intubation,  691 
Browne,  Sir -Thomas,  on  tuberculosis,  795 
Brun  on  dengue,  160 
Brunton  on  cholera,  315 
Bubo,  851,  856 

plague,  391 
Buboes  in  plague,  395,  396 
Buchanan  and  tuburculosis,  744 

on  typhus  fever,  248 
Bullae  in  leprosy,  926 

CACHEXIA,  chronic  malarial,  89,  128 
malarial,  dinguosis  of,  143 
treatment,  154 
Calcareous   fragments  in  chronic  phthisis, 

790 
Caley  on  enteric  fever,  207 
Calmette  on  leprosy,  932 
Calomel  in  cholera,  326 

in  dysentery,  382 

fumigation  in  diphtheria,  686 

and  syphilis,  902 
Cameron  on  yellow  fever,  268 
Canalis  on  a?stivo-autumnal  fever,  121 

on  malaria,  22,  27,  37,  47,  57 
Cancer  and  syphilis  compared,  869 
Cantani  on  cholera,  328 
Carbuncle  and  septicaemia,  507 
Carbuncles  in  plague,  396 
Cardialgic  tvpe  of  pernicious  malarial  fever, 

115 
Cardio-vascular  svstem  in  chronic  phthisis, 

801 
Caries,  dry  syphilitic,  881,  883 
Carmack  on  relapsing  fever,  258 
Carreau  on  lepros}',  930,  932 
Carter  on  enteric  fever,  230 

on  relapsing  fever,  259 
Caseation,  749 
Caseous  degeneration.  749 

pneumonia.     See  Phthisis. 
Cases  of  cholera,  333-337 

of  typhus  fever,  244-246 
Castor  oil  in  dysentery,  382 
Catarrh  of  bladder  in  enteric  fever,  177 

in  influenza,  413 
Catarrhal  bronchitis  and  tuberculosis,  745 

dysentery,  acute,  347 
clinical  course,  357 
symptoms,  357 

laryngitis  in  enteric  fever,  187 
Caustics  in  diphtheria,  684 
Cavities  of  phthisis,  782,  798,  799 
Ceci  on  cholera,  313 
Celli  on  malaria,  21,  22,  30,  32,  35,  37,  47 


Cells,  giant,  748 

of  leprosy,  924 
Celsus  on  intermittent  fever,  18 

on  leprosy,  921 
Cephalic  tetanus,  939 

Cerebral  meningitis,  diagnosis  from  typhus, 
251 
paralysis,  malarial,  131 
symptoms  of  pernicious  malaria,  115 
Cerebro-spinal  fever,  425 
meningitis,  425 
abortive  cases,  441 
cause  of  death,  442 
in  children,  437,  438 
complientions  of,  441,  447 
counter-irritants  in,  446 
definition,  425 
diagnosis,  443 
etiology,  425 
eyes  in,  438 
fever  in,  439 
fulminant  cases,  441 
herpes  in,  439 
history,  425 
incubation,  436 
and  influenza,  444 
joints  in,  440 
and  meningitis,  444 
ordinary  form,  436 
pathological  anatomy,  433 
prognosis,  445 
pulse  in,  440 
remission  in,  441 
sequelae,  441 
symptoms,  436 
synonyms,  425 
treatment  of,  445 
and  typhoid  fever,  443 
and  typhus  fever,  444 
varieties,  436 
venesection  in,  446 
Cervical  glands  and  tuberculosis,  762 
Cervix  uteri,  tuberculosis  of,  830 
Chancre,  850,  854 
dry  papule,  857 
of  ear,  889 
erosion,  856 
extra-genital,  856 
forms,  856 
genital,  856 
induration,  856 
mixed,  858 
of  mouth,  868 
pustule,  858 
sites,  855 
of  tongue,  868 
of  tonsil,  869 
treatment  of,  897 
ulcer,  858 
Chancroid,  893 

Channing  on  tuberculous  peritonitis,  772 
Chapin  on  typhus  fever,  255 
Chaplin  on  fibroid  phthisis,  805 
Chapparo  amargoso  in  dysentery,  389 
Charles  on  dengue,  160 
Chaulmoogra  oil  and  leprosy,  930 
Cheeseman  on  typhus  fever,  234 


INDEX. 


955 


Cheyne-Stokes  breathing  in  cerebro-spiiial 
meningitis,  440 
and  meningeal  tuberculosis,  758 
in  niiliarv  tnliereiilosis,  753 
in  pernicious  malaria,  114 
Chiari  on  tubercle,  747 
Chickiilioniiny  (Harrhcea,  356 
Chicken-pox.     See   Varicella. 
Children,  cerebro-spinal  meningitis  in,  437, 
438 

intermittent  fever  in,  102 

prognosis  of  dysentery  in,  376 

and  yellow  lever,  293 
Childhood  mortalitv  in  enteric  fever,  207 

syphilis  of,  914-919 

and  yellow  fever,  274 
Chill  in  erysipelas,  459 

in  phthisis,  777 

in  py:¥niia.  484,  485,  488 

in  smallpox,  523 

of  tertian  fever,  100 

in  yellow  fever,  281 
Chills  and  fever,  17.     See  Malaria. 
Chincon,  Del,  18 
Chisholm  on  leprosy,  932 
Chloral  in  tetanus,  944 
Chlorate  of  potash  in  leprosy,  930 
Chloride  of  iron  and  diphtheria,  685 
Cholera,  301 

and  age,  304 

algid  stage,  301,  314 

in  Asia,  321 

Asiatic,  301 

bacteriological  diagnosis,  308 

brain  in,  311 

climate,  304 

collapse  in,  317 

complications  of,  319 

convalescence,  318,  332 

definition,  301 

diagnosis,  319 

disinfection,  322,  323 

duration,  319 

etiology,  304 

heart  in,  311 

history,  301 

hydrochloric  acid  in,  327 

infectiosa,  301 

intestines  in,  312 

kidnevs  in,  312 

liver  in,  312 

lungs  in,  312 

maligna,  301 

mortality,  303 

pathological  anatomy,  311 

predisposing  causes,  304 

premonitory  stage,  treatment,  314,  326 

prognosis,  321 

prophylaxis,  322 

and  quarantine,  324 

and  race,  305 

and  raw  food,  323 

reaction  in,  314,  318 

season,  304 

sequelae,  319 

and  sex,  304 

sicca,  317 


Cholera,  splocn  in,  312 
stage  of  asphyxia,  314 
of  collapse,  314 
of  reaction,  332 
of  serous  (liarrha?a,  314 
stinuilation  in,  332 
stomach  in,  312 
stools,  307 
symptoms,  314 
synonyms,  301 
systematic  treatment,  326 
treatment  of,  325 
collapse  stage,  327 
Choleriform  tvpe  of  pernicions  malaria,  116 
Cholerine,  301,  303,  319 
Chorea  and  enteric  fever,  198 
Choroiditis,  syphilitic,  889 
Chromatin  in  malarial  germs,  62 
Chronic  anannia  in  malaria,  130 

dysentery,  jjost-mortem  appearances,  356 
malarial  cachexia,  89,  94,  128 
diagnosis  of,  143 
treatment,  154 
phthisis,  780 

and  dyspnoea,  792 
haemoptysis  in,  790 
pleura  in,  784 
pulmonary   tuberculosis.       See    Phthisis, 
Chronic. 
Cicatrices  of  smallpox,  552 
tubercular,  835 
of  varicella,  571 
Cicatrix  of  vaccinia,  562 

of  vaccination,  564,  565 
Cicatrization  of  enteric  ulcers,  174 
Ciliary  body,  syphilis  of,  888 
Cinch  onism,  152 
Circulation  and  pyaemia,  482 
Circulatory  apparatus  and  diphtheria,  678 
system  in  enteric  fever,  185 
and  scarlet  fever,  599 
Cirrhosis,  malarial,  95,  131 
Civil  War,  dysentery  in,  341,  349,  370 
Clark  on  fibroid  phthisis,  805 

on  intermittent  fever,  19 
Clements  on  yellow  fever,  294 
Cleanliness  in  cholera,  322 
Climate  and  cholera,  304 
and  dysentery,  340 
and  enteric  fever,  168 
influence  on  dengue,  156 
and  malaria,  79 
and  tuberculosis,  842,  843 
and  yellow  'fever,  269,  270 
Climatic  treatment  of  tuberculosis,  842 
Clinical  cases  of  dipbtlieria,  700 
of  pseudo-diphtheria,  708 
course  of  acute  catarrhal  dysentery,  357 
of  diphtheritic  dysentery,  359 
of  enteric  fever,  179 
of  secondary  dysentery,  365 
history  of  dengue,  159 
of  fibroid  phthisis,  805 
Cloisters  and  tuberculosis,  742 
Clothing,  disinfection  of  in  cholera,  323 
Cnopp  on  tuberculosis,  738 
Cod-liver  oil  in  syphilis,  918 


956 


INDEX. 


Cod-liver  oil  and  tuberculosis,  841,  845 
Cohnlieim  on  tuberculosis,  811 
Cold  bathing.     See  Baths. 
Coley  on  typhus  fever,  234 
Collapse  in  cholera,  315 

in  enteric  fever,  219 

in  relapsing  fever,  262 

stage  of  cholera,  327 
Colles'  law,  914 
Colon  bacillus  in  yellow  fever,  281 

inflammation  of,  339 

photograph  of  dysenteric,  349 

plate  of  transverse  section  in  dysentery, 
348 
Colorado  and  tuberculosis,  843 
Coma,  malarial,  114 
Comatose  malarial  fever,  114 

pernicious  fever,  diagnosis,  142 
Combined   infections   with   malarial   para- 
sites, 122 
Comma  bacillus,  305-311 
Communicability  of  pseudo-diphtheria,  670 
Complications  of  cerebrospinal  meningitis, 
441,  447 

of  cholera,  319 

of  chronic  phthisis,  799 

of  dengue,  162 

of  diphtheria,  679 

of  enteric  fever,  198 
treatment  of,  215 

of  erysipelas,  467 

of  influenza,  415 

of  malaria,  127 

of  measles,  632 

of  parotiditis,  729 

of  pertussis,  718 

in  the  pleura  in  chronic  phthisis,  800 

pulmonary,  of  malaria,  132 

of  relapsing  fever,  262 

in  rubella,  643 

of  scarlet  fever,  597 

of  secondary  dysentery,  366 

of  smallpox,  538 

of  typhus  fever,  248 

of  vaccinia,  561 

of  varicella,  573 

of  Weil's  disease,  946 
Condylomata  of  ear,  890 

syphilitic,  862 
Confederate  army,  dysentery  in,  341 
Confluent  variola,  531 
Congenital  scarlet  fever,  580 
Conjunctiva  in  cholera,  315 

in  smallpox,  535 

syphilis  of,  887 
Conjunctivitis  and  scarlet  fever,  619 
Constipation  and  dysentery,  342 

in  enteric  fever,  217 
Consumption,  780.     See  Phthisis. 

pulmonary.     See  Tuberculosis. 
Contagium  of  diphtheria,  647 

of  dysentery,  344 

of  enteric  fever,  169 

of  erysipelas,  455 

of  leprosy,  922 

of  plague,  393 

of  scarlet  fever,  582 


Contagium  of  smallpox,  518,  519 

of  syphilis,  850 

of  typhus  fever,  234 

of  varicella,  570 
Continued  fever,  948 
Convalescence  in  cholera,  332 

of  dengue,  159 

of  diphthei'ia,  664 

of  diphtheritic  dysentery,  361 

of  dysentery,  358 

of  enteric  fever,  221 

of  influenza,  423 

of  plague,  396 

of  relapsing  fever,  262 

of  smallpox,  554 
Convulsions  in  enteric  fever,  193 

in  meningeal  tuberculosis,  757 

and  pertussis,  7 1 8 

in  scarlet  fever,  597,  623 

in  smallpox,  550 

in  tetanus,  938,  939 
Cooper  on  tuberculosis,  832 
Copland  on  scarlet  fever,  577 
Coplin  on  enteric  fever,  179 
Cord,  syphilis  of,  885 

tuberculosis  of,  831 
Cornea,  syphilis  of,  887 
Cornet  on  tuberculosis,  741,  837 
Cornil  on  cerebro-spinal  meningitis,  431 
Corpulency  in  enteric  fever,  207 
Corrosive  sublimate  in  diphtheria,  684 
in  dysentery,  384 
in  syphilis,  902 
Coryza  and  measles,  629 

syphilitic,  916 
Cough  in  chronic  phthisis,  787 

in  influenza,  413,  423 

in  pertussis,  716 

in  tuberculosis,  846 
Councilman  on  amoebic  dysentery,  352-354 

on  crescents,  57 

on  flagella,  27 

on  malarial  pigment,  22 

on  yellow  fever,  278,  280 
Counter-irritants   in  cerebro-spinal  menin- 
gitis, 446 
Courmont  on  erysipelas,  454 
Course  of  syphilis,  849 
Cowpox,  555,  561 
Cramps  in  cholera,  317 

relief  of,  331 
Creasote  and  tuberculosis,  845 
Creoles  and  yelloAv  fever,  274,  293 
Creolin  in  cholera,  330 
Crescentic  bodies  in  malaria,  21,  27,  54,  60 
Crimean  War  and  dysentery,  369,  370 
Crises  in  relapsing  fever,  26l 
Croup.     See  Pseudo-diphtheria. 
Croupous  pneumonia  and  enteric  fever,  187, 

206  _ 

Cryptogenetic  infection,  455 

septicEemia,  508 
Culture  media,  diphtheritic,  651 

of  tetanus  germs,  935,  936 
Cultures  of  amoeba  dysenterica,  345 

of  cholera  bacteria,  308-310 

of  erysipelas  germs,  452 


INDEX. 


957 


Ciinissct  on  yellow  fever,  276 
Ciinningliaui  on  dysentery,  345 
Cure,  spontaneous,  of  tnbereulosis,  834 
Curry  on  enteric  lever,  'I'l'l 
Curselunann  on  smallpox,  516 
Cyanosis  in  eiiolera,  333,  334 

and  chronic  phthisis,  793 
Cystitis  in  enteric  fever,  177 

syphilitic,  888 
Czerny  and  tuberculosis,  741 

DA  COSTA  on  enteric  fever  relapse,  203 
Dairies,  ins{>ection  of,  839 
Daland  on  cholera,  333 
Dandy  fever.     See  Denc/ue. 
Danielewsky  on  malaria,  56,  74 
Dantes  on  yellow  fever,  277 
Davidson  on  typhus  fever,  235 
Davis  on  cerebro-spinal  meningitis,  447 
Deafness  in  cerebro-spinal  meningitis,  442 

in  enteric  fever,  193 
D'Aquin  on  dengue,  159 
Death  rate.     See  Mortality. 
Decomposing  vegetation  and  dysentery,  343 
D'Espine  on  diphtheria,  648 
Definition  of  cholera,  301 

of  diphtheria,  647 

of  dysentery,  339 

of  enteric  fever,  167 

of  erysipelas,  451 

of  intiuenza,  399 

of  leprosy,  921 

of  measles,  625 

of  miliary  fever,  947 

of  parotiditis,  725 

of  pertussis,  713 

of  plague,  391 

of  pyaemia,  477 

of  relapsing  fever,  257 

of  rubella,  639 

of  scarlet  fever,  577 

of  septicemia,  495 

of  simple  continued  fever,  948 

of  smallpox,  513 

of  syphilis,  849 

of  tetanus,  935 

of  tuberculosis,  731 

of  vaccination,  555 

of  Weil's  disease,  945 

of  yellow  fever,  267 
Degeneration,  amvloid,  in  chronic  malaria, 
95 
after  malaria,  131 

caseous,  749 

of  tubercle,  749 
Deglutition  pneumonia  in  enteric  fever,  187 
Dejecta,  choleraic,  308,  324 

of  dysentery,  377 
Delafield  on  enteric  fever,  207 

on  simple  continued  fever,  950 
Delavan  on  erysipelas,  467 
Del  Chinchon  and  quinine,  145 
Delirium  in  ajstivo-autumnal  fever,  141 

in  enteric  fever,  181,  192,  215 

ferox,  529 

and  meningeal  tuberculosis,  757,  758 

in  smallpox,  529 


Delirium  in  tertian  intermittent  fever,  101 

in  typhus  fever,  248 
Dengue,  155 

clinical  history,  159 

communicable,  158 

complications,  162 

course  of  fever,  160 

definition,  155 

diagnosis,  162 

eruption  of,  160 

etiology,  155 

glandular  injections,  161 

hemorrhages  in,  161 

liistory,  155 

and  influenza,  420 

medicinal  treatment,  164 

muscular  and  arthritic  pains,  160 

pathological  anatomy,  158 

prognosis.  164 

relapses,  161 

seqnelse,  162 

specific  causes,  156 

symptoms,  159 

treatment  of,  164 

varieties  of,  161 

and  yellow  fever,  291 
Denguis  maligna,  162 
DeEenzi  on  cholera,  316 
Dermatitis  gangrenosa,  573 

and  scarlet  fever,  608 
Dermatosis  and  scarlet  fever,  607 
Desquamation  in  enteric  fever,  197 

in  measles,  630 

of  rubella,  643 

in  scarlet  fever,  593 
Desiccation  stage  of  smallpox,  530 
De  Toma  on  tubercle  bacillus,  736 
Dewevre  on  dysentery,  372 

on  enteric  fever,  178 
Diabetes  and  enteric  fever,  198 

and  tuberculosis,  746 
Diagnosis  of  acute  pneumonic  phthisis,  778 

of  sestivo-autumnal  fever,  142 

of  cerebro-spinal  meningitis,  443 

of  cholera,  319 

of  chronic  phthisis,  803 

of  dengue,  162 

of  diphtheria,  654,  655,  680 

of  dysentery,  374 

of  enteric  fever,  205 

of  erysipelas,  470 

of  fibroid  phthisis,  806 

of  influenza.  419 

of  leprosv,  928 

of  malaria,  136 

of  measles,  634 

of  meningeal  tuberculosis,  759 

of  miliary  tuberculosis,  754 

of  parotiditis,  729 

of  pernicious  malaria,  142 

of  pertussis,  719 

of  plague,  396 

of  pyaemia,  491 

of  relapsing  fever,  263 

of  rubella,  644 

of  scarlet  fever,  604 

of  septicfemia,  508,  509 


958 


INDEX. 


Diagnosis  of  smallpox,  540 

of  syphilis,  892 

of  tetanus,  940 

of  tuberculosis,  839 

of  tuberculous  adenitis,  764 
pericarditis,  770 
pleurisy,  768 

of  typhus  fever,  249 

of  varicella,  574 

of  Weil's  disease,  946 

of  yellow  fever,  287 
Diapedesis  in  malaria,  73 
Diaphoretics  in  scarlet  fever,  621 
Diarrhoea  in  amoebic  dysentery,  363 

Chickahominy,  356 

choleraic,  327 

in  enteric  fever,  180,  188 

and  scarlet  fever,  599 

serous,  in  cholera,  315 

in  tuberculosis,  846 
Diazo-reaction  in  enteric  fever,  195 

in  malaria,  141 
Dickson  on  dengue,  158 
Dicrotism  in  enteric  fever,  185,  219 
Diet  of  amoebic  dysentery,  387 

in  cerebro-spinal  meningitis,  449,  450 

in  cholera,  326 
convalescence,  332 

in  diphtheria,  685 

in  dj'sentery,  385,  386 

and  enteric  fever,  171,  212,  226 

errors  of,  and  dysentery,  342 

in  erysipelas,  473 

in  influenza,  421,  422 

in  malaria,  145 

in  malarial  cachexia,  154 

in  measles,  636 

in  pyaemia,  494 

in  relapsing  fever,  264 

in  scarlet  fever,  613 

in  septicaemia,  512 

in  syphilis,  895 

in  tuberculosis,  840 

in  typhus  fever,  253 

in  yellow  fever,  300 
Dietetic  treatment  of  tuberculosis,  840 
Differential  diagnosis.     See  Diagnosis. 
Digestive  system  and  diphtheria,  678 
and  enteric  fever,  187 
in  influenza,  413 

tract  and  syphilis,  871 
in  typhus  fever,  247 
Di  Mattel  on  malarial  inoculation,  75 
Dionisi  on  malarial  blood,  125 
Diphtheria,  647 

antitoxin,  692 
conclusions,  707 

bacilli,  647 

in  healthy  throats,  663 
sources  of,  666 
summary,  663,  664 

circulation  in,  678 

complications,  679 

convalescence  and  bacilli,  664 

cultures,  651-653 

definition,  647 

diagnosis,  654,  655,  680 


Diphtheria,  diet  in,  685 

digestion  in,  678 

and  enteric  fever,  198 

epidemics,  669 

general  condition,  678 
treatment,  685 

heart  in,  674 
failure  in,  679 

immunization,  692,  696 

intubation,  686,  689 
instruments,  687,  688 

irrigation  in,  683,  684 

joints  in,  679 

kidneys  in,  674 

laryngeal,  677 
treatment,  685 

local  treatment,  683 

lymph  glands  in,  679 

malignant  cases,  676 

nervous  system  in,  675,  678   . 

paralysis  in,  679 

pathological  anatomy  of,  673 

pharyngeal,  675 
mild  cases,  675 
symptoms,  675 

pneumonia  in,  679 

prognosis,  681 

prophylaxis,  682 

pseudo-,  bacteriology  of,  670 

relapses,  679 

and  scarlet  fever,  609 

and  septic  infection,  508 

severe  cases,  675 

skin  in,  679 

symptoms  in  detail,  678 

temperature,  678 

tracheotomy,  686 

treatment,  682 

urine  in,  679 
Diphtheritic  dysentery,  349 

pathological  anatomy  of,  349 
symptoms,  359 
Diplococci  in  cerebro-spinal  meningitis,  426 
Diseases  associated  with  pulmonary  tuber- 
culosis, 807 
Disinfectants  in  diphtheria,  684 
Disinfection  of  cholera  patients,  322 

of  cholera  stools,  323 

of  dj'senteric  stools,  377 

of  enteric  stools,  208 

in  erysipelas,  472 

in  scarlet  fever,  611,  612 

in  smallpox,  546,  547 

of  tubercular  sputum,  837 

in  typhus  fever,  252 
Distribution  of  malaria,  77,  79 

of  tubercle  bacillus,  736,  737 
Diuretics  in  scarlet  fever,  622 

in  yellow  fever,  299 
Dobie  on  dysentery,  380 
Dock  on  dysentery,  346,  353,  362,  364,  374 

on  malarial  germs,  23,  29,  66 
Doehle  on  scarlet  fever,  586 
Domestic  animals,  tuberculosis  in,  731 
Donnet  on  yellow  fever,  290 
Double  quartan  intermittent  fever,  105 
Dowler  on  yellow  fever,  274 


INDEX. 


959 


Drainage  and  enteric  fever,  210 

anil  malaria.  79 
Drake  on  inlerniittent  fever,  19 
Drepanidiuni  Kavanun  in  malaria,  74 
Drinking  water  and  dysentery,  342 
and  enteric  fever,  209 
and  malaria,  81 

pathogenic  micro-organisms  in,  343 
and  relapsing  fever,  259 
Dropsy  of  the  brain,  754 
Drug  eruptions  and  measles,  635 
and  scarlet  fever,  606,  607 
rashes  and  smallpox,  542 
Dry  cholera,  317 
Dubar  on  tuberculosis,  832 
Dubini's  disease  after  malaria,  132 
Duffin  on  scarlet  fever,  582 
Dunham's  culture  method,  308,  309 
Duration  of  cholera,  319 

of  pulmonary  tuberculosis,  836 
of  relapsing  fever,  262 
Dust  and  tuberculosis,  741 
Dysenteric  am«ba,  354 
arthropatiiies,  372 
paralyses,  373 
Dysentery,  339 

abdominal  symptoms  in,  365 
abscess  of  liver  in,  353 

of  lung  in.  354 
acute  catarrhal,  347 
clinical  course,  357 
pathological  anatomy,  347 
symptoms,  357 
and  age,  340 
amoebic,  340 
clinical,  361 
masked  forms,  361 
pathological  anatomy  of,  351 
symptoms,  361 
and  ansmia,  366 
antiseptics  in,  384 
in  armies,  341 
calomel  in,  382 
castor  oil  in,  382 
catarrhal,  340 

chronic,  post-mortem  appearances,  356 
circulation  in,  362 
and  climate,  340 
complications,  366 
contagium,  344 
definition,  339 
diagnosis,  374 
diphtheritic,  340 
clinical  course,  359 
symptoms,  359 
and  drinking  water,  342 
etiology,  340 
fever  in,  365 
follicular  ulceration,  356 
gangrenous  form,  363 
and  hepatic  abscess,  367-369 
ipecac  in,  379 
and  malaria,  143,  370 
opium  in,  380 
and  peritonitis,  366 
in  pneumonia,  369 
prognosis,  375 


Dysentery,  prophylaxi.s,  376 
purgatives  in,  382 
rectal  medication,  385 
in  relapsing  fever,  263 
respiration  in,  365 
and  season,  340 
secondary,  340,  355 

clinical  course,  365 

pathological  anatomy  of,  355 

symptoms,  365 
sequeiie,  374 
and  scurvy,  370 
and  sex,  340 
sporadic,  340 
tenesmus  in,  365 
treatment  of  amoebic,  387 

of  catarrhal,  385 

of  diphtheritic,  386 

of,  in  general,  376 
tropical,  340 
and  tuberculosis.  369 
and  typhoid  fever,  371 
and  typhus  fever,  371 
urine  in,  365 
Dysidi'osis  and  leprosy,  929 
Dyspepsia  and  chronic  phthisis,  786 

and  tuberculosis,  841 
Dyspnoea  in  chronic  phthisis,  792 
in  influenza,  414 
in  miliary  tuberculosis,  753 

EAK  and  erysipelas,  468 
in  smallpox,  539 

syphilis  of,  889 
Eberth  on  cerebro-spinal  meningitis,  425 

on  enteric  fever,  169 
Eberth's  bacillus,  169,  177,  197 
Echinacea  augustifolia,  255 
Eczema  of  syphilis,  894 
Edward  11.  and  smallpox,  550 
Efinsion,  sero-fibrinous  in  pleurisy,  767 
Eggs  in  enteric  fever,  226 

and  tuberculosis,  841 
Ehrlich's   diazo-reaction   in   enteric   fever, 
195 
in  malaria,  141 
Elastic  tissue  in  phthisical  sputum,  789 
Electric  chorea  after  malaria,  132 
Electrolysis,  329-331 

Emaciation   in    cerebro-spinal    meningitis, 
441 

in  chronic  phthisis,  795 

in  enteric  fever,  181 
Emboli  in  pyemia,  480,  483,  487 
Emetics  in  yellow  fever,  295 
Emphysema  in  chronic  phthisis,  800 
Endarteritis  obliterans,  syphilitic,  873 

tuberculous,  756 
Endocarditis  and  chronic  phthisis,  808 

in  enteric  fever,  186 

and  erysipelas,  469 

malignant  and  cerebro-spinal  meningitis, 
442 

in  pya?mia,  484,  490 

and  scarlet  fever,  604 
Endophlebitis  in  pysemia,  481 
Enemata  in  dysentery,  385 


960 


INDEX. 


Enemata  in  yellow  fever,  297 
Enteric  (or  typhoid)  fever,  167 

abdominal  tenderness  in,  189 

abortive  form,  200 

afebrile  type,  200 

and  age,  168 

in  the  aged,  203 

albuminuria  in,  195 

ambulatory,  199 

anaemia  in,  186 

angina  in,  188 

antipyretics  in,  216 

aphasia,  194 

and  appendicitis,  206 

asthenia  in,  221 

bacillus,  169 

and  bedsores,  197,  220 

bloodvessels  in,  177 

and  bronchitis,  186,  220 

and  broncho-pneumonia,  187 

cardiac  asthenia  in,  219 

and  catarrhal  laryngitis,  187 

central  nervous  system  in,  179 

circulatory  system  in,  185 

and  climate,  168 

collapse  in,  219 

complications,  198 

constipation  in,  217 

convalescence,  221 

convulsions  in,  198 

and  croupous  pneumonia,  1 87,  206 

cutaneous  hyperesthesia,  194 

cystitis  in,  177 

deafness  in,  193 

definition,  167 

delirium  in,  192 

and  desquamation,  197 

diagnosis,  205 
from  typhus,  249 

diarrhoea  in,  188 

diet  in,  212,  226 

differential  diagnosis,  206 

and  digestive  system,  187 

dilatation  of  pupils,  193 

disinfection  of  stools,  208 

and  en tero- colitis,  207 

epidemics,  171 

and  epistaxis,  187,  219 

eruption  in,  196 

and  erythema,  196 

etiology,  167 

and  furuncles,  197,  221 

general  clinical  course,  179 
management  of  patient,  211 

geographical  distribution,  168 

headache  in,  192 

heart  in,  177 

hemorrhage  in,  175 

hemorrhagic  type,  200 

and  herpes,  197 

hydrotherapy  in,  222 

incubation,  179 

and  influenza,  410 

insanity  in,  194 

intercurrent   and    concurrent    diseases, 
198 

intestinal  hemorrhage  in,  189,  218 


Enteric  fever,  intestinal  perforation  in,  21& 
intestines  in,  173 
jaundice  in,  192 
kidneys  in,  177 
latent  form,  199 
liver  in,  176 

localized  tenderness  of  muscles,  194 
and  malaria,  205 
mesenteric  glands  in,  175 
mild  form,  199 
mortality,  207 
muscular  weakness  in,  193 
and  nervous  system,  192 
neuralgia  in,  194 
neuritis,  194 

organs  of  special  sensation,  193 
and  osseous  s^'stem,  197 
otitis  media  in,  188 
pancreas  in,  178 
parotiditis  in,  221 
pathological  anatomy,  173 
perforation  in,  175 

of  intestine  in,  190 
peripheral  neuritis  in,  222 
peritonitis  in,  191,  206,  218 
physiognomy,  197 
and  pleurisy,  187 
and  pregnancy,  203 
and  prognosis,  207 
prophylactic  inoculations,  229 
prophylaxis,  207 
and  pulmonary  tuberculosis,  807 
pulse  in,  185 
pyuria  in,  196 
recrudescence,  204 
reduction  of  temperaturCj  220 
and  relapses,  203 
respiratory  organs  in,  178 
respiratory  system,  186 
retention  of  urine  in,  219 
salivary  glands  in,  178 
and  season,  168 
second  attacks,  205 
serum  inoculations,  230 
and  sex,  169 
skin  in,  196 
somnolence  in,  192 
special  management  of  individual  cases, 

214,  215 
specific  treatment,  222 
spleen  in,  176,  191 
sporadic  cases,  173 
and  sudamina,  197 
symptoms,  179 
synonyms,  167 
and  synovitis,  198 
temperature  chart,  180,  182-185,  189, 

199-202,  204 
thi-ombosis  in,  222 
tongue  in,  187 
transfusion  of  blood  in,  230 
treatment,  207 

of  complications,  215 
tremor  in,  193 
and  trichinosis,  206 
and  tuberculosis,  206 
tympanites  in,  189,  217 


INDEX. 


961 


Enteric  fever,  iiJceiation  in,  174 
urinary  system  in,  194 
urine  in,  194,  217 
and  nrticaria,  197 
varieties,  198 
vertigo,  19o 

voluntary  nniscles  in,  178 
Vdiniliui;-  in,  188 
and  weatlier,  1(38 
Entero-et)litis  and  enteric  lever,  207 
Environment  and  tuberculosis,  743 
Epidemic  catarrhal  fever,  399 
cerebro-spinal   meningitis.     See    Cerebro- 
spinal Men  iiM/itis. 
cholera,  301 

parotiditis.     See  Parotiditis. 
Epidemics  of  cholera,  301-304 
of  diphtheria,  669 
of  dysentery,  349 
of  iiiHueiizaV 399-405 
of  scarlet  fever,  577 
of  smallpox,  513 
of  typhus  fever,  233,  242 
of  yellow  fever,  267 
Epidermis  in  erj'sipelas,  456,  457,  460 
Epilepsy  and  enteric  fever,  198 
Ej)istaxis  in  enteric  fever,  187,  219 
in  relapsing  fever,  263 
in  typhus  fever,  247 
Epizootics  and  influenza,  404 
Erb  on  syphilis,  885 
Ernst  on  enteric  fever,  170 
Eruption  of  dengue,  160 

of  enteric  fever,  180,  181,  196 
of  erysipelas,  460,  470 
of  leprosy,  926 
of  measles,  627-629 
of  pyaemia,  482 
of  relapsing  fever,  261 
of  rubella,  641,  642 
of  septic  infection,  506 
of  smallpox,  525,  526 
of  typhus  fever,  241,  242 
of  varicella,  572 
of  varioloid,  537 
Erysipelas,  451 
afebrile,  461 
and  albuminuria,  468 
ambulant,  463 
antiseptics  in,  474 
bullous,  463,  464 
and  chronic  phthisis,  807 
complications,  467 
definitions,  451 
diagnosis,  470 
diet,  473 

and  enteric  fever,  198 
erratic,  463 
etiology,  451 
of  face,  465 
gangrenous,  464 
hemorrhagic,  463 
incubation,  459 
of  the  larynx,  466 
and  lymphangitis,  470 
migrating,  463 
of  mucous  membranes,  465 
Vol.  I.— 61 


Erysipelas  of  nose,  466 

cedematous,  463 

patliological  anatomy,  456 

patliology,  451 

pemphigoid,  463 

petecliial,  163 

and  pharynx,  466 

phlegmonous,  464 

prognosis,  471 

and  scarlet  fever,  606 

sequela?,  467 

of  special  regions,  465 

stimulants  in,  474 

symptoms,  459 

synonyms,  451 

transmission  of,  to  foetus,  467 

treatment,  472 

and  vaccinia,  562 

variations  in  local  lesion,  403 

wandering,  463 
Erysipeloid,  471 
Erythema  in  enteric  fever,  196 

scarlatiniforme,  607 
Erythemata  in  sestivo-autumnal  fever,  141 
Erythematous  syphiloderni,  894 
Escherich  on  diphtheria,  659,  660 
Esmarch  on  cholera,  309 
Etiology  of  cholera,  304 

of  dysentery,  340 

of  enteric  fever,  167 

of  erysipelas,  451 

of  influenza,  404 

of  leprosy,  922 

of  malaria,  77 

of  Malta  fever,  946 

of  measles,  625 

of  meningeal  tuberculosis,  755 

of  miliary  fever,  948 

of  parotiditis,  725 

of  pertussis,  713 

of  plague,  392 

of  pyiemia,  477 

of  relapsing  fever,  257 

of  rubella,  639 

of  scarlet  fever,  577 

of  septicsemia,  495 

of  simple  continued  fever,  949 

of  smallpox,  513 

of  syphilis,  852 

of  tetanus,  935 

of  tubercle,  746 

of  tuberculosis,  731 

of  typlius  fever,  233 

of  vaccinia,  557 

of  varicella,  569 

of  Weil's  disease,  945 

of  yellow  fever,  267 
Eucalyptus  globulus  and  malaria,  79 
Ewart  on  dysentery,  379 
Examination  of  malarial  blood,  137 

of  syphilitic  patients,  893,  894 
Exanthem.     See  Eruption. 
of  enteric  fever,  196 

in  smallpox,  524,  525 
Exanthemata  and  malaria,  135 
and  measles,  634,  635 
and  scarlet  fever,  585 


962 


INDEX. 


Exostoses,  syphilitic,  882,  884 
Expectoration.     See  Spulum. 

in  chronic  phthisis,  788 
Exudate,  diphtheritic,  653,  654,   673,  680, 

681 
Eye  symptoms  in  cerebro-spinal  meningitis, 
438 

syphilis  of,  886 
Eyelids,  syphilis  of,  886 
Eyes  and  erysipelas,  468 

in  smallpox,  539 

FACE  in  erysipelas,  465 
Fades  of  cholera,  320 
Fseces  and  dysentery,  364,  377 

and  enteric  fever,  172,  208,  209 

in  yellow  fever,  272 
Faget  on  yellow  fever,  283 
Fagge    on    cerebro-spinal  meningitis,   430, 
434 

on  dysentery,  343 
Faggioli  on  malarial  germs,  69 
Falk  on  tubercle  bacillus,  736 
Falkenstein  and  tuberculosis,  844 
Fallopian  tube,  tuberculosis  of,  819,  830 
Famine  fever,  258 

and  typhus  fever,  235 
Febris  carnis,  184 
Fehleisen  on  erysipelas,  451,  456 
Feletti  on  hsemoproteus,  75 

on  malaria,  81 

on  malarial  germs,  38,  57,  61 
Fermentative  fever,  495,  498,  502 
Fever,  sestivo-autumnal,  99,  106 
diagnosis  of,  141 

African,  17 
and  ague,  17 

aseptic,  498 

autumnal,  17 

Batavia,  17 

black  water,  17 

break-bone,  155 

of  cerebro-spinal  meningitis,  439 

Chagres,  17 

in  chronic  phthisis,  793,  794 

course  of,  in  dengue,  1 60 

in  dysentery,  365 

enteric,  167 
treatment,  207 

famine,  258 

fermentative,  495,  498,  502 

hsematuric,  117 

Hungarian,  17 

infectious,  of  obscure  nature,  945 

of  influenza,  410 

intermittent,  17 
diagnosis,  136 

irritative,  498 

malarial,  with  long  intervals,  120 

malignant  tertian,  107 

Malta,  946 

Mediterranean,  946 

and  meningeal  tuberculosis,  757,  758 

miasmatic,  17 

miliary,  947 

tuberculosis,  753 

Neapolitan,  946 


Fever,  Panama,  17 

periodical,  17 

pernicious  malarial,  113 

of  plague,  395 

quartan,  99,  105 

quotidian  intermittent,  99,  104 

relapsing,  257 

resorption,  498 

rock,  946 

simple  continued,  948 

swamp,  17 

sweating,  947 

tertian,  99 

intermittent,  99 

of  tuberculosis,  846 

typhoid  and  malaria,  133 

typho-malarial,  134 

typhus,  233 

Walcherian,  17 

yellow,  267 
Fibroid  phthisis,  804 

tuberculosis  and  peritonitis,  772 
Fiesinger  on  scarlet  fever,  595 
Fievre    bileuse    melanurique    and    yellow 

fever,  291 
Filehne  on  erysipelas,  455 
Finger  on  dysentery,  342 
Fisher's  Island  epidemic  of  diphtheria,  669 
Fissui'es,  syphilitic,  870 
Fixed  cells  and  tubercles,  748 
Flagella  of  malaria,  21,  27-29,  47 
Flagellation,  76 
Flexner  on  cerebro-spinal  meningitis,  426 

on  diphtheria,  648 

on  enteric  fever,  177 

on  malaria,  73 

on  septicaemia,  498 

on  tuberculosis,  812 
Flick  on  tuberculosis,  742 
Flies  and  enteric  fever,  172 
Flint  on  cholera,  315 

on  dysentery,  358,  359 

on  tuberculosis,  835 
Foetus,  smallpox  in  the,  515 
Follicular  ulceration  in  dysentery,  356 
Food.     See  Diet. 

raw,  and  cholera,  323 
Foster  on  dengue,  160 
Foudrovante  cerebro-spinal  meningitis,  441, 

■  442 
Fowler  on  phthisis,  780 

on  tuberculosis,  738 
Fowler's  solution  in  malarial  anaemia,  153 
Fox  on  chronic  phthisis,  788 
Fragmentation  of  malarial  parasite,  30 
Friinkel  on  enteric  fever,  229,  230 

on  phthisis,  775 

on  tetanus,  937 
Eraser  on  leprosy,  932 
Frerichs  on  malarial  cachexia,  94 
pigment,  73 

on  tuberculosis,  811 
Fresh  air  and  tuberculosis,  842 
Friedlander  on  cerebro-spinal  meningitis,430 

on  tuberculosis,  829 
Fulminant   cerebro-spinal  meningitis,  441, 
442,  445 


INDEX. 


963 


Fiiniit-ation  after  scarlet  fever,  Oil,  612 
tvpliiis  t'ovi'r,  'J'l'J,  '!•'>?> 

local,  of  sypiiilis,  1)09 

ami  pertussis,  I'l'l 

in  sypiiilis,  W,\ 
Furbriii<j;er  on  cholera,  31  o 
Furuncles  in  enteric  fever,  107,  221 
Futcher  on  tuberculosis,  731 

GABBET-FRNST   solution,  735 
(iaflky  un  enteric  fever,  1(J9 
Gairdner  on  tuberculous  peritonitis,  773 
Galen  on  dysentery,  oSl 
on  intermittent  fever,  18 
on  leprosy,  921 
on  the  plague,  391 
on  tuberculosis,  744 
Galtier  on  tubercle  bacillus,  736 
Gallon  on  tuberculosis,  745 
Gangrene  of  lung  in  chronic  phthisis,  800 
Gangrenous  erysipelas,  464 
Gargles  and  syphilis,  912 
Gamier  pill,  900 
Gastralgic  tvpe  of  pernicious  malarial  fever, 

llo 
Gastric  fever,  167 
Gastro-enteritis,  and  meningeal  tuberculosis 

759  _ 
Gastro-intestinal  mucosa,  atrophy  of,  after 
malaria,  131 
system  in  chronic  phthisis,  801 
tract  and  influenza,  419 
in  malai'ia,  88 
Generative  organs,  female,  tuberculosis  of, 

829 
Genital  tuberculosis,  829 
Genito-urinarv  system  in  chronic  plithisis, 
802  " 
svphilis  of,  874 
tuberculosis,  818,  819 
Geographical  distribution  of  enteric  fever, 
168 
position  and  tuberculosis,  732 
Geological  conditions  in  dysentery,  340 
Gerber  on  tuberculosis,  741 
Gerhard  on  meningeal  tuberculosis,  754 
Gerhardt  on  malaria,  34 
Germ  of  dengue,  156,  157 

of  enteric  fever,  171 
Germs.     See  Bacilli. 
Giant  cells  in  leprosv,  924 
of  syphilis,  892' 
and  tubercles,  748 
Gibbs  on  cholera,  306 
Gigantoblasts  in  malarial  cachexia,  94 
Glands,  adrenal,  in  malaria,  89 

bronchial,  in  chronic  phthisis,  785 
cervical,  in  rubella,  643 
lymphatic,  in  i)lague,  394,  395 

and  tuberculosis,  760-764 
mammary,  in  chronic  phthisis,  802 

tubercular,  8^52 
mesenteric,  in  enteric  fever,  175 
in  tuberculous  peritonitis,  773 
parotid,  in  parotiditis,  727 
prostate,  tubei'culosis  of,  826 
salivary,  in  enteric  fever,  178 


Glands,  salivary,  tuberculosis  of,  811 

syphilitic,  treatment  of,  901 
(ilandular  injections  in  dengue,  101 
Glasgow  epidemic  of  scarlet  fever,  587 

tulierculosis  in,  733 
Glass  pock,  56'J 
Glaucoma,  syphilitic,  88S 
Glossitis  variolosa,  532 
Goerbersdorf  and  tuberculosis,  844 
Golgi  on  malaria.  22,  32,  44,  53,  71,  120,  121 

on  phagocytosis  in  malaria,  67,  68 

on  (|uinine  in  malaria,  146 
Gonococcus  in  septicaemia,  497 
Goodhart  on  cerebro-spinal  meningitis,  432 
Gowers  on  cerebro-spinal  meningitis,  430 

on  tuberculosis,  831 
Graham  on  tuberculosis,  746 
Grassi  on  dysentery,  345 

on  h;eraoproteus,  75 

on  malarial  germs,  38,  57,  61 
Graves  on  dysentery,  387 
Gray  powder  in  hereditary  syphilis,  918 
Gregory  on  variola,  517 
Grethe  on  tuberculosis,  821 
Griesinger  on  dysentery,  369 

on  malaria,  70 

on  relapsing  fever,  262 

on  typhus  fever,  243 
Grippe,  399.     See  Influenza. 
Guarnieri  on  malaria,  73,  86 

on  malarial  germs,  31,  61 
Guersant  on  meningeal  tuberculosis,  754 
Guaiacol  and  tuberculosis,  845 
Guinea-pigs,  inoculation  of  tuberculosis,  821 
Guinon  on  erysipelas,  455 
Guiteras  on  influenza,  406 
Gumma,  891 
Gummata  of  bones,  881 

in  brain,  884 

of  eye,  888 

of  liver,  879 

of  lung,  878 

of  nervous  system,  884 

of  orbital  bones,  886 

periosteal,  882 

of  rectum,  880 

syphilitic,  865,  871 

treatment  of,  912 
Gummy  tumor,  891 
Gurgling  in  enteric  fever,  189 
Gurgun  oil  in  leprosy,  930 
Guterbach  on  cholera,  316 
Guttman  on  cholera,  313 
Gymnastics,  pulmonary,  842 

HADLEY  on  fibroid  phthisis,  805 
Hsematozoa  in  birds,  75 
inoculation  of,  75 
of  malaria,  74,  75 
Hsematozoon  falciparum,  36,  47,  51,  68,  69, 
76 
febris  quartanse,  40 

tertiana^,  44 
malarise,  23 
Hien  aturia  in  vesical  tuberculosis,  825 
Htematuric  fever,  117 
Hiemoglobin  in  malaria,  49,  55,  71,  125, 126 


964 


INDEX. 


Hsemoglobinuria,  explanation  of,  in  mala- 
ria, 72 
malarial,  diagnosis,  143 
Hsemoglobinuric  type  of  pernicious  malaria, 

116 
Hsemoproteus,  75 

in  birds,  75 
Haemoptysis  and  chronic  phthisis,  786,  790 

in  miliary  tuberculosis,  753 
Hsemosiderm  in  malarial  blood,  64,  66 
Hsemosporidium  malarise,  24 
Haffkine  on  cholera,  325 
Hair,  falling  of,  in  enteric  fever,  221 

syphilis  of,  866 
Halsted  on  pyaemia,  478 
Hamilton  on  scarlet  fever,  582 
Hammerschlag  on  enteric  fever,  230 

on  tuberculosis,  734 
Hance  on  tuberculosis,  742 
Hanford  on  enteric  fever,  176 
Hanot  on  tuberculosis,  817 
Hansen  on  bacillus  leprae,  924 
Hare  on  enteric  fever,  229 
Headache  in  cerebro-spinal  meningitis,  438 
in  enteric  fever,  179-181,  192,  215 
in  influenza,  414 
in  relapsing  fever,  260,  264 
Healed  tuberculosis,  835 
Health  Board  of  New  York  and  tuberculo- 
sis, 838 
Department  and  diphtheria,  654,  655 
disinfection  methods,  252,  253 
Heart  in  cholera,  311 

diseases  and  chronic  phthisis,  808 

in  diphtheria,  674 

disease  and  tuberculosis,  746 

in  enteric  fever,  177 

failure  in  diphtheria,  679 

in  enteric  fever,  219 
gummata  of,  872 
in  relapsing  fever,  259 
syphilis  of,  872 
in  yellow  fever,  276 
Heat,  application  of,  in  cholera,  331 
Hebra  on  scarlet  fever,  579 
Heitler  on  tuberculosis,  834 
Hektoen  on  tuberculosis,  833 
Hlava  on  dysentery,  346 
Hemiplegia  and  dysentery,  374 

syphilitic,  884 
Hemitritaeus,  18 

Hemorrhage,  capillary,  in  malaria,  73 
in  dengue,  159,  161 
in  enteric  fever,  175 
intestinal,  in  enteric  fever,  189,  218 
and  tuberculosis,  809 
in  vesical  tuberculosis,  825 
Hemorrhagic  enteric  fever,  200 
measles,  631 

pernicious  malaria,  diagnosis,  142 
scarlet  fever,  594 
smallpox,  534 

type  of  pernicious  malarial  fever,  115 
Henderson  on  typhus  fever,  248 
Hendon  outbreak,  587 
Henoch  on  infantile  remittent  fever,  203 
Hepatic  abscess  in  dysentery,  353,  367-369 


Hepatitis  in  malaria,  95,  131 
Hereditary  syphilis,  849,  914 

transmission  of  tuberculosis,  737,  819 
Hernandez  on  tuberculous  pleurisy,  768 
Herpes  in  aestivo-autumnal  fever,  141 
of  cerebro-spinal  meningitis,  439 
in  enteric  fever,  197 
in  influenza,  409 
Hershey  on  scarlet  fever,  578 
Hersman  on  scarlet  fever,  577 
Herter  on  tuberculosis,  832 
Hertz  on  malaria,  97 
Hewetson  on  malaria,  23,  39,  52,  80 
on  malarial  germs,  67 
nephritis,  130 
parasites,  122 
on  tertian  fever,  100 
Heydenreich  on  relapsing  fever,  258 
Hillis  on  leprosy,  929 
Hinemann  on  yellow  fever,  274 
Hippocrates  on  dysentery,  343 
Hirsch  on  cerebro-spinal  meningitis,  429 

on  intermittent  fever,  18 
History  of  cholera,  301 
of  influenza,  399 
of  leprosy,  921 
of  plague,  391 
of  smallpox,  513 
of  typhus  fever,  233 
of  vaccination,  555 
of  vaccinia,  555 
of  varicella,  569 
Hochstetter  on  enteric  fever,  170 
Hofmann  on  diphtheria,  656,  658 
Holiday  on  dengue,  160 

on  leprosy,  930 
Holt  on  cerebro-spinal  meningitis,  436 
House  of  reception  and  antitoxin,  704 
Howard  on  fibroid  phthisis,  804 
Hughes  on  enteric  fever,  230 
Hunger  in  enteric  fever,  181 
Hunger-pest,  258 
Humidity  and  enteric  fever,  168 

influence  on  dengue,  156 
Hunter  on  pyemia,  477 
Huss  on  typhus  fever,  240 
Hutchinson  on  scarlet  fever,  582 
on  tuberculosis,  740 
on  typhus  fever,  240 
Hyaline  bodies  in  malarial  blood,  59 
Hydrargyrism,  905 
Hydrocephalus,  acute,  754 
Hydrochlorate  of  quinine  in  malaria,  149 
Hydrophobia  and  tetanus,  940 
Hydrophobic  tetanus,  939 
Hydropic  bodies  in  malarial  blood,  30,  43 
Hydrotherapy  in  enteric  fever,  222 
Hygiene  of  scarlet  fever,  612 
of  syphilis,  895 
and  tuberculosis,  840 
Hyperesthesia  in  cerebro-spinal  meningitis, 
441 
in  enteric  fever,  194 
Hvperpvrexia  in  cerebro-spinal  meningitis, 
448 
in  enteric  fever,  184 
in  relapsing  fever,  260 


INDEX. 


965 


Hyperpyrexia  in  scarlet  fever,  596 
Hypertropliy  nf  inuininary  gland  in  chronic 
piitliisis,  802 

and  tnhercnlosis,  744 
Hypodermic  stimulation  in  cholera,  ;^32 

"treatment  of  sypiiilis,  904 
Hypodennoclysis,  WIS 
Jlypophospiiites  and  tnberculosis,  845 
Hysteria  in  tetanus,  i'41 

ICTfjRUS  in  jestivo-autumnal  fever,  141 
Ichthyol  in  leprosy,  930 
trauniaticin,  47o 
varnisii,  47:i 
Ileo-c;ecal  tuberculosis,  815 
Ileo-typhus,  167 

Inimerman  on  enteric  fever  relapse,  203 
Immunity  of  measles,  633 
and  relapsing  fever,  259 
from  scarlet  fever,  583 
from  tetanus,  942 
by  vaccinia,  562 
from  yellow  fever,  273 
Immunization   bv  antitoxin   in  diphtheria, 
705,  706 
in  diphtheria,  692,  696 
Incubation  of  enteric  fever,  179 
of  malaria,  81,  96 
of  measles.  627 
of  parotiditis,  726 
of  pertussis,  715 
of  relajjsing  fever,  260 
of  scarlet  fever,  584 
of  smallpox,  522 
of  syphilis,  850,  851,  854 
of  tetanus,  935 
of  typhus  fever,  240 
of  yellow  fever,  281 
India,  cholera  in,  322 
leprosy  in,  921,  923 
Individual  predisposition  and  tuberculosis, 

744 
Induration  of  cliancre,  856 
Infancy  and  cholera,  306 
and  chronic  phthisis,  808 
syphilis  of,  914-919 
and  yellow  fever,  274 
Infantile  remittent  fever,  201 
Infection  of  enteric  fever,  171,  172 
manner  of,  in  malaria,  82 
of  measles,  626 
of  parotiditis,  725 
of  plague,  393 
of  py;emia,  477-482 
septic,  495,  504 
of  smallpox,  515-520 
by  tubercle  bacillus,  737 
tubercular,  bv  direct  extension,  820 
through  blood,  819 
by  inhalation,  741 
by  meat,  743 
by  milk,  743 
through  peritoneum,  S19 
in  tuberculous  peritonitis,  771 
of  yellow  fever,  267 
Infections  combined  with  malaria,  122 
Infectious  double  intermittent  fever,  104 


Infectiousness  of  enteric  fever,  172,  173 

of  scarlet  fever,  584 
luliUration  tubercle,  750 
Inllammalion,  chronic,  in  dysentery,  356 
Inllammatorv  [jrocess  in  tubercles,'751 
lulliiciiza.  399 
and  an;i'mia,  418 

analysis  of  ])rincipal  symptoms,  410 
antipyretics  in,  422 
and  asthenia,  415 
and  bronchitis,  416 
and  broncho-pneumonia,  416 
catarrh  in,  413 
catarrhal  symptoms  of,  408 
and  cerebro-spinal  meningitis,  444 
complications,  415 
convalescence,  423 
cough  in,  413 
crises,  410 

and  croupous  pneumonia,  416 
defervescence,  409 
definition,  399 
in  dengue,  163 
diagnosis,  419 
diet,  421,  422 
duration,  410 
dyspnoea  in,  414 
etiologv,  404 
in  Europe,  401-403,  405 
exciting  cause,  405-407 
fever  of,  410,  411 
general  description,  407 
headache  in,  414 
history,  399 
incubation,  407 
management  of  cases,  421 
mortality  of,  420 
nervous  system  in,  408,  414 
and  neuritis,  415 
and  otitis  media,  417 
pathological  anatomy  of,  407 
and  pleurisy,  417 
prognosis  of,  420 
progress  of,  405 
prophylaxis,  421 

and  pulmonary  consumption,  417 
and  scarlet  fever,  606 
sequelse,  415 

relating  to  the  circulatory  system,  418 
gastro-intestinal  tract,  419 
nervous  system,  419 
respiratory  tract,  416 
skin  in,  413 
special   senses   in,  414 
syrajitoms,  407 
synonyms,  399 
temperature  of,  409-412 
treatment,  421 

in  the  United  States,  403,  404 
Inhalations  in  pertussis,  722 

of  tubercular  infection,  741 
Inherited  syphilis,  914 
Initial  lesion  of  syphilis,  854 
Injections,  fluid,  in  cholera,  328-330 
Inoculations  of  diphtheria,  651 
in  enteric  fever,  229 
in  influenza,  406,  407 


966 


INDEX. 


Inoculations  in  leprosy,  922,  923 

of  malaria,  34,  75 

with  relapsing  fever,  259 

in  scarlet  fever,  586 

and  septicaemia,  499 

in  smallpox,  514 

with  tubercle  bacilli,  738,  807 

of  tuberculosis,  740 
Insanity  in  enteric  fever,  194 
Insolation  and  malaria,  136 
Insomnia  in  enteric  fever,  215 

in  typhus  fever,  248 
Inspection  in  chronic  phthisis,  796 

of  dairies,  839 
Instruments,  intubation,  687 
Intemperance  and  smallpox,  543 

and  typhus  fever,  235 
Intermittent  fever,  17 
blood  in,  125 
in  children,  102 
diagnosis,  136 
prognosis,  144 
quartan,  105 
quinine  in,  151 
quotidian,  99 
tertian,  99 

temperature  in  enteric  fever,  181 

quotidian  fever,  104 
Intestinal  antisepsis  in  enteric  fever,  222 

complications  of  malaria,  134 

fever,  167 

hemorrhage  in  enteric  fever,  189,  218 

perforation  in  dysentery,  366 
in  enteric  fever,  190,  219 

tuberculosis,  secondary,  814 
Intestines  in  cholera,  312 

in  enteric  fever,  173 

in  pyaemia,  484 

in  relapsing  fever,  260 

secondary  tuberculous  ulceration  of,  816 

syphilis  of,  872 

tuberculosis  of,  813 

in  yellow  fever,  277 
Intoxication,  septic,  495,  500,  503 
Intravenous  injection  of  quinine  in  malaria, 

150 
Intubation  in  diphtheria,  686 

and  tracheotomy  compared,  692 
Inunction  in  hereditary  sypliiMs,  917 

local,  of  syphilis.  910 

in  syphilis,  901,  902 
Invasion  of  relapsing  fever,  260 

of  typhus  fever,  240 
Iodide  of  potassium  and  syphilis,  906-909 
Iodine  in  syphilis,  906 
Ipecac  in  dysentery,  379,  380 
Iris,  syphilis  of,  887 
Iritis,  syphilitic,  887 
Iron  in  syphilis,  901 

in  tuberculosis,  846 
Irrigation  and  diphtheria,  683,  684 
Italian  fever,  399 
Itching  in  smallpox,  530,  552 
Ivory  points  for  vaccination,  564 

JACCOUD  on  enteric  fever,  207 
Jackson  on  yellow  fever,  273 


Jamieson  and  scarlet  fever,  586 
Jani  on  tuberculosis,  819 
Janowsky  on  enteric  fever,  170 
Jaundice,  black,  17 

in  enteric  fever,  192 

in  Weil's  disease,  945,  946 
Jenner  on  smallpox,  514 

on  typhus  fever,  241,  242 

on  vaccinia,  555,  556,  558,  563 
Jersin  on  diphtheria,  648 
Jesuits'  powder  in  malaria,  146 
Johns  Hopkins  Hospital  and  tuberculosis, 

743 
Johnston  on  pertussis,  720 
Joint  lesions  in  dysentery,  372 
Joints  in  cerebro-spinal  meningitis,  440 

in  diphtheria,  679 

and  erysipelas,  469 

in  pytemia,  486,  487 

syphilis  of,  883 
Jones  on  malarial  haematuria,  117 

on  yellow  fever,  283 
Jiirgensen  on  miliary  tuberculosis,  754 
Juvenile  asylum  and  antitoxin,  704 

KALINDERO  on  malarial  blood,  125 
Kaposi  on  scarlet  fever,  583 
Karlinski  on  enteric  fever,  170 
Kartulis  on  dysentery,  345,  346 
Karyokinesis  in  malarial  germs,  61 
Keen  on  enteric  fever,  197 
Kelly  on  tuberculosis,  829 

on  tuberculous  peritonitis,  771 
Kelsch  on  noalarial  blood,  125 

kidneys,  87 
Kidney,  abscess  in  pyaemia,  488 
Kidneys  in  ciiolera,  312 

of  chronic  malaria,  94 

in  diphtheria,  674 

in  enteric  fever,  177 

in  malai'ia,  87 

in  relapsing  fever,  259 

syphilis  of,  876 

tuberculosis  of,  821 

in  typhus  fever,  240 

in  yellow  fever,  279 
Kiener  on  malarial  kidneys,  87 
Kine-pox,  555 
Kirchner  on  cholera,  313 
Kirkebride  on  blood,  125 
Kitasato  on  enteric  fever,  229 

on  tetanus,  935 
Klebs  on  cholera,  313 

on  pyaemia,  477 

on  scai'let  fever,  590 

on  septicEcmia,  496 

on  tuberculosis,  818 
Klebs'  bacillus,  647 
Klein  on  cholera,  306 

on  scarlet  fever,  586,  587 
Klemperer  on  enteric  fever,  230 
Knockel  Koorts,  155 
Knopf  on  tuberculosis,  844 
Knox  on  dysentery,  389 
Koch  on  cholera,  320 

comma  bacillus,  301,  305-311 

on  dysentery,  345 


lyDL'X. 


1J67 


Koch  on  erysipelas,  451 

on  relapsing  fever,  259 

tuberele  bacillus,  7'.V6 

on  typiioid  bacillus,  169 
Kuplik  on  tiibeicnlar  testis,  828 
Kost  on  tuberculous  (lericarditis,  770 
Kostenitsch  on  tubercle,  749 
Kouniyss  in  typhus  fever,  "254 
Kruse  on  ha'nioproteus,  75 
Krzyincki  on  tuberculosis,  826,  827 
Kuptl'er's  cells  in  malarial  liver,  91,  92 

LACHRYMAL  a()paratus,  syphilis  of,  886 
Laennec  and  tuberculosis,  741,  835 
Lafleur  on  auKvbic  dysentery,  352-354,  357 

on  dysentery,  346,  347 
Lanibel  on  dysentery,  344 
Lanioureux,  900 

Lancisi  on  intermittent  fever,  18,  19 
Landouzy  on  tuberculous  pleurisy,  765 
Langhans'  giant  cell,  749 
Lannois  on  enteric  fevei',  177 
La  Roche  on  yellow  fever,  273 
Laryngeal  diphtheria,  677 
treatment,  685 
under  antitoxin  treatment,  697 

symptoms  of  chronic  phthisis,  786 
Laryngitis  in  enteric  fever,  187 

and  erysipelas,  469 

membranous,  707 
Larynx  and  erysipelas,  466 

in  smallpox,  532 
Latency  of  tuberculosis,  738 
Latent  enteric  fever,  199 
Laveran  on  crescents,  57 

on  flagella,  29 

on  malarial  germs,  33 
pigment,  20,  21 

on  quinine  in  malaria,  146 
Lebert  on  relapsing  fever,  264 
Lebut  on  typhus  fever,  240 
Leeches  and  malarial  germs,  31 
Leiter's  coils  in  enteric  fever,  220 
Leloir  on  leprosy,  921-923 
Lemoine  on  malarial  urine,  123 
Lenticular  papules,  syphilitic,  860 
Lepine  on  malarial  urine,  124 
Lepromes,  922 
Leprosy,  921 

ansesthetic,  922,  927 

detinition,  921 

diagnosis,  928 

distribution,  921 

etiology,  922 

history,  921 

invasion,  928 

legislation  against,  933 

macular,  922 

mixed,  922,  928 

paralyses,  928 

pathology,  924 

predisposition,  923 

prognosis,  929 

prophylaxis,  932 

public  protection  from,  933 

serum  treatment,  932 

symjJtomSj  925 


Leprosv,  svnonvms,  921 

and  syphilis,* 929 

treatment,  929 

tubercular,  922,  926 

varieties,  922 
Leptomeningitis,  425 
Lesions  of  chronic  phthisis,  780-787 
Letorey  on  tuberculosis,  813 
Leucocytes,  pigmented,  in  malaria,  68 

and  tuberculosis,  748 
Leucocytosis  absent  from  enteric-  fever,  186 

in  ajstivo-autunnial  fever,  126 

in  cerebro-spinal  meningitis,  440 

and  miliary  tubercidosis,  753 

in  yellow  fever,  279,  280 
Levy  on  enteric  fever,  230 

on  typhus  fever,  238 
Lichen  planus  and  leprosy,  929 
Lips,  tuberculosis  of,  810 
Litten  on  meningeal  tuberculosis,  758 

on  relapsing  fever,  259 

on  tuberculosis,  813 
Liver  abscess  in  dysentery,  353,  367-369 
in  pyaemia,  483 

in  cholera,  312 

in  enteric  fever,  176 

in  malaria,  86 

of  malarial  cachexia,  90 

in  relapsing  fever,  260 

syphilis  of,  879 

tuberculosis  of,  816 

in  typhus  fever,  239 

in  yellow  fever,  277 
Lloyd  on  tuberculosis,  832 
Local  conditions  and  tuberculosis,  745 
Locality  in  scarlet  fever,  580 

and  tuberculosis,  744 
Lockjaw,  938 
Loffler  bacillus,  647 
characteristics,  649 
gi-owth  in  blood  serum,  649 
in  broth,  650 
Loffler's  blood  serum  mixture,  651 
Lombard  on  tuberculosis,  818 
Lonaconing,   cerebro-spinal    meningitis    in, 

427-429 
London  Fever  Hospital  and  scarlet  fever, 
579 
and  typhus  fever,  235,  237 
Loorais  on  relapsing  fever,  258 

H.  P.,  on  tuberculosis,  763 
Lord  on  tuberculosis,  810 
Losch  on  dysentery,  344,  345 
Louis  XV.  and  smallpox,  517 
Lung,  or  lungs,  abscess  of,  in  dysentery,  354 

in  cholera,  312 

chronic  ulcerative  tuberculosis  of,  780 

in  enteric  fever,  178 

gummata,  878 

in  malaria,  86 

in  phthisis,  776 

syphilis  of,  878 

tuberculosis  of,  775 

in  yellow  fever,  276 
Lustgarten  on  syphilis,  852 
Lymph,  bovine,  549 

glands  in  diphtheria,  679 


968 


INDEX. 


Lymph  glands,  tuberculosis  of,  760 

of  vaccinia,  559 
Lymphadenitis,  generalized  tuberculous,  761 
Lymphangitis  and  erysipelas,  470 
Lymphatic  glands  in  erysipelas,  466 
in  plague,  394,  395 
in  rubella,  642 
vessels  in  erysipelas,  457-459 
Lymphatics  and  pysemia,  481 

McLaughlin  on  dengue,  156,  157 
Maclean  on  dysentery,  371,  379 
Macrophages  in  malarial  spleen,  85 
Macules,  syphilitic,  859 
Maillot  on  malaria,  97 
Mails  and  cholera,  325 
Malaria,  17 

adrenal  glands  in, 89 

in  Africa,  77 

age,  81 

and  altitude,  81 

amyloid  degeneration  after,  131 

arsenic  in,  153 

in  Asia,  77 

bone  marrow  in,  89 

brain  in,  83 

and  chronic  phthisis,  786 

and  climate,  79 

definition,  17 

in  dengue,  164 

diagnosis  of,  136 

diet,  145 

distribution,  77,  79 

and  drainage,  79 

and  drinking  water,  81 

and  dysentery,  143,  370 

etiology,  77 

in  Europe,  77 

and  exanthemata,  135 

gastro-intestinal  tract  in,  88 

hepatitis  in,  95 

history,  17 

incubation  of,  81,  96 

influence  of  soil,  78 

inoculation,  34,  75 

and  insolation,  136 

intestinal  complications,  134 

kidneys  in,  87 

liver  in,  86 

lungs  in,  86 

manner  of  infection,  82 

mental  diseases  after,  132 

method  of  blood  examination,  137 

methylene  blue  in,  152 

and  moisture,  79 

in  New  England,  79 

nomenclature,  23 

parasitology,  20 

pathogenesis,  69 

pathological  anatomy  of,  83 

pernicious,  diagnosis  of,  142 

phenocoll  in,  153 

physical  geography  of,  78 

and  pleurisy,  133,  143 

and  pneumonia,  132,  143 

post-operative,  135 

post-partum,  135 


Malaria,  post-partum,  diagnosis  of,  143 
predisposing  causes,  82 
prognosis,  144 
prophylaxis,  154 
quinine  in,  145 
and  race,  81 
relapses  in,  128 
and  season,  80 
and  soil  cultivation,  79 
spleen  in,  85 
summary  of  etiology,  83 
symptoms,  96 
synonyms,  17 
tables  of  seasons,  80 
treatment  of,  145 
and  tuberculosis,  135 
types  of  fever,  98 
with  typhoid  fever,  133 
in  the  United  States,  77 
and  variola,  135 
and  vegetation,  78 
virulence,  70 
and  winds,  80 
Malarial    cachexia,  amyloid    degeneration 
in,  95 

anaemia  in,  93,  94 

blood  in,  93,  129 

bone  marrow  in,  93 

chronic,  89,  128 

diagnosis  of,  143 

kidnevs  in,  94 

liver  of,  90 

prognosis,  144 

spleen  of,  89 

treatment,  154 
cirrhosis,  95,  131 
coma,  114 
complications,  127 
fever,  17 

anaemia  in,  125 

blood  in,  125 

and  enteric  fever,  205 

pernicious,  113 

types  of,  98 

and  yellow  fever,  288-291 
fevers,  113 

algid  type,  115 

bilious  type,  115 

blood  in,  119 

cardialgic  type,  1 15 

cerebral  symptoms,  115 

choleriforra  type,  116 

comatose  type,  114 

diagnosis,  142 

dyspnoeic  type,  116 

gastralgic  type,  115 

hsemoglobinuric  type,  116 

hemorrhagic  type,  115 

pneumonic  type,  116 

prognosis,  144 

sudoriferous  type,  115 
hsemoglobinuria,  diagnosis,  143 

prognosis,  144 

quinine  in,  152 
hepatitis,  131 
nephritis,  130 
paralysis,  131 


f\i)i:\'. 


969 


Malarial    parasiti-s,    with    combined    iiil'ei'- 
tioiis.  I'il' 
(ietceiieratii)ii  of,  oO 
ditleieiitial  diagnosis,  58 
intimate  structure,  fiO 
metliods  ol'  invest iii'ation,  24 
morplu)lo,<;v  and  biology,  24 
varieties,  58 
zoological  position.  23 
pisrment,  19-22,  25,  Go 
seqiiehe,  127 
nrine,  toxicity  of,  128 
Malijjnant  forms  of  scarlet  fever,  593 
smallpox,  534 
tertian  fever,  107 
Malta  fever,  94(5 
etiology,  946 

pathological  anatomy,  947 
prognosis,  947 
symptoms,  947 
synonyms,  946 
treatment,  947 
Mammary  gland,  tuberculosis  of,  832 
Manchot  on  enteric  fever,  229 
Manfredi  on  erysipelas,  454 
Mannaberg  on  inalaria,  25,  29,  38,  57,  63 

on  quinine  in  malaria,  146,  147 
Manson  on  crescents,  57 

on  malarial  flagellpe,  29 
Maragliano  on  serum-therapy,  848 
Marchiafava  on  malaria,  21,  22,  32,  35,  37, 
47,  51,  53,  64,  73,  84 
on  quinine  in  malaria,  147 
Marfan  on  scrofula,  761 

on  tuberculosis,  813 
Marino  on  malaria,  81,  82 
Marmorek  on  erysipelas  antitoxin,  472 
Marriage  and  syphilis.  919 

and  tuberculosis,  836 
Marson  on  vaccination,  565 
Martialis  on  dengue,  160 
Masern,  625 

Massuriany  on  intermittent  fever,  102 
Materia  peccans  in  malaria,  70,  71 
Measles,  625 
afebrilis,  630 
age,  625 

anomalous  forms,  630 
and  broncho-pneumonia,  632 
catarrhal  symptoms,  629 
complications,  632 
definition,  625 
desquamation,  630 
diagnosis,  634 

from  typhus,  250 
diet,  636 

and  drug  eruptions,  635 
in  enteric  fever,  178,  198 
eruption,  628 
etiology,  625 
hemorrhagic,  631 
immunity,  633 
incubation,  627 
invasion,  627 
isolation,  636 
pathology  of,  626 
and  pertussis,  718 


Measles,  prognosis,  635 
recurrence,  633 
relapse,  633 
and  rubella,  634 
and  scarlet  fever,  634,  644 
season,  626 
sequelic,  632 
sex,  625 
sine  catarrho,  630 

eruptione,  630 
symptoms,  627 
synonyms,  625 
temperature  in,  628,637 
treatment,  635 

of  the  attack,  636 
and  typhoid  fever,  634 
and  typhus  fever,  634 
urine  in,  630 
and  variola,  634 
Meat  and  tubercular  infection,  743 
Meckel  on  malarial  pigment,  19,  20 
Medicinal  treatment  of  dengue,  164 

of  dysentery,  378 
Mediterranean  fever,  946 
Melansemia  in  chronic  malaria,  91 

in  malaria,  71 
Melanosis  in  chronic  malaria,  91 
Membranes,  serous,  tuberculosis  of,  764 
Membranous  laryngitis,  707 
Meningeal  tuberculosis,  755 
diagnosis,  759 
etiology,  755 
and  gastro-enteritis,  759 
and  meningitis,  759 
and  otitis  media,  759 
pathological  anatomy,  755 
prognosis,  760 
symptoms,  756 
and  typhoid  fever,  759 
Meninges  in  cerebro-spinal  meningitis,  433- 
435 
tuberculosis  of,  831 
of  yellow  fever,  276 
M^ningite  foudroyante,  441 
Meningitis,  acute  tuberculous,  754 
basilar,  in  chronic  phthisis,  802 
cerebral,  diagnosis  from  typhus,  250 
cerebro-spinal,  425 

diagnosis  from  typhus,  251 
syphilitic,  884 

tubercular.     See  Meningeal  Tuberculosis. 
Meningo-encephalitis,  tubercular,  831 
Mental  diseases  after  malaria,  132 

symptoms  of  chronic  phthisis,  802 
Mercatus  on  intermittent  fever,  18 
Merck  on  tetanus,  943 
Mercurv  fumigation  in  syphilis,  903 

and  syphilis',  899-908  " 
Mesenteric  glands  in  enteric  fever,  175 
tubercular,  764 
in  tuberculous  peritonitis,  773 
Metchnikoft'  on  erysipelas,  458 

on  malarial  germs,  65,  69 
Meteorological  influences  in  dysentery,  341 
Methylene  blue  in  malaria,  152 
Metz,  dysentery  in,  343 
Mexico  and  tuberculosis,  843 


970 


INDEX. 


Miasm,  17 

Miasmatic  fever,  17 

Micrococci  in  erysipelas,  451-455,  458 

in  septicaemin,  497,  498 
Micrococcus   of  cerebro-spinal   meningitis, 
425' 
lanceolatus  encapsnlatus,  425-427 
in  pysemia,  478 
in  septicaemia,  497 
Microorganism.     See  Germs. 

in  scarlet  fever,  585 
Microscopical    examination    of    phthisical 

sputum,  789 
Microsporon  septicum,  496 
Middle  Ages,  smallpox  in,  514 
Miliary  eruption   in   tuberculous  pleurisv, 
767 
fever,  947 

definition,  947 
etiology,  948 
prognosis,  948 
symptoms,  948 
treatment,  948 
papules,  syphilitic,  860 
tubercles,  781 
tuberculosis,  751 
diagnosis,  758,  754 
and  enteric  fever,  206 
local  form,  753 
symptoms,  752 
and  typhoid  fever,  753 
Milk  and  enteric  fever,  211,  212,  226 
tubercular  infection  by,  743 
and  tuberculosis,  841 
Millbank  Prison,  dysentery  in,  343 
Milles  on  cholera,  315 
Minor  on  yellow  fever,  268 
Miquel  on  scarlet  fever,  583 
Mitchel  on  dysenteric  paralysis,  373,  374 
Mitchell  on  intermittent  fever,  19 

on  yellow  fever,  298 
Mixed  infections,  132 

and  malaria,  diagnosis  of,  143 
treatment,  908 
Moisture  and  malaria,  79 

and  yellow  fever,  270 
Molluscum  fibrosurn  and  leprosy,  929 
Monti  on  malarial  fever,  53,  84,  85 

on  malarial  germs,  31,  68 
Montreal  General  Hospital  and  tuberculo- 
sis, 834 
Moore  on  typhus  fever,  239 
Morbid  anatomv  of  septicaemia,  500 
Morbilli,  625 

Morphcea  and  leprosy,  929 
Mortal  it  V  of  cholera,  303 
of  diphtheria,  696-700 
of  dysentery,  375 
of  enteric  fever,  207,  229 
of  influenza,  420 
of  measles,  635 
of  pertussis,  720 
of  plague,  397 
of  relapsing  fever,  263 
of  smallpox,  543 
of  tuberculosis,  834 
of  yellow  fever,  270,  273,  293 


Morton  on  tuberculosis,  741 
Morvan's  disease,  929 
Mosny  on  enteric  fever,  210 
Mosquitoes  and  malarial  germs,  29 
Moss  on  enteric  fever  relapse,  204 
Motschutkoffsky  on  relapsing  fever,  259 
Mouth,  syphilis  of,  868 
Mucous  membranes  in  diphtheria,  674 
and  erysipelas,  465 
genital,  and  erysipelas,  467 
in  scarlet  fever,  588 
in  smallpox,  521,  528 
patches,  869_,  870 
Multiple  neuritis  in  enteric  fever,  194 
Mumps.     See  Parotiditis. 
Munich  Pathological   Institute  and  tuber- 
culosis, 814 
Municipal   Hospital   of  Philadelphia   and 

smallpox,  556 
Murchison  on  enteric  fever,  172 
eruption,  196 
relapse,  203,  204 
on  relapsing  fever,  260-262 
on  scarlet  fever,  580 
on  typhus  fever,  284,  236,  237,  238,  242 
Muscles  in  cholera,  317 

in  tetanus,  938 
Muscular  cramps  in  cholera,  317,  318 
pains  indengue,  160 
weakness  in  enteric  fever,  193 
Musser  on  dysentery,  346 

on  tuberculous  pericarditis,  769 
Myocarditis  in  enteric  fever,  186 

syphilitic,  872 
Myoidema,  797 

NAILS,  syphilis  of,  867 
Nausea  in  enteric  fever,  188 
Neapolitan  fever,  946 
Neck,  tuberculous  glands  of,  762 
Necrosis,  dysenteric,  351 

syphilitic,  882 
Negroes  and  yellow  fever,  293 
Neisser  and  bacillus  leprae,  924 
Nephritis,  acute,  in  malaria,  123 
malarial,  130 
scarlatinal,  601-603 
in  scarlet  fevei",  589 
syphilitic,  877 
tubercular,  823 
in  yellow  fever,  290 
Nephro-typhus,  199 
Nerves,  peripheral,  syphilis  of,  885 

syphilis  of,  884 
Nervous  symptoms  of  meningeal  tubercu- 
losis, 757 
system  in  chronic  phthisis,  802 
in  diphtheria,  675,  678 
in  enteric  fever,  179,  192 
and  influenza,  408,  414,  419 
and  scarlet  fever,  597 
and  smallpox,  551 
syphilis  of,  883 
and  tetanus,  937 
in  typhus  fever,  248 
in  yellow  fever,  287 
Neuritis  in  chronic  phthisis,  802 


INDEX. 


071 


Neuritis  in  enteric  fever,  194 
and  int]iien/.a,  415 
optif,  sypiiilitii-,  N89 
jieriplieral.  in  enteric  fever,  222 
after  malaria.  132 
New-born,  erysipelas  of.  407 
New  York  Jioanl  of  Health   and   tubercu- 
losis, 838 
Health  Department  and  diphtheria,  066 
Hospital   for  Contagious   Diseases  and 
diphtheria,  084 
Nicolaier  on  tetanus,  9.>o 
Niemeyer  on  chronic  phthisis.  791 
Nikiforoff  on  relapsing  fever,  259 
Nikiforofl's  method  of  blood  examination, 

139 
Nitro-glycerin  in  cholera,  333 
Nodes,  syphilitic,  882 
Noma  and  enteric  fever,  198 
Northru|)  on  tubercular  bronchial  glands, 

763 
Nose  and  erysipelas,  466 
Nothniigel  on  cholera,  329 
Nununular  sputum,  788 
Nursery  and   Child's   Ho.spital   and   diph- 
theria, 703 
Nurses  and  tuberculosis,  742 
Nuttall  on  tubercle  bacillus,  737 
on  tuberculosis,  837 

OAKES  on  dysentery,  343 
Occupation  and  malaria,  81 
and  scarlet  fever,  581 
and  tuberculosis,  745 
Odor  of  yellow  fever,  284 
©"Dwyer  on  diphtheria  intubation,  687,  691 
(Esophagus,  perforation  of,  in  tuberculosis, 
763 
syphilis  of,  871 
tuberculosis  of,  812 
Ointments  in  ervsipehis,  473 

in  syphilis.  910,  911 
Old  age  and  tuberculosis,  809 
Omental  tumoi"s  in  tuberculous  peritonitb, 

Onychia,  syphilitic,  867 
Ophthalmia  in  relapsing  fever,  263 
Opisthotonos  in  tetanus,  938 
Opium  in  dysentery,  380,  381 
Optic  neuritis,  syphilitic,  889 
Orbit,  syphilis  of,  886 
Orchitis  in  parotiditis,  728,  729 

syphilitic,  876 
Organisms  of  malaria,  35,  36 
Orth  on  pysemia,  483 

on  tubercular  prostate,  826 
0.sler  on  cerebro-spinal  meningitis,  442 

on  dysentery.  346,  371 

on  enteric  fever,  210,  229 

on  pyfemia,  490 
Osseous  system  in  enteric  fever,  197 
Osteomyelitis  in  pyaemia,  489 

and  septic  infection,  504,  505 
Osteo-jieriostitis,  881 
Os  uteri,  syphilis  of,  876 
Otitis  and  cerebro-spinal  meningitis,  432 

and  scarlet  fever,  598,  619 


Otitis,  syphilitic,  890 

media  in  enteric  fever,  188 

and  inliuenza.  417 

and  meningeal  tuberculosis,  759 
Ovary,  tuberculosis  of,  831 
Overcrowding  in  ty[)hus  fever,  235 
Ovum  and  tuberculosis,  739 
Oysters  and  enteric  tever,  172 
Ozjena,  .syphilitic,  913 

PAGET  on  scarlet  fever,  585 
on  tuberculosis,  810 
Pain,  abdominal,  in  enteric  fever,  189 

in  chronic  phthisis,  793 

relief  of,  in  cholera,  331 

in  smallpox,  524 
Paine  on  dengue,  158 
Painter  on  diphtheria,  669 
Palate,  syphilis  of,  869 

tuberculosis  of,  211 
Palpation  in  chronic  phthisis,  796 
Paludism.     See  Maloria. 
Pancreas  in  enteric  fever,  178 

tuberculosis  of,  817 
Papules,  moist  syphilitic,  862 

in  smallpox,  520,  521 

syphilitic,  860 
Paquin  on  serum-therapy,  84S 
Paralyses,  dysenteric,  373 
Paralysis  in  cerebro-spinal  meningitis,  442 

in  diphtheria,  679 

in  leprosy,  928 

malarial,  131 

and  meningeal  tuberculosis,  758 

scarlatinal,  603 

syphilitic,  885 
Parasite,  Eestivo-autumnal,  35,  36,  47 

of  sestivo-autumnal  fever,  76 

of  dengue,  156,  157 

of  malaria,  23,  24 

of  quartan  fever,  76 

of  tertian  fever,  76 
Parasites,  differential  diagnosis,  58 

of  malaria.  classificatif)n,  35,  36 
intimate  structure,  60 
and  quinine,  146 
varieties,  58 

malarial,  in  combined  infections,  122 
localization  of,  72 

quartan,  35,  36,  40 

tertian,  35,  36,  44 
Parasitology  of  malaria,  20 
Paris  hospitals  and  tuberculosis.  742 

Morgue  and  tuberculosis,  834 
Parke  on  typhus  fever,  248 
Parkes  on  yellow  fever,  271 
Paronychia,  syphilitic,  868 
Parotiditis,  725 

age,  725 

complications,  729 

definition,  725 

diagnosis,  729 

in  enteric  fever,  221 

etiology,  725 

incubation,  726 

initial  stage,  720 

orchitis  in,  728,  729 


972 


INDEX. 


Parotiditis,  pathological  anatomy,  726 
pathology,  726 
prognosis,  730 
prophyhixis,  730 
recurrence,  729 
relapse,  729 

in  relapsing  fever,  263,  265 
season,  725 
sequelae,  729 
stage  of  swelling,  727 
symptoms,  726 
synonyms,  725 
treatment,  730 
Parotitis.     See  Parotiditis. 
Paroxysm  of  sestivo-autumnal  fever,  107 
of  pei'tussis,  716,  717 
of  tertian  fever,  100 
Parry  on  relapsing  fever,  258 
Pasteur  on  cholera,  307 

on  septicaemia,  497 
Pathogenesis  of  malaria,  69 
Pathological   anatomy   of   acute   cataiThal 
dysentery,  347 
of  amoebic  dysentery,  351 
of  cerebro-spinal  meningitis,  433 
of  cholera,  311 
of  chronic  phthisis,  780 
of  dengue,  158 
of  diphtheria,  673 
of  diphtheritic  dysentery,  349 
of  enteric  fever,  173 
of  ei'ysipelas,  456 
of  influenza,  407 
of  malaria,  83 
of  Malta  fever,  947 
of  meningeal  tuberculosis,  755 
of  parotiditis,  726 
of  plague.  394 
of  pyajmia,  482 
of  relapsing  fever,  259 
of  scarlet  fever,  587 
of  secondary  dysentery,  355 
of  smallpox,  520 
of  syphilis,  890 
of  tetanus,  937 
of  typhus  fever,  239 
of  vaccinia,  559 
of  varicella,  571 
of  Weil's  disease,  945 
of  yellow  fever,  275 
Pathology  of  erysipelas,  451 
of  leprosy,  924 
of  measles,  626 
of  parotiditis,  726 
of  pertussis,  714 
of  phthisis,  775 
of  rubella,  640 
Peiper  on  enteric  fever,  230 
Pellarin  on  malarial  kidneys,  87 
Pelvic  organs  in  cholei'a,  314 
Pemberton  on  tuberculosis,  818 
Pemphigus  gangrenosa,  57 

and  leprosy,  929 
Penis,  syphilis  of,  874 
Pensuti  on  malarial  urine,  124 
Penzolt  on  tuberculosis,  812 
Percussion  in  chronic  phthisis,  797 


Perforation  in  enteric  fever,  175 
intestinal  and  dysentery,  366 
of  intestine  in  enteric  fever,  190,  219 
of  lymph  glands  in  tuberculosis,  763 
Pericarditis,  acute  tuberculous,  769 
chronic  tuberculous,  769 
in  enteric  fever,  186 
tuberculous,  769 
diagnosis,  770 
Pericardium,  tubercular,  769 

in  yellow  fever,  276 
Periodical  fever,  17 
Periodicit}'  of  malaria,  70 

of  scarlet  fever,  577 
Periostitis,  syphilitic,  881,  882 
Peripheral  nerves,  syphilis  of,  885 

neuritis  after  malaria,  132 
Peritoneum  in  cholera,  312 

tubercular  infection  through,  819 
tuberculosis  of,  770 
Peritonitis,  acute  tuberculous,  754 
and  dysentery,  366 
in  enteric  fever,  191,  206,  218 
and  scarlet  fever,  600 
tuberculous.     See  Tuberculous  Pei-itonitis. 
Pernicious  ansemia  and  influenza,  418 
Pertussis,  713 
age,  713 

catarrhal  stage,  716 
complications,  717 
definition,  713 
diagnosis,  719 
and  enteric  fever,  198 
etiology,  713 
general  treatment,  723 
hygiene,  721 
incubation,  715 
local  treatment,  721 
mortality,  720 
paroxysmal  stage,  716 
pathology,  714 
prognosis,  720 
prophylaxis,  720 
recurrence  of,  719 
relapse,  719 
and  scarlet  fever,  600 
sequelse,  718 
sex  and,  713 
stage  of  decline,  717 
symptoms,  715 
synonyms,  713 
treatment,  720 
Peruvian  bark  in  malaiia,  146 
Pest,  391 
Pestilentia,  391 
I  Petechia?  in  enteric  fever,  197 

in  relapsing  fever,  260 
I  Petechial  typhus,  168 
Pettenkofer  on  enteric  fever,  172 
Pever's  patches  in  enteric  fever,  174 
Pfeiffer  on  influenza,  406,  407 
Phagocytes  in  malaria,  65,  67,  69,  73 
Piiagocytosis,  76 

in  sestivo-autumnal  fever,  120 
in  erysipelas,  458 
in  malaria,  43 
Pharyngeal  diphtheria,  675 


l\J)j:x. 


973 


Pharynx  and  erysipelas,  466 
in  smallpox,  ;").'{2 
syphilis  of,  <S()'.) 
tubeiviilosis  of,  STJ 
Phenocoll  in  malaria,  lA.'i 
Plula(k'i[iiiia,  tiibcroiilosis  in,  742 
l'iiK'l)itis  in  |iy:i'mia,  479,  487 
Phlegmonous  erysipelas,  404 
Photophobia  in  eerebro-spinal   meningitis, 

441 
Phthisis,  775 

acute  pneumonie,  775 

diagnosis,  77S 
bronoho-pnenmonic  form,  777,  779 
calculeuse,  790 
chronic,  780 

and  an;emia,  786 

auscultation  in,  797 

blood  in,  801 

bronciii  in,  784 

bronchial  glands  in,  785 

and  bronchitis,  786 

and  cardio-vascnlar  system,  801 

cavities  in,  782,  798 

complications  of,  799 

and  cougli,  787 

and  cutaneous  system,  803 

and  cyanosis,  793 

diagnosis,  803 

distribution  of  lesion,  780 

and  dyspepsia,  786 

emaciation  in,  795 

emphysema  in,  800 

and  eruptive  fevers,  807 

and  erysipelas,  807 

and  expectoration,  788 

fever  in,  793,  794 

gangrene  of  lung  in,  800 

and  gastro-intestinal  system,  801 

general  symptoms,  793 

and  genito-urinary  system,  802 

and  hjemoptysis,  786 

and  heart  disease,  808 

and  infancy,  808 

inspection  in,  796 

and  laryngeal  symptoms,  786 

and  lobar  pneumonia,  807 

local  symptoms,  787 

and  malarial  fever,  786 

mental  symptoms,  802 

mode  of  onset,  785 

and  nervous  system,  802 

palpation  in,  796 

pathological  anatomy,  780 

percussion  in,  797 

physical  signs  of,  796 

pleura  in,  784 

and  pleurisy,  786 

pneumonia  in,  781,  800 

pneumothorax  in,  800 

pulse  in,  795 

rales  in,  798 

sweats  in,  795 

symptoms,  785 
confirmata,  787 
desperata,  787 
fibroid,  804,  806 


Phtliisis,  fil)roi(i,  clinical  liistory,  805 
morbid  anatomy,  804 

florida,  775,  779 

incipii'us,  7X7 

and  iullucn/.a,  417,  420 

morbid  anatomy,  775 

palliology,  775 

pneinnonic,  course,  779 
diagnosis,  775,  776 

puimonum,  780 

renum.     Hee  Tuherciilosia  of  tin:  Kidneys. 

symptoms,  777 

of  pneumonic  form,  777 

synonyms,  775 
Physical  geography  of  malaria,  78 

signs  of  chronic  phthisis,  796 
Physiognomy  of  enteric  fever,  197 
Pigment  in  chronic  malaria,  91 

malarial,  19-22,  25,  28,  41,  44,  49,  55,  63, 
m,  67 
Pillet  on  tuberculosis,  817 
Plague,  391 

buboes  in,  395,  396 

convalescen(!e,  396 

definition,  391 

diagnosis,  396 

etiology,  392 

fever  of,  395 

history  of,  391 

infection  of,  393 

pathological  anatomy,  394 

prognosis,  397 

symptoms,  394 

treatment,  397 
Planer  on  malarial  pigment,  20 
Plasmodium,  22,  23,  26 
Plate  of  amoebae  coli,  348 

of  dysenteric  colon,  348 
Plehn  on  malaria,  40,  96 
Pleura  in  chronic  phthisis,  784 

tuberculosis  of,  764 
Pleurisy,  acute  tuberculous,  754,  766 
secondary,  766 
suppurative,  767 

chronic  adhesive  tuberculous,  767 

in  chronic  phthisis,  786 

in  enteric  fever,  187 

and  influenza,  415,  417 

with  malaria,  133,  143 

in  scarlet  fever,  599 

subacute  tuberculous,  767 
Pleuro-typhus,  199 
Pneumonia,  caseous.     See  Phthiais. 

in  eerebro-spinal  meningitis,  442 

in  chronic  phthisis,  781,  800 

complicating  malaria,  132 

croupous  in  enteric  fever,  187 

diagnosis  from  typhus,  251 

in  diphtheria,  679 

and  dysentery,  369 

and  enteric  fever,  178 

and  erysipelas,  469 

and  influenza,  415,  416 

loljar,  and  pulmonary  tuberculosis,  807 

and  malaria,  143 

and  meningeal  tuberculosis,  759 

in  relapsing  fever,  262 


974 


INDEX. 


Pneumonia  and  scarlet  fever,  599 

scrofulous.     See  Phthisis. 

white,  879 
Pneumonic  jDhthisis,  775 

type  of  pernicious  malaria,  116 
Pneumococcus    and    cerebro-spinal    menin- 
gitis, 426,  430 

lanceolatus,  430,  431 
Pneumothorax  in  chronic  phthisis,  800 
Pneumo-tvphus,  199 
Pock,  521^  560 
Pocken,  513 
Poggio  on  dengue,  158 
Ponfick  on  pernicious  malaria,  117 
Porcher  on  dengue,  162 

on  yellow  fever,  295,  296 
Post-febrile  insanity  in  enteric  fever,  194 
Post-malarial  anaemia,  103 
diagnosis,  143 
prognosis,  144 
Post-opei'ative  malaria,  135 

diagnosis,  143 
Post-partum  malaria,  135 

diagnosis,  143 
Potassium  chlorate  in  leprosy,  930 

iodide  in  syphilis,  906-909 
Powers  on  tuberculosis,  832 
Predisposition  to  tuberculosis,  744 
Pregnancy  and  enteric  fever,  203 

in  relapsing  fever,  263 

and  scarlet  fever,  581 

and  smallpox,  516,  539 

in  tuberculosis,  836 

in  typhus  fever,  248 
Premonitory  stage  of  cholera,  326,  327 
Presegmenting  bodies  in  malarial  blood,  59 
Prevention  of  disease.     See  Prophylaxis. 
Primary  syphilis.     See  Syphilis. 
Pringle  on  dysenterv,  378 
Proctitis,  359" 

Prodromata  of  relapsing  fever,  260 
Prognosis  of  festivo-autumnal  fever,  144 

of  cerebro-spinal  meningitis,  445 

of  cholera,  321 

of  chronic  malarial  cachexia,  144 

of  dengue,  164 

of  diphtheria,  681 

of  dysenter}',  375 

of  enteric  fever,  207 

of  erysipelas,  471 

of  influenza,  420 

of  leprosy,  929 

of  malaria,  144 

of  malarial  hsemoglobinuria,  144 

of  Malta  fever,  947 

of  measles,  635 

of  meningeal  tuberculosis,  760 

of  miliary  fever,  948 

of  parotiditis,  730 

of  pernicious  fevers,  144 

of  pertussis,  720 

of  plague,  397 

of  post-malarial  ansemia,  144 

of  pseudo-diphtheria,  711 

of  pyaemia,  492 

of  relapsing  fever,  263 

of  rubella,  645 


Prognosis  of  scarlet  fever,  608,  609 

of  septicaemia,  510 

of  smallpox,  542 

of  tetanus,  941 

of  tuberculosis,  834 

of  typhus  fever,  251 

of  varicella,  576 

of  Weil's  disease,  946 

of  yellow  fever,  292 
Prophylaxis  of  cholera,  322 

of  diphtheria,  682 

of  dysentery,  376 

of  enteric  fever,  207 

of  erysipelas,  472 

of  hydrargyrism,  906 

of  leprosy,  932 

of  malaria,  154 

of  measles,  635 

of  parotiditis,  730 

of  pertussis,  720 

of  pyaemia,  492 

of  rubella,  645 

of  scarlet  fever,  610 

of  smallpox,  519,  545 

of  tetanus,  941 

of  tuberculosis,  836 

of  typhus  fever,  252 
Prostate  gland,  enlargement  of,  827 

tuberculosis  of,  825,  826 
Protection  from  consumption,  837 

by  vaccination,  557 
Proteus  vulgaris,  498 

Protiodide  of  mercury  in  syphilis,  900,  901 
Protozoa  of  malaria,  74 
Prudden  on  cerebro-spinal  meningitis,  426 

on  enteric  fevei-,  170 

on  phthisis,  775 

on  tubercle,  749 
Pseudo-diphtheria,  707 

bacillus,  658 

bacteriology,  670 

clinical  cases,  671,  672 
division,  708 

illustrative  cases,  708 

inoculations,  870 

prognosis,  711 

treatment,  711 
Pseudo-membrane  of  diphtheria,  647,  673 
Ptomaine-poisoning  and  cholera,  321 
Ptomaines  in  septicaemia,  497 
Puerperal  tetanus,  937 
Puerperium  and  scarlet  fever,  581 
Pugibet  on  dysenteric  paralysis,  373,  374 
Pulmonary  complications  of  malaria,  132 

gymnastics,  842 

miliary  tuberculosis,  753 

symptoms  in  enteric  fever,  186 

tuberculosis.      See  Phthisis,  chronic,  and 
Tuberculosis. 
duration  of,  836 
Pulse  in  cerebro-spinal  meningitis,  440 

in  cholera,  318,  320 

in  ciironic  phthisis,  795 

in  enteric  fever,  180,  185 
convalescence,  185 

in  erysipelas,  459,  461 

in  pyaemia,  486 


IMJKX. 


975 


Pulse  in  typliiis  fever,  246 

in  yellow  lever,  *JS,S 
Pupils,  dilatiitiou  of,  in  enteric  fever,  193 

in  nu'iiinyeal  tuhereulosis,  758 
Purgatives  in  dysentery,  382 

in  yellow  fever,  295 
Purpuric  smallpox,  534 
Pus  in  septica'inia,  501 
Pnstula  variolosa,  536 
Pustules  in  smallpox,  530 

sypliilitii',  S63 
Putrefaction,  dysenteric,  351 

and  septitaMiiia,  497,  500,  501 
PvaMnia.  477 

"arterial,  490 

eiironic,  489,  490 

definition,  477 

diagnosis,  491 

diet  in.  494 

embolism,  487 

etiology,  477 

food  in,  494 

metastatic  abscess,  488 

pathological  anatomy,  482 

phlebitis,  487 

prognosis,  492 

prophylaxis,  492 

puerperal,  489 

pulse  in,  486 

and  relapsing  fever,  264 

symptoms  of,  484 

temperature  in,  485,  490 

treatment,  492-494 
Pyelitis,  tubercular,  823 
Pylephlebitis  in  enteric  fever,  177 
Pyrexia  of  cerebro-spinal  meningitis,  439 

in  tetanus,  939 
Pyrosoma  bigeminum,  82 
Pyuria  in  chronic  phthisis,  803 

in  enteric  fever,  195,  196 

tubercular,  823 

QUARANTINE  and  cholera,  303,   305, 
324 
epidemic,  307 
of  dengue,  1G4 
New  York,  cholera  at,  320 
of  plague,  397 
and  smallpox,  547 
Quartan  fever,  99,  105 
prognosis,  144 
parasites,  35,  36,  40 
Quinine,  action  on  malarial  germs,  71,  75 
parasite,  146 
urine,  124 
in  aestivo-autumnal  fever,  151 
contraindications  in  malaria,  152 
in  dengue,  165 
in  dysentery,  386,  388 
effects  on  human  being  in  malaria,  148 
in  intermittent  fever,  151 
in  malaria,  145 

in  malarial  hsemoglobinuria,  152 
and  pertussis,  721 
salts  of,  classified,  148,  149 
in  septicsemia,  511 
time  for  administration  in  malaria,  150 


(Quinine  in  yellow  fever,  295 
(Quotidian  intermittent  fever,  99,  104 

1)  Ar.lUTS  and  tubercidosis,  744 
A)  Kace  and  cholera,  305 
and  malaria,  81 
and  scarlet  fever,  580 
and  smallpox,  515 
and  tuberculosis,  732,  745 
Rags  and  cholera,  325 
Rales  of  chronic  phthisis,  798 
Randolph  on  cerebro-spinal  meningitis,  427 

438,  439 
Rash.     See  Eruplion. 
of  measles,  627-629,  631 
of  scarlet  fever,  591 
Rashes,  antitoxic,  701 
and  smallpox,  542 
Raynaud's  disease  after  malaria,  132 
Reaction  in  cholera,  314,  318 
of  dysenteric  stools,  364 
stage  of  cholera,  332 
Recovery  in  tubei'culosis,  835 
Recrudescence  of  enteric  fever,  184,  204 
Rectum,  medication  by,  in  dysentery,  385 
syphilis  of,  880 
tuberculosis  of,  816 
Recurrence  of  erysipelas,  462 
of  measles,  633 
of  parotiditis,  729 
of  pertussis,  719 
of  rubella,  644 
Reed  on  enteric  fever,  176 
Reinhold  on  miliary  tuberculosis,  753 
Relapse  in  dengue,  161 
of  enteric  fever,  203 
in  malaria,  144 
in  measles,  633 
of  parotiditis,  729 
of  pertussis,  719 
of  relapsing  fever,  261 
of  rubella,  644 
of  yellow  fever,  283,  287 
Relapses  of  diphtheria,  679 
in  dysentery,  358 
of  malaria,  128 
in  scarlet  fever,  596 
Relapsing  fever,  257 
abortive  cases,  262 
complications,  262 
crises,  261 
definition,  257 
diagnosis  of,  263 
diet,  264 
duration,  262 
etiology,  257 
.  incubation,  260 
inoculation  of,  259 
invasion,  260 

pathological  anatomy,  259 
prodromnta,  260 
prognosis,  263 
pseudo-crisis,  262 
relapse,  261 
sequelse,  262 
symptoms  of,  260 
treatment  of,  264 


976 


INDEX. 


Kemittent  fever,  infantile,  201 

and  yellow  fever,  288 
Renal  tuberculosis.     See  Tuberculosis  of  the 

Kidney. 
Respiratory  organs  in  enteric  fever,  178 

system  in  enteric  fever,  186 
and  influenza,  415 
in  pertussis,  716,  717 
in  pulmonary  tuberculosis,  799 
in  smallpox,  519 
in  typhus  fever,  246 
Retention  of  urine  in  enteric  fever,  196 
Retinitis,  syphilitic,  889 
Retino-choroiditis  after  malaria,  132 
Retroperitoneal  glands,  tubercular,  764 
Revaccination,  565 
Rheumatism  and  scarlet  fever,  600 
Rice-water  stools,  321 
Richard  on  malarial  germs,  21 
Rigor  mortis  in  cholera,  311 
Ringer  on  quinine  in  malaria,  148 
Risus  sardonicus,  938 
Riverside  Hospital,  tvphus  fever  in,  244- 

246 
Robin  on  enteric  fever  urine,  194 
Rock  fever,  946 
Roger  on  erysipelas,  454 
Romanowsky  on  malarial  fever,  61 

method  of  blood  examination,  139 

on  quinine  in  malaria,  147 
Roque  on  malarial  urine,  123 
Rose  on  tetanus,  939 
Roseola,  639 

variolosa,  525 
Rossoni  on  malarial  blood,  125 
Rotheln  and  scarlet  fever,  606 
Rougeole,  625 
Roux  on  diphtheria,  648 
Roval  Commission  on  Tuberculosis,  743 
Rubella,  639 

age,  639 

complications,  643 

definition,  639 

desquamation,  643 

diagnosis,  644^ 

eruption,  641 

etiology,  639 

incubation,  640 

invasion,  640 

lymphatic  glands  in,  643 

and  measles,  634 

pathology  of,  640 

prognosis,  645 

prophylaxis,  645 

recurrence,  644 

relapse,  644 

sequelae,  643 

symptoms,  640 

synonyms,  639 

temperature,  642 

treatment,  645 
Rubeola.     See  Measles. 
Rules  for  protection  from  consumption,  837 
Rumpf  on  enteric  fever,  230 
Rupia,  syphilitic,  864 
Russell  on  tuberculosis,  741 
Rutty  on  relapsing  fever,  258 


SACHAROFF  on  malarial  flagella,  29 
germs,  38,  50 
Saline  purgatives  in  dysentery,  383 
Salivary  glands  in  enteric  fever,  178 

tuberculosis  of,  811 
Salpingitis,  tubercular,  830 
Salt  solution  injections  in  cholera,  328,  329 
Sandwich  Islands  and  leprosy,  922,  923,  933 
Sanitaria  and  tuberculosis,  844 
Sanitarium,  Adirondack,  844 
Sanitary  conditions  in  yellow  fever,  271 
Saprsemia,  498 
Saranac  Sanitarium,  844 
Scarlatina.     See  Scarlet  Fever. 
Scarlatinal  nephritis,  601-603 
Scarlatine,  577 
Scarlet  fever,  577 

and  age,  579 

anginosa,  594 

circulatory  system  in,  599 

cold  bathing  in,  616,  617 

complications  of,  597 

congenital,  580 

convulsions  in,  597 

definition,  577 

desquamation  in,  593 

diagnosis,  604 

diet  in,  613 

disinfection,  611,  612 

drug  rashes  and,  606 

and  endocarditis,  604 

and  enteric  fever,  198 

and  erysipelas,  606 

etiology,  577 

hemorrhagic,  594 

immunity,  583 

incubation,  584 

influence  of  previous  health,  581 

and  influenza,  606 

isolation  in,  610 

local  treatment,  614,  615 

and  locality,  580 

in  the  lower  animals,  586 

malignant,  593 

and  measles,  634 

medicinal  treatment,  613 

and  micro-organisms,  585 

mode  of  communication,  583 

nephritis  in,  589,  620 

nervous  system  in,  597 

and  occupation,  581 

ordinary  form,  590 

and  other  exanthemata,  585 

otitis  in,  598,  619 

papulata,  588 

pathological  anatomy,  587 

period  of  infection,  584 

periodicity,  577 

and  peritonitis,  600 

and  pneumonia,  599 

and  pregnancy,  581 

prognosis,  608,  609 

prophylaxis,  610 

and  pseudo-diphtheria,  709 

and  race,  580 

rash,  591 

relapses,  596 


INDEX. 


^11 


Scarlet  fever  and  rheumatisra,  600 
and  nil li el II,  OOG 
ami  suaj-oii,  579 
and  septic  infection,  508 
setiiiehe,  597 
and  sex,  580 
sine  cxantliemata,  588 
skin  in,  591 
and  smallpox,  606 
and  social  position,  580 
suscei)til)ility,  581 
symptoms  of,  590 
synonyms,  577 
temperature  in,  590,  596 
and  tonsillitis.  588 
treatment,  610 
nrseniia  in,  622 
and  urine,  592,  602 
variations  in,  594 
in  type,  596 
rash,  577 
Scliarlacli,  577 
Schmidt  on  yellow  fever,  276 
Sclerosis,  ditilise  chronic  interstitial  syphi- 
litic, 878 
disseminated,  after  malaria,  132 
syphilitic,  854,  891 
of  tubercle,  750 
Sclerotic,  syphilis  of  tlie,  887 
Scrofula,  abdominal,  764.     See  Tuberculosis 

of  (he  Lymphatic  System. 
Scrofulous  kidney,  82.3 

pneumonia.     See  Phthisis. 
Scurvy  and  dysentery,  370 
Season  and  cholera.  304 
and  dysentery,  340 
and  enteric  fever,  168 
influence  on  dengue,  156 
and  malaria,  80 
and  measles,  626 
and  parotiditis,  725 
and  scarlet  fever,  577 
and  typhus  fever,  236 
Seborrhcea  and  erysipelas,  470 
Secondary  anaemia  in  malaria,  130 

syphilis.     See  Syphilis. 
Segmentation  of  quotidian  malarial  para- 
sites, 104 
Semen,  tubercle  bacilli  in,  821 
Senn  on  pyaemia,  478,  493 
on  septicaemia,  496,  499 
Septic  infection,  495,  504 
eruptions  in,  506 
urine  in,  506 
intoxication,  495,  500,  503 
Septiciemia,  495 

artificial  production  of,  496 

blood  of,  501 

and  carbuncle,  507 

definition,  495 

diagnosis,  508,  509 

diet  in,  512 

etiology,  495 

morbid  anatomy,  500 

prognosis,  510 

quinine  in,  511 

spleen  in,  501 

Vol.  I.— 62 


Septicsemia,  .stimulation  in,  511 

strychnine  in,  511 

symptoms,  502 

treatment,  510 
8eptico-i)yn'mia,  482,  495 
Setpielit;  of  cerebro-spinal  meningitis,  441 

of  cholera,  319 

of  dengue,  162 

of  dysentery,  374 

of  erysipelas,  467 

of  influenza,  415 

of  malaria,  127 

of  measles,  632 

of  pertussis,  718 

of  relapsing  fever,  262 

of  rubella,  643 

of  scarlet  fever,  597 

of  smallpox,  538 

of  typhus  fever,  248 

of  vaccinia,  561 

of  Weil's  disease,  946 
Serous  diarrhoea  in  cholera,  315 

membranes,  tuberculosis  of,  764 
tuberculosis,  general,  774 
Serum  antitoxin  in  diphtheria,  695 
for  erysipelas,  472 
in  tetanus,  942 

cultures  of  diphtheria,  651 

growth  of  diphtheria  bacillus  in,  649 

inoculations  in  enteric  fever,  230 

treatment  of  leprosy,  932 
Serum-therapy  in  tuberculosis,  848 
Sex  and  cholera,  304 

and  dysentery,  340 

and  entei'ic  fever,  169 

and  measles,  625 

and  pertussis,  713 

and  relapsing  fever,  259 

and  scarlet  fever,  579,  580 

and  smallpox,  515,  543 

and  tuberculosis,  745 

and  typhus  fever,  236 
Sezary  on  malaria,  154 
Shakspeare  on  scarlet  fever,  586 
Sharon  institution  for  tuberculosis,  844 
Simmonds  on  tuberculosis,  817 
Simple  continued  fever,  948 
definition,  948 
etiology,  949 
symptoms,  949 
treatment,  950 
Simpson  on  cholera.  325 
Skin  in  cholera,  311,  317 

in  chronic  phthisis,  803 

in  diphtheria,  679 

in  enteric  fever,  196 

in  erysipelas,  456,  457,  460 

in  influenza,  413 

in  leprosy,  926 

in  scarlet  fever,  591 

in  smallpox,  520-525,  538 

syphilis  of,  859 

in  typhus  fever,  239 
Skin-grafting  and  smallpox,  519 
Smallpox,  513 

abscesses  in,  522 

and  age,  515 


978 


INDEX. 


Smallpox  and  antiseptics,  550 
bacteriology,  518 
brain  in,  522 
and  cicatrization,  552 
complications,  538 
continent,  531,  544 
convalescence,  554 
definition,  513 
delirium  in,  529 
diagnosis  of,  540 
disinfection,  546,  547 
epidemics,  513 
etiologV;  514 
eyes  in,  522 
hemorrhagic,  521,  534 
history,  513 
immunity,  517 
incubation,  522 
initial  stage,  523 
itching  in,  530 
malignant,  534 

mucous  membranes  in,  521,  528 
nose  in,  528 
pain  in,  524 

pathological  anatomy,  520 
petechial,  534 
prodromal  rash,  524 
prognosis,  542 
prophylaxis,  519,  545 
purpuric,  534 
pustules  in,  530 
quarantine,  547 
and  race,  515 
recurrent,  517 
and  scarlet  fever,  606 
secondary,  517 
sequelte,  538 
and  sex,  515 
skin  in,  520 

stage  of  desiccation,  530 
eruption,  525 
suppuration,  526 
susceptibility  to,  517 
symptoms,  522 
synonyms,  513 

temperature  in,  528,  529,  532 
treatment,  548 
urine  in,  524 
vaccination,  545,  546 
varieties,  531 
viscera  in,  522 
Smegma  bacilli,  821 
Smith,  E.  F.,  on  enteric  fever,  210 

J.  Lewis,  on   cerebro-spinal   meningitis, 

429 
Xathan,  on  enteric  fever,  222 
Theobald,  on  malaria,  82 
Social  position  and  scarlet  fever.  580 
Soil  and  malaria,  78 

and  tuberculosis,  744 
Somnolence  in  enteric  fever,  1 92 
Sonnenberger  and  pertussis,  723 
Sorel  on  malaria,  97 
Spanish  fever,  399 
Spasm  of  tetanus,  938,  939 
Special  senses  in  influenza,  414 
Spinal  cord  in  cerebro-spinal  meningitis,  434 


Spinal  cord,  syphilis  of,  885 

tuberculosis  of,  831 
Spirillum  of  Asiatic  cholera,  309 
of  cholera,  301,  306 
of  relapsing  fever,  257 
Spirochffita  Obermeieri,  257 
Spit-cup  for  tuberculosis,  837 
Spleen  in  cholera,  312 
in  enteric  fever,  176,  180 
in  malaria,  85 
of  malarial  cachexia,  89 
in  relapsing  fever,  259 
in  septicemia,  501 
rupture  of,  in  relapsing  fever,  263 
in  typhus  fever,  239 
Spores  of  amceba  dysenterica,  345 

in  malaria,  26.  50,  58,  67,  71 
Sporadic  cases  of  enteric  fever,  173 
Sporulating  bodies  in  malarial  blood,  59,  62 
Spotted  fever,  425 
Sputa  in  chronic  phthisis,  785,  788 
nummular,  in  chronic  phthisis,  788 
of  pneumonic  phthisis,  778 
Sputum,  disinfection  of  tubercular,  837 
elastic  tissue  in,  789 
of  miliary  tuberculosis.  754 
tubercular,  734 
Staining  reactions  of  tubercle  bacillus,  733 

syphilis  bacilli,  853 
Staphylococcus  in  pysemia,  478 
in  scarlet  fever,  589 
in  septiccemia,  497 
in  smallpox,  518 
Starr  on  tuberculosis,  831 
Statistics  of  tuberculosis,  732 

of  vaccination,  557 
Steam  inhalation  in  diphtheria,  686 
Stengel  on  dysentery,  346 
Stern  on  enteric  fever,  229 
Sternberg  on  cholera,  306,  307 
Stewardson  on  intermittent  fever,  19 
Stimulation  in  cholera,  332 

in  septica-mia,  511 
Stimulants  in  erysipelas,  474 
in  influenza,  422 
in  malaria,  145 
in  typhus  fever,  255 
in  yellow  fever,  299 
Stoll  on  dysentery,  373 
Stomach  in  cholera,  312 
in  relapsing  fever,  260 
tuberculosis  of,  813 
in  yellow  fever,  276 
Stools,  choleraic,  307 

in  chronic  dysentery,  363 
of  diphtheri'tic  dysentery,  360 
disinfection  of  choleraic,  323 
dysenteric,  disinfection  of,  208,  377 
microscopical  examination  of,  in  dysen- 
tery, 364 
rice-water,  .321 
Strabismus  and  meningeal  tuberculosis,  758 
Strassmann  on  tuberculosis,  811 
Strauss  on  tubercle  bacillus,  736 
Streptococci  in  pseudo-diphtheria,_709 
Streptococcus  of  Fehleisen,  451,  454 
inoculation  and  pseudo-diphtheria,  670 


INDEX. 


979 


Streptococcus    in    pnlmonarv    tuberculosis. 
807 
in  pyaemia,  478 
pyogenes  in  erysipelas,  451 
in  scarlet  fever,  589 
in  smallpox,  518 
Strieker  on  liienioptysis,  791 
Stricture,  sypiiiiitic,  880 
Striinipell  on  dysentery,  339 

on  enteric  fever,  187 
Strychnine  in  leprosy,  930 

in  septiai?niia.  511 
Strychnine-poisoning  and  tetanus,  940 
Stumpf  on  erysipelas,  455 
Snbcontinua  typhoidea,  141 
Subsultus  tendinuni  in  enteric  fever,  181 
Sudakow  on  erysipelas,  458 
Sudani ina  in  enteric  fever.  197 
Sudor  Anglicus,  948 
Sudoriferous   type   of    pernicious    malarial 

fever,  115 
Sulphate  of  quinine  in  malaria,  149 
Suppuration  in  amoebic  dysentery,  352 

in  pyjemia,  484 

ami  smallpox,  551 
Suppurative  pleurisy,  acute  tuberculous,  767 

stage  of  smallpox.  526 
Susceptibility  to  yellow  fever,  273 
Swamp  fever,  17 
Sweating  fever,  947 

stage  of  tertian  fever,  102 

in  tuberculosis,  846 
Sweats  in  chronic  phthisis,  795 
Swinburue  Island,  cholera  on,  330 

cholera  epidemic,  307.  308 
Sydenhatn  on  dysentery,  372 

on  intermittent  fever,  18 
Symptoms,  abdominal,  in  dysentery,  365 

of  acute  catarrhal  dysentery,  357 

of  cerebro-spinal  meningitis,  436 

of  cholera.  314 

of  chronic  phthisis,  785,  793 

of  dengue,  159 

of  diphtheria  in  detail,  678 

of  diphtheritic  dysentery,  359 

of  dysenteric  arthropathies,  373 

of  enteric  fever,  179 

of  erysipelas,  459 

of  induenza,  407 

of  inherited  syphilis,  915 

of  laryngeal  diphtheria,  677 

of  leprosy,  925 

of  malaria.  96 

of  Malta  fever,  947 

of  measles,  627 

of  meningeal  tuberculosis,  756 

of  miliary  fever,  948 
tuberculosis,  752 

of  parotiditis,  726 

of  pertussis,  715 

of  phthisis,  777 

of  plague,  394 

of  pvEemia.  484 

of  rubella,  640 

of  scarlet  fever,  590 

of  secondary  dysentery,  365 

of  septicaemia,  502 


Symptoms  of  simple  continued  fever,  949 

of  smallp(jx,  522 

of  syphilis,  853 

of  tetanus,  938 

of  tui)erculous  adenitis,  763 

of  vaccinia,  560 

of  varicella,  572 

of  Weil's  disease,  945 

of  yellow  fever,  281 

prodromal,  of  syphilis,  851 
Syncope  and  tuberculosis,  809 
Synechia,  syphilitic,  888 
Synonyms  of  cholera,  301 

of  enteric  fever,  167 

of  erysipehis,  451 

of  influenza,  399 

of  leprosv,  921 

of  MaltaVever,  946 

of  measles,  625 

of  parotiditis,  725 

of  pertussis,  713 

of  phthisis,  775 

of  rubella,  639 

of  scarlet  fever,  577 

of  smallpox,  513 

of  typhus  fever.  233 

of  vaccinia,  555 
Svnovitis  in  enteric  fever,  198 
Syphilis,  849 

and  abortion,  915 

acquired,  849 

and  alcohol,  896 

of  anus.  880 

of  bladder,  876 

of  bloodvessels,  872,  873 

of  bones.  881 

of  brain,  884 

of  conjunctiva,  887 

of  cord.  885 

of  cornea.  887 

course,  849 

definition,  849 

diagnosis,  892 

dietetic  treatment,  895 

of  digestive  tract,  871 

of  ear,  889 

and  eczema.  894 

etiology  of,  852 

of  eve,"  886 

of  evelids,  886 

fibroid,  of  the  lung,  806 

first  period  of  incubation,  850,  854 

of  genito-urinary  system.  874 

of  hair,  866 

of  heart,  872 

hereditary,  849,  914 

symptoms,  915 
hygienic  measures,  895 
hypodermic  treatment,  904 
inherited,  849 

treatment.  916 
insontium,  850 
and  iodine,  906 
of  iris,  887 
of  joints,  883 
of  kidney,  876 
of  lachrymal  apparatus,  886 


980 


INDEX. 


Syphilis  of  liver,  879 
local  treatment,  909 
of  lungs,  806,  878 
and  marriage,  919 
and  mercury,  899-908 
of  mouth,  868 
of  nails,  867 
nature  of,  849 
of  nerves,  -884 
of  nervous  system,  883 
of  optic  nerve,  889 
of  orbit,  886 
and  ozEena,  913 
pathological  anatomy,  890 
of  penis,  874 
primary,  851 
prodromal  symptoms,  851 
of  rectum,  880 
and  rupia,  864 
of  sclei'otic,  887 
secondary,  851 
of  skin,  859 
and  smallpox,  542 
stages  of,  851 
symptoms  of,  853 
tertiary,  851 
of  testicles,  875 
and  tobacco,  896 
of  tongue,  868 
treatment  of,  895 

by  fumigation,  903 

by  inunction,  902,  903 

mixed,  908 

systematic,  898 
and  tubercles,  864 
and  vaccinia,  562 
Syphilitic  alopecia,  866 
arterial  sclerosis,  874 
choroiditis,  889 
coryza,  916 
endarteritis,  873 
gummata,  865 
meningitis,  884 
myocarditis,  873 
nephritis,  877 
onychia,  867 
orchitis,  876 
otitis,  890 
paronvchia,  868 
rash,  894 
retinitis,  889 
sclerosis,  878 
Syphilodermata,  859-866 

treatment,  909 
Systematic  treatment  of  cholera,  326 
Syzygia  of  malarial  parasites,  38 

TABES  mesenterica,  764 
Table  of  diphtheria  antitoxin,  696,  697 
bacilli,  605 

immunization,  706,  707 
of  diagnosis  of  rubella,  644 
of  diphtheria  cultures,  650,  662 
of  influence  of  age  in  typhus  fever,  236 
of  mortality  in  yellow  fever,  270 
of  protection  by  vaccination,  557,  564,  566 
of  pseudo-diphtheria,  672 


Table  of  i-espiratory  range  in  typhus  fever, 
247 
of  salts  of  quinine,  148,  149 
of  scarlet  fever  incubation,  584 
of  seasons  of  scarlet  fever,  578 
of  temperatures  in  yellow  fever,  293 
of  urine  analysis  in  yellow  fever,  285 
of  virulence  of  diphtheria  bacilli,  656, 

658 
of  yellow  fever  mortality,  270,  294 
Tache  bleuatre  in  enteric  fever,  197 
cerebrale,  757 

in  enteric  fever,  197 
Tannic  acid  in  cholera,  330 

in  dysentery,  383 
Taupin  on  enteric  fever,  198 
Temperature  in  diphtheria,  678 
of  enteric  convalescence,  184 

fever,  179,  181,  182 
in  erysipelas,  459,  461 
of  parotiditis,  728 
in  phthisis,  777 
in  pysemia,  485,  490,  503 
reduction  of,  in  enteric  fever,  220 
in  rubella,  642 
in  scarlet  fever,  590,  596,  616 
in  septic  intoxication,  503 
in  smallpox,  523,  528,  529,  551 
subnormal  in  enteric  fever,  184 
tertian  intermittent  fever,  101 
in  tetanus,  938 
in  typhus  fever,  236,  243 
in  yellow  fever,  269,  282,  292 
Temperature  chart,  sestivo-autumnal  fever, 
108-110,  112 
double  tertian  fever,  104 
of   enteric    fever,    180,    182-185,   189, 

199-202,  204 
of  fermentative  fever,  502 
of  influenza,  409-412 
of  pyfemia,  485 

quartan  intermittent  fever,  106 
of  septic  infection,  505,  507 

intoxication,  504 
of  smallpox,  533 
of  tertian  intermittent  fever,  101 
charts  of  typhus  fever,  244,  245 
of  yellow  fever,  289 
Tenderness  of  muscles  in  enteric  fever,  194 
Tenesmus  in  dysentery,  358,  365 
Tertian  fever,  99 
chill,  100 
malignant,  107 
paroxysm,  100 
prognosis,  144 
intermittent  fever,  99 
in  childi'en,  102 
parasites,  35,  36,  44 
Tertiary  syphilis.     See  Syphilis. 
Testicles,  syphilis  of,  875 
Testis,  tuberculosis  of,  828 
Tetanus,  935 
bacillus,  935 
cephalic,  939 
course,  940 
cultures,  935 
definition,  935 


im)j:x. 


981 


Tetanus,  diagnosis,  940 
etiology,  035 

general  management,  944 
and  liy<iroj)li(il)ia,  939,  940 
and  liysteria,  941 
medicinal  agents,  944 
neonatorum,  937 
pathological  anatomy,  937 
prognosis,  941 
prophylaxis,  941 
pulse  in,  939 

and  strychnine-poisoning,  940 
symptoms,  938 
temperature  in,  939 
and  tetany,  941 
toxalbumin,  937 
treatment.  941-944 
Tetany  and  tetanus,  941 
Thayer  on  malaria,  23,  39,  52,  56 

on  malarial  germs,  67 
Therapeutics  of  typhus  fever,  253 
Thirst  in  cholera,  331 
in  yellow  fever,  286 
Thomas  on  dengue,  158 

on  mammary  tuberculosis,  833 
Thompson,  charts  of  malarial  fever  asso- 
ciated with  enteric  fever,  199,  200, 
205 
on  typho-maiarial  fever,  198 
Thorne  on  tuberculosis,  744 
Thrombo-arteritis,  480 
Thromboses,  syphilitic,  885 
Thrombosis,  cardiac,  in  relapsing  fever,  264 
in  enteric  fever,  186,  222 
in  pyaemia,  479,  480 
Tizzoni-Cattani  on  tetanus,  943 
Tobacco  and  sypliilis,  870,  896 
Tongue,  chancre  of,  868 
in^cholera,  316,  321 
in  enteric  fever,  180,  187,  216 
syphilis  of,  868 
tuberculosis  of,  810 
in  yellow  fever,  283 
Tonics  in  leprosy,  930 

in  syphilis,  918 
Tonsillitis  and  pseudo-diphtheria,  710 

in  scarlet  fever.  588 
Tonsils  and  pseudo-diphtheria,  670,  671 
syphilis  of,  869 
tuberculosis  of,  811,  840 
Tormina  in  dysentery,  358 
Torti  on  intermittent  fever,  18 
ToxEcmia  of  cerebro-spinal  meningitis,  442 
Toxalbumin  of  yellow  fever,  272 
Toxicity  of  malarial  urine,  123 
Toxin  of  tetanus,  935,  936 

of  yellow  fever,  272 
Toxins,  none  of  malaria,  74 
in  pulmonary  tuberculosis,  807 
in  septicemia,  497 
syphilitic,  883 
Tracheites,  ulcerative,  in  chronic  phthisis, 

800 
Tracheo-bronchial  glands  and  tubereialosis. 

762 
Tracheotomy  in  diphtheria,  686 
Trade  winds  and  vellow  fever,  270 


Transfusion  in  cholera,  327 
Transmission  of  erysipelas  to  foetus,  467 

Traiibc  on  pneumonii'  [ihthisis,  778 
Trauma  and  tuberculosis,  746 
Traumatism  and  malaria,  82 
Treatment  of  amebic  dysentery,  387 
Brand's,  of  enteric  fever,  222,  223 
of  catarrhal  dysentery,  385 
of  cerebro-spinal  meningitis,  445 
of  chancre,  897 
of  cholera,  325 

of  chronic  malarial  cachexia,  154 
climatic,  of  pulmonary  tuberculosis,  842 
of  dengue,  164 
of  diphtheria,  682 
by  diphtheria  antitoxin,  696 
of  diphtheria,  general,  685 
of  diphtheritic 'dy.senter3',  386 
of  dysentery  in  g'eneral,'376 
of  enteric  fever,  207 

by  hydrotherapy,  222-229 
of  erysipelas,  472 

general  medical,  of  tuberculosis.  845 
of  gummata,  912 
of  influenza,  421 
of  inherited  syphilis,  916 
of  intubated  patient,  689 
of  laryngeal  diphtheria,  685 
of  leprosy,  929 
local,  of  syphilis,  909 
of  malaria,  145 
of  Malta  fever,  947 
of  measles,  635 
medicinal,  of  dysentery,  378 
of  miliary  fever,  948 
mixed,  of  syphilis,  908 
of  parotiditis,  730 
of  pertussis.  720 
of  plague,  397 
of  pseudo-diphtheria,  711 
of  py;emia,  492-494 
of  relapsing  fever,  264 
of  rubella,  645 
of  scarlet  fever,  610 
of  septica?mia,  510 
of  simple  continued  fever,  950 
of  smallpox,  548 
specific,  of  enteric  fever,  222 
of  syphilis,  895 
systematic,  of  svphilis,  898 
of  tetanus,  941-944 
of  tuberculosis,  840 
of  typhus  fever,  253 
of  varicella,  576 
of  varioloid,  552 
of  Weil's  disea.se,  946 
of  yellow  fever,  294 
Tremor  in  enteric  fever,  193,  216 
Trichinosis  and  enteric  fever,  206 
Tripier  on  enteric  fever,  229 
Triple  quartan  intermittent  fever,  105 
Trismus,  938 
Troje  on  phthisis,  775 
Trousseau  on  dysentery,  339 
Trudeau  on  tuberculosis,  744,  844 
Tubbing  in  enteric  fever,  223 
Tubercle,  746 


982 


INDEX. 


Tubercle,  distribution  in  body,  746 
etiology,  746 

general,  morbid  anatomy,  746 
infiltration,  750 
nodular,  747 
nodules  in  phthisis,  776 
bacilli,  changes  produced  by  the,  747 

in  chronic  phthisis,  790 

inoculation,  738 

multii^lication  of,  747 

in  semen,  821 

toxins,  848 

in  tuberculous  pleurisy,  768 
in  urine,  82i 
bacillus.     See  Bacillus  Tuberculosis. 

distribution,  736,  737 

modes  of  infection,  737 
Tubercles,  781 
in  bladder,  825 
in  chronic  phthisis,  780 
of  leprosy,  926 

of  meningeal  tuberculosis,  756 
in  prostate  gland,  826 
secondary  inflammatory  process,  751 
syphilitic,  864 
Tubercular  fibroid  phthisis.     See   Phthms, 
fibroid. 
infection,  conditions  influencing,  743 
leprosy,  922 
nephritis,  823 
sputum,  734 
Tuberculin,  848 
Tuberculosis,  731 

acute,  751.     See  Miliary  Tuberculosis. 

and  age,  745 

and  alcohol,  841 

of  the  alimentary  system,  810 

in  animals,  731 

of  the  arteries,  833 

and  asphyxia,  809 

and  asthenia,  809 

of  bladder,  821,  824 

of  the  brain,  831 

of  bronchial  glands,  762 

and  catarrhal  bronchitis,  745 

of  cervical  glands,  761 

chronic  ulcerative,  of  the  lungs,  780 

climatic  treatment,  842 

of  the  cord,  831 

and  cough,  846 

and  creasote,  845 

definition,  731 

and  diarrhoea,  846 

dietetic  treatment,  840 

duration  of  pulmonary,  836 

and  dust,  741 

and  dysjjepsia,  841 

and  dysentery,  369 

and  enteric  fever,  198,  206 

etiology,  731 

of  Fallopian  tubes,  819,  880 

of  female  generative  organs,  829 

fever  of,  846 

general  medical  treatment,  845 

general  statistics,  732 

of  the  genito-urinary  system,  818 

and  geographical  position,  732 


Tuberculosis,  hereditary  transmission,  737, 
819 
and  hemorrhage,  809 
and  infancy,  808 
infection  from  milk,  743 
infective  nature  of,  740 
and  influenza,  417 
by  inhalation,  741 
of  the  kidneys,  821 
of  the  lips,  810 
of  liver,  816 
and  local  conditions,  745 
of  the  Inngs,  775.     See  Phthisis. 
of  the  lymphatic  system,  760 
and  malaria,  135 
of  the  mammary  gland,  832 
and  marriage,  836 
meningeal,  254,  755 
of  mesenteric  glands,  764 
miliary,  751 
morbid  anatomy,  731 
and  occupation,  745 
of  oesophagus,  812 
and  old  age,  809 
of  ovary,  831 
of  palate,  811 
of  the  pancreas,  817 
of  the  pericardium,  769 
of  the  peritoneum,  770 
of  pharynx,  812 
of  the  pleura,  764 
primary,  intestinal,  813 
prognosis  of,  834 
prophylaxis  in,  836,  837 
of  prostate  gland,  826 
pulmonary,  concurrent  infections  in,  806 

modes  of  death  in,  809 

peculiarities  of,  at  extremes  of  life,  808 
and  race,  732,  745 
of  rectum,  816 
renal,  822  _ 

of  retroperitoneal  glands,  764 
of  salivary  glands,  811 
of  the  serous  membranes,  764 
serum-therapy,  848 
and  sex,  745 
spontaneous  cure,  834 
of  stomach,  813 
and  sweating,  846 
and  syncope,  809 
of  the  testes,  828 
of  the  tongue,  810 
of  tonsil,  811 
treatment  of  840 

in  sanitaria,  844 

of  special  symptoms,  846 
of  ureters,  824 
of  urethra,  824 
of  uterus,  830 
of  vagina,  829 
of  vesiculse  seminales,  826 
of  vulva,  829  _ 
Tuberculosis  bacillus.  733 
Tuberculous  adenitis,  760 

diagnosis,  764 

local,  761 

symptoms,  763 


INDEX. 


983 


Tulierciiloiis  infection  by  meat,  743 
iiiHlinition.     St-o  I'/il/ilsla. 
Ivnipluulenitis,  generalized,  761 
periciirditis,  acute,  7(59 

clironie,  76!) 
peritonitis,  770 

and  acute  miliary  tuberculosis,  771 
ascites  in,  77o 
diagnosis,  77o 
mode  of  infection,  771 
an(!  lypiioid  lever,  77o 
pleurisies,  subacute  and  chronic,  767 
pleurisy,  764 

chronic  adhesive,  767 
diagnosis,  7()8 
with  purulent  exudate,  767 
with  sero-tibrinous  effusion,  767 
ulcers  of  the  intestine,  813-815 
Tubes,  Fallopian,  tuberculosis  of,  830 
Tumor,  gummy,  of  syphilis,  891 
Tussis  convulsiva,  713 
Tympanites  in  enteric  fever,  180,  189,  217 
Typho-dengue,  164 
Typho-malarial  fever,  134,  198 
Typhoid  condition  in  erysipelas,  461 
fever.     See  Enteric  Fever. 
and  cerebro-spinal  meningitis,  443 
and  cholera,  321 
in  dengue,  164 
and  dysentery,  371 
with  malaria,  133 
and  measles,  634 
and  miliary  tuberculosis,  753 
and  septic  infection,  508 
and  tuberculous  meningitis,  759 
peritonitis,  773 
form  of  miliary  tuberculosis,  752 
Typhus  abdominalis,  167 
bacillus.  233 
fever,  233 
and  age,  236 

and  cerebro-spinal  meningitis,  444 
cold  baths  in,  254 
complications,  248 
definition,  233 
diagnosis,  249 
diet  in,  253 
digestive  tract,  247 
and  dysentery,  371 
epistaxis  in,  247 
eruption  of,  241,  242 
etiology,  233 
history,  233 
incubation  of,  240 
invasion  of,  240 
and  measles,  634 
nervous  system  in,  248 
pathological  anatomy,  239 
predisposing  causes,  235 
prognosis,  251 
prophylaxi.s,  252 
pulse  in,  246 
respiration  in,  246 
and  season,  236 
sequelae,  248 
and  sex,  236 
symptoms  of,  240 


Typhus  fever,  synonyms,  233 
temperature  in,  236,  243 
treatment  of,  253 
urine  in,  247 
levissinms,  183,  199 

UFFELMANN  on  enteric  fever,  170 
Ulceration,  chronic,  of  dysentery,   356, 
357 
follicular,  in  dysentery,  356 
intestinal,  tubercular,  813 
Ulcerations  in  enteric  fever,  174 
Ulcerative    endocarditis    in   pysemia,    484. 
490 
and  septic  infection,  505 
tuberculosis  of  the  lungs,  chronic,  780 
and  peritonitis,  772 
Ulcers  of  amcebic  dysentery,  352 
cicatrization  of  enteric,  174 
dysenteric,  350 
of  leprosy,  928 
of  seconclarv  dysentery,  366 
syphilitic,  863,"  866 
Umbilication,  520 
in  vaccinia,  559 
United  States  census  and  tuberculosis,  732 

cholera  in,  303 
Units  of  antitoxin,  695 
Unna,  588 

on  erysipelas,  456 
ichthyol  varnish,  473 
on  leprosy,  930 
Uraemia  in  relapsing  fever,  264 

and  scarlet  fever,  622 
Urea  in  yellow  fever,  285 
Urinary  system  in  enteric  fever,  194 
Urine  in  cerebro-spinal  meningitis,  441 
in  diphtheria,  679 
in  erysipelas,  461 
of  diphtheritic  dysentery,  360 
in  enteric  fever,  194,  217 
in  malarial  fever,  123 
in  measles,  630 

in  pernicious  malaria,  117,  118 
in  relapsing  fever,  261 
retention  of,  in  enteric  fever,  219 
in  septic  infection,  506 
in  scarlet  fever,  592,  602 
in  smallpox,  524 
toxicity  of,  in  enteric  fever,  195 

of  malarial,  123 
tubercle  bacilli  in,  821 
in  typhus  fever,  247 
in  yellow  fever,  285,  293 
Uro-genital  tuberculosis.   See  Genito-urinary 

Tuberculosis. 
Ureters,  tuberculosis  of,  824 
Urethra,  tuberculosis  of,  820,  824,  826 
Urticaria  and  antitoxin,  701,  704 

in  enteric  fever,  197 
Uterus,  tuberculosis  of,  830 

VACCINATION,  514,  546 
table,  557,  564-566 
technique,  563 
and  varioloid,  537 
Vaccine,  animal,  563 


984 


INDEX. 


Vaccine  lymph,  559 

scars,  565 
Vaccinia,  555 

complications,  561 
course,  560 
definition,  555 
and  erysipelas,  562 
etiology,  557 

pathological  anatomy,  559 
sequelae,  561 
statistics,  557 
symptoms,  560 
synonyms.  555 
and  syphilis,  562 
Vacuolation  of  malarial  parasite,  30 
Vagina,  tuberculosis  of,  829 
Vance  on  typhus  fever,  255 
Varicella,  569 
cicatrices,  571 
complications,  573 
definition,  569 
diagnosis,  574 
and  enteric  fever,  198 
gangrsenosa,  573,  574 
incubation,  570 
pathological  anatomy,  571 
prognosis,  576 
symptoms,  572 
synonyms,  569 
treatment,  576 
and.  variola  vera,  574,  575 
Varieties  of  enteric  fever,  198 

of  yellow  fever,  282 
Variola.     See  Smallpox. 
discreet,  527 

hsemorrhagica  pustulosa,  536 
and  malaria,  135 
and  measles,  634 
miliaris,  538 
nigra,  535 

sine  exanthemata,  516,  525 
vera,  537,  538 
verrucosa,  538 
Variolse  vaccinae,  555 

pnsillse,  569 
Varioloid,  536 

treatment  of,  552 
Vauvray  on  dengue,  160 
Vegetation  and  malaria,  78 
Velpeau  on  tuberculosis,  832 
Venereal  disease.     See  Syphilis. 

sores,  862 
Venesection   in   cerebro -spinal   meningitis, 

446 
Ventilation  and  typhus  fever,  235 
Vertigo  in  enteric  fever,  193 
Vesical  tuberculosis,  825 
Vesicles  in  smallpox,  520 

of  varicella,  571 
Vesiculse  seminales,  tuberculosis  of,  826 
Vierordt  on  tuberculosis,  774 
Vignal  on  tuberculosis,  738 
Villemin  on  tuberculosis,  733 
Vincenzi  on  sestivo-autumnal  fever,  121 
Virchow  on  erysipelas,  467 
on  malarial  pigment,  19,  20 
on  pysemia,  479 


Virchow  on  tubercle,  750 

Virulence  of  diphtheria  bacilli,  656-658 

Virus,  vaccine,  559 

humanized,  549,  563 

of  smallpox,  519 
Vitrium  anlimonii  ceratuni,  379 
Vomiting  in  cholera,  316,  331 

in  enteric  fever,  188,  216 

in  scarlet  fever,  590 

in  meningeal  tuberculosis,  757 

in  yellow  fever,  286 
Von  Eehring's  antitoxin,  695 
Von  Hildenbrand  on  scarlet  fever,  582 
Von  Jaksch  on  relapsing  fever,  257,  258 
Von  Kanke  on  diphtheria,  698 
Von  Ziemssen  on  cerebro-spinal  meningitis, 
434 

on  cholera,  326 
Vulva,  syphilis  of,  876 

tuberculosis  of,  829 

WAGNEE,  on  enteric  fever,  176 
on  tubercles,  748 
Walking  typhoid,  199 
Ware  on  haemoptysis,  791 
Warfield  on  dysentery,  372 
Wartmann  on  tuberculosis,  746 
Warts,  venereal,  862 
Wassermanu  on  enteric  fever,  229 
Water  on  the  brain,  754 

cold,  in  yellow  fever,  297,  298 
and  dysentery,  377 
injection  of,  in  cholera,  328-330 
pollution  of,  and  enteric  fever,  209,  210 
Waterhouse  on  vaccinia,  556 
Waterpock,  569 
Webster  on  typhus  fever,  255 
Weichselbaum  on  staining  bacilli,  821 
Weigert  on  tubercle  bacillus,  734 
Weil's  disease,  945 

complications.  946 
definition,  945 
diagnosis,  946 
etiology,  945 

pathological  anatomy,  945 
prognosis,  946 
sequelae,  946 
symptoms,  945 
treatment,  946 
Welch  on  diphtheria,  648 
antitoxin,  693-695 
on  enteric  fever,  177 
on  septicaemia,  499,  500 
Wells  on  tuberculosis,  732 
White  on  influenza,  406 
Whittaker  on  dysentery,  377 
Whytt  on  tubercular  meningitis,  754 
Wilks  on  pyaemia,  490 
Williams  on  scarlet  fever,  589 
on  tuberculosis,  740,  829 
on  tuberculous  peritonitis,  771 
Wind  and  yellow  fever,  271 
Winds  and  malaria,  80 
Wintrich's  sign,  799 
Wood  on  dysentery,  359 
W^oodhead  on  tuberculosis,  764 
Woodward  on  dysentery,  339,  341,  349 


IXDhX. 


985 


"NVortaliet  on  denirue,  160 
AVouuds  in  pyaemia,  493 

YELLOW  FEVEK,  267 
acclimatization,  274 
aiitipyretic-s  in,  297 
antitoxin,  295 
bacteriology,  271 
black  vomit  in,  267,  276 
blood,  275 
brain,  276 
convalescence,  2S2 
definition,  207 
and  dengue,  162,  163,  291 
diagnosis,  2S7 
diet  in.  300 
etiology,  267 
face  in!  281,  284 
febrile  stage  in,  282 
immunity,  273 
incubation,  281 
intestines,  277 
kidneys.  279 
liver,  277 

and  malarial  fevei-s,  288-291 
meninges,  276 
mortality,  293 


Yellow  fever,  nervous  system  in,  28 
odor  in,  284 

pathological  anatomy,  275 
prognosis,  292 
pulse  in,  283 
relapses,  287 
sanitary  conditions,  271 
siderante,  282 
skin  in,  281,  284 
stage  of  calm,  282 
stimulants  in,  299 
stomach,  276 
susceptibility,  273 
symptoms,  281 
symptomatic  treatment,  296 
temperature  in,  282,  292,  293 

charts,  289 
treatment  of,  294 
urine  in,  285,  293 
varieties,  282 
vomiting,  286 

ZERI  on  malaria,  81,  82 
Ziehl's  staining  fluid,  734 
Zorkendorfer  on  cerebro-spinal  meningitis, 

426 
Ziilzer  on  smallpox,  518 


I 


.  '-'11 

^  •-.••.'.-^■'•±<1' 


